Ariel J. Lang

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00347269.

A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain

Summary Acceptance and commitment therapy (ACT) and cognitive‐behavioral therapy are both effective for pain interference and mood in chronic pain patients; ACT may be more satisfactory. ABSTRACT Individuals reporting chronic, nonmalignant pain for at least 6 months (N = 114) were randomly assigned to 8 weekly group sessions of acceptance and commitment therapy (ACT) or cognitive‐behavioral therapy (CBT) after a 4–6 week pretreatment period and were assessed after treatment and at 6‐month follow‐up. The protocols were designed for use in a primary care rather than specialty pain clinic setting. All participants remained stable on other pain and mood treatments over the course of the intervention. ACT participants improved on pain interference, depression, and pain‐related anxiety; there were no significant differences in improvement between the treatment conditions on any outcome variables. Although there were no differences in attrition between the groups, ACT participants who completed treatment reported significantly higher levels of satisfaction than did CBT participants. These findings suggest that ACT is an effective and acceptable adjunct intervention for patients with chronic pain.

Sensitivity and specificity of the PTSD checklist in detecting PTSD in female veterans in primary care

PTSD affects a substantial number of women in medical settings and is associated with significant distress and impairment. There are effective methods of treating trauma-related distress, but a minority seek such care. Thus, primary care is an important setting in which to identify individuals with PTSD. We sent questionnaires, including the PTSD Checklist—Civilian Version (PCL-C), to 419 female veterans who were seen in our primary care clinic in 1998; 56% (N = 221) returned the measures. A random subset (n = 49) was interviewed to establish psychiatric diagnoses. The results provide qualified support for the use of the PCL-C total score with a lowered cutoff score as a screening measure for PTSD in female veterans in primary care.

Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS)

BACKGROUND The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that can be used to assess severity and impairment associated with any anxiety disorder or multiple anxiety disorders. A prior investigation with a nonclinical sample supported the reliability and validity of the OASIS; however, to date it has not been validated for use in clinical samples. METHODS The present study assessed the psychometric properties of the OASIS in a large sample (N=1036) of primary care patients whose physicians referred them to an anxiety disorders treatment study. Latent structure, internal consistency, convergent/discriminant validity, and cut-score analyses were conducted. RESULTS Exploratory and confirmatory factor analyses supported a unidimensional structure. The five OASIS items displayed strong loadings on the single factor and had a high degree of internal consistency. OASIS scores demonstrated robust correlations with global and disorder-specific measures of anxiety, and weak correlations with measures of unrelated constructs. A cut-score of 8 correctly classified 87% of this sample as having an anxiety diagnosis or not. LIMITATIONS Convergent validity measures consisted solely of other self-report measures of anxiety. Future studies should evaluate the convergence of OASIS scores with clinician-rated and behavioral measures of anxiety severity. CONCLUSIONS Overall, this investigation suggests that the OASIS is a valid instrument for measurement of anxiety severity and impairment in clinical samples. Its brevity and applicability to a wide range of anxiety disorders enhance its utility as a screening and assessment tool.

Sexual Trauma, Posttraumatic Stress Disorder, and Health Behavior

Abstract The authors tested whether sexual traumatization is associated with poorer health behavior and also evaluated the role of posttraumatic stress disorder (PTSD) in this relationship. They mailed questionnaires to 419 women who had visited a San Diego Veterans Administration primary care clinic in 1998 and received 221 responses, a 56% return rate. They found that a history of sexual assault was associated with increased substance use, risky sexual behaviors, less vigorous exercise, and increased preventive healthcare. They then used regression-based techniques to test whether PTSD mediates the relationship between a history of sexual assault and health behaviors and discovered support for this hypothesis in relation to substance use. PTSD symptoms were also associated with less likelihood of conducting regular breast self-examinations. Findings from the study highlight the value of programs designed to (1) identify trauma victims, (2) screen for problematic behaviors, and (3) intervene to improve long-term health outcomes.

