Donald J. Robinaugh

Mental Disorders as Causal Systems: A Network Approach to Posttraumatic Stress Disorder

Debates about posttraumatic stress disorder (PTSD) often turn on whether it is a timeless, cross-culturally valid natural phenomenon or a socially constructed idiom of distress. Most clinicians seem to favor the first view, differing only in whether they conceptualize PTSD as a discrete category or the upper end of a dimension of stress responsiveness. Yet both categorical and dimensional construals presuppose that PTSD symptoms are fallible indicators reflective of an underlying, latent variable. This presupposition has governed psychopathology research for decades, but it rests on problematic psychometric premises. In this article, we review an alternative, network perspective for conceptualizing mental disorders as causal systems of interacting symptoms, and we illustrate this perspective via analyses of PTSD symptoms reported by survivors of the Wenchuan earthquake in China. Finally, we foreshadow emerging computational methods that may disclose the causal structure of mental disorders.

Randomized Controlled Trial of Mindfulness Meditation for Generalized Anxiety Disorder: Effects on Anxiety and Stress Reactivity

OBJECTIVE Mindfulness meditation has met increasing interest as a therapeutic strategy for anxiety disorders, but prior studies have been limited by methodological concerns, including a lack of an active comparison group. This is the first randomized, controlled trial comparing the manualized Mindfulness-Based Stress Reduction (MBSR) program with an active control for generalized anxiety disorder (GAD), a disorder characterized by chronic worry and physiologic hyperarousal symptoms. METHOD Ninety-three individuals with DSM-IV-diagnosed GAD were randomly assigned to an 8-week group intervention with MBSR or to an attention control, Stress Management Education (SME), between 2009 and 2011. Anxiety symptoms were measured with the Hamilton Anxiety Rating Scale (HAMA; primary outcome measure), the Clinical Global Impressions-Severity of Illness and -Improvement scales (CGI-S and CGI-I), and the Beck Anxiety Inventory (BAI). Stress reactivity was assessed by comparing anxiety and distress during pretreatment and posttreatment administration of the Trier Social Stress Test (TSST). RESULTS A modified intent-to-treat analysis including participants who completed at least 1 session of MBSR (n = 48) or SME (n = 41) showed that both interventions led to significant (P < .0001) reductions in HAMA scores at endpoint, but did not significantly differ. MBSR, however, was associated with a significantly greater reduction in anxiety as measured by the CGI-S, the CGI-I, and the BAI (all P values < .05). MBSR was also associated with greater reductions than SME in anxiety and distress ratings in response to the TSST stress challenge (P < .05) and a greater increase in positive self-statements (P = .004). CONCLUSIONS These results suggest that MBSR may have a beneficial effect on anxiety symptoms in GAD and may also improve stress reactivity and coping as measured in a laboratory stress challenge. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01033851.

Autobiographical memory for shame or guilt provoking events: Association with psychological symptoms

The diagnostic criteria for posttraumatic stress disorder (PTSD) specify that a qualifying traumatic stressor must incite extreme peritraumatic fear, horror, or helplessness. However, research suggests that events inciting guilt or shame may be associated with PTSD. We devised a web-based survey in which non-clinical participants identified an event associated with shame or guilt and completed questionnaire measures of shame, guilt, PTSD, and depression. In addition, we assessed characteristics of memory for the event, including visual perspective and the centrality of the memory to the participants autobiographical narrative (CES). Shame predicted depression and PTSD symptoms. There was no association between guilt and psychological symptoms after controlling statistically for the effects of shame. CES predicted the severity of depression and PTSD symptoms. In addition, CES mediated the moderating effect of visual perspective on the relationship between emotional intensity and PTSD symptoms. Our results suggest shame is capable of eliciting the intrusive and distressing memories characteristic of PTSD. Furthermore, our results suggest aversive emotional events are associated with psychological distress when memory for those events becomes central to ones identity and autobiographical narrative.

Network analysis of persistent complex bereavement disorder in conjugally bereaved adults.