Adult Psychopathology and Intimate Partner Violence among Survivors of Childhood Maltreatment

Childhood maltreatment is associated with psychopathology and revictimization in adulthood. Whether different types of childhood maltreatment have different long-term consequences, however, is largely unknown. The participants in this study included 42 female victims of intimate partner violence and 30 women with no history of serious trauma. These women completed measures of their trauma history, current psychological symptoms, and severity of current abuse. Regression-based techniques were used to assess the relationships among these constructs. Childhood maltreatment was associated with current distress and current conflict in relationships. There was a positive relationship between number of types of childhood traumatization and psychopathology. Symptoms of post-traumatic stress disorder (PTSD) and depression were negatively associated with current relationships involving physical assault. This work underscores the importance of assessing multiple types of childhood maltreatment and of considering the cumulative effects of such experiences.

Adaptive Disclosure: An Open Trial of a Novel Exposure-Based Intervention for Service Members With Combat-Related Psychological Stress Injuries

We evaluated the preliminary effectiveness of a novel intervention that was developed to address combat stress injuries in active-duty military personnel. Adaptive disclosure (AD) is relatively brief to accommodate the busy schedules of active-duty service members while training for future deployments. Further, AD takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that may not receive adequate and explicit attention by conventional treatments that primarily address fear-inducing life-threatening experiences and sequelae. In this program development and evaluation open trial, 44 marines received AD while in garrison. It was well tolerated and, despite the brief treatment duration, promoted significant reductions in PTSD, depression, negative posttraumatic appraisals, and was also associated with increases in posttraumatic growth.

Disorder-Specific Impact of Coordinated Anxiety Learning and Management Treatment for Anxiety Disorders in Primary Care

CONTEXT Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered. OBJECTIVE To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD). DESIGN A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments. SETTING Seventeen US primary care clinics. PATIENTS Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up. INTERVENTIONS CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC. MAIN OUTCOME MEASURES Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores. RESULTS CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders. CONCLUSIONS CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

Anxiety sensitivity as a predictor of labor pain.

Psychosocial factors have been implicated in the pain experience during childbirth, which can have both short‐ and long‐term consequences on the mothers health and her relationship with her infant. The present study evaluated important demographic, social, and psychological factors as predictors of multiple dimensions of labor pain among 35 mothers during childbirth. The results indicated that anxiety sensitivity (AS), as measured by the Anxiety Sensitivity Index, shared a significant relation with maximum pain during labor as well as sensory and affective components of pain as measured by the McGill Pain Questionnaire. AS predicted both maximum pain during labor and sensory aspects of pain above and beyond demographic and social factors as well as other theoretically important psychological factors (e.g., depression and state anxiety). These data replicate previous research that has demonstrated the significant impact of AS on pain responding in other areas (e.g., chronic pain) and extend knowledge in this literature to demonstrate the important role that AS serves among women and their experience of labor pain. Clinical implications are highlighted and discussed.

A consideration of select pre-trauma factors as key vulnerabilities in PTSD

Posttraumatic stress disorder (PTSD) is a pathological response to a traumatic event. A number of risk and vulnerability factors predicting PTSD development have been identified in the literature. Many of these variables are specific factors occurring during and after exposure to a traumatic event or are not measured prospectively to assess temporal sequence. Recent research, however, has begun to focus on pre-trauma individual differences that could contribute to risk for developing PTSD. The present review proposes that a number of biological and cognitive vulnerability factors place individuals at risk for PTSD development prior to the actual experience of trauma. Accordingly, this review provides a summary of evidence for a select number of these factors as pre-trauma vulnerabilities to PTSD. Included is a discussion of biological factors, including molecular genetic studies of systems regulating serotonin, catecholamines, and glucocorticoids as well as aspects of the neuroendocrine system. Specific cognitive factors are also considered, including intelligence, neuropsychological functioning and cognitive biases such as negative attributional style and appraisals. For each factor, the present review summarizes evidence to date regarding PTSD vulnerability and highlights directions for future research in this area.