Persistent complex bereavement disorder (PCBD) is a bereavement-specific syndrome characterized by prolonged and impairing grief. Most research on this syndrome rests on the traditional latent variable model, whereby symptoms reflect an underlying entity. The network (or causal system) approach offers an alternative framework for understanding PCBD that does not suffer from limitations inherent in the latent entity approach. The network approach to psychopathology conceptualizes the relation between symptoms and disorder as mereological, not reflective. That is, symptoms do not reflect an inferred, unobservable category or dimension, but rather are themselves constitutive of the disorder. Accordingly, we propose that PCBD constitutes a causal system of mutually reinforcing symptoms that arise following the death of a loved one and settle into a pathological equilibrium. In this study, we used data from the Changing Lives of Older Couples database to identify symptoms central to PCBD, to distinguish the PCBD network from an overlapping but distinct network of depression symptoms, and to examine how previously identified risk factors may contribute to the maintenance or development of PCBD. Together, these findings provide an important first step toward understanding the nature and etiology of the PCBD network.

Trauma Centrality and PTSD Symptom Severity in Adult Survivors of Childhood Sexual Abuse

Theorists have posited that regarding a trauma as central to ones identity leads to greater posttraumatic stress disorder (PTSD) symptom severity. To test this hypothesis, we administered the Centrality of Events Scale (CES) to women reporting a history of childhood sexual abuse (N = 102). The CES scores were correlated with PTSD symptom severity, depression severity, and self-esteem. In addition, we conducted a principal component analysis (PCA) to evaluate factors underlying the CES. The PCA yielded 3 factors reflecting (a) the centrality and integration of the trauma, (b) whether the event is regarded as a turning point in ones life story, and (c) whether the event is a reference point for expectations about the future. Each factor was associated with PTSD symptom severity.

Understanding the relationship of perceived social support to post-trauma cognitions and posttraumatic stress disorder.

Poor social support in the aftermath of a traumatic event is a well-established risk factor for posttraumatic stress disorder (PTSD) among adult trauma survivors. Yet, a great deal about the relationship between social support and PTSD remains poorly understood. In this study, we analyzed data from 102 survivors of a serious motor vehicle accident (MVA) at 4 weeks (Time 1) and 16 weeks (Time 2) post-MVA. We assessed the role of perceived dyadic social support, positive dyadic interaction, and negative dyadic interaction in the development and maintenance of PTSD. In addition, we examined how these social support constructs work together with negative post-trauma cognitions to affect the maintenance of PTSD. Neither perceived social support nor the quality of social interaction (i.e., positive or negative) was associated with PTSD symptom severity at Time 1. However, among those with elevated PTSD symptom severity at Time 1, greater social support and positive social interaction and lower negative social interaction were each associated with reductions in PTSD symptom severity from Time 1 to Time 2. For social support and negative social interaction, this association ceased to be significant when jointly assessed with negative post-trauma cognitions, suggesting that perceived social support and negative dyadic interaction were associated with maintenance of PTSD symptom severity because of their association with negative post-trauma cognitions. These results provide support to models and treatments of PTSD that emphasize the role of negative post-trauma cognitions in maintenance of PTSD.

Cross-cultural variations in the prevalence and presentation of anxiety disorders

Considerable cross-cultural variation exists in the prevalence and presentation of the anxiety disorders as defined by the fourth edition of the Diagnostic and Statistical Manual. Researchers debate whether this variation represents cultural differences in the phenomenology of universal disorders or the existence of unique culturally constructed disorders. This article reviews recent literature on the prevalence and presentation of five anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, specific phobia and post-traumatic stress disorder, both across countries and within the USA. This article indicates that certain anxiety disorders (e.g., generalized anxiety disorder and panic disorder) may vary greatly in rate across cultural groups. It indicates that the clinical presentation of anxiety disorders, with respect to symptom presentation and the interpretation of symptoms, varies across cultures. A difference in catastrophic cognitions about anxiety symptoms across cultures is hypothesized to be a key aspect of cross-cultural variation in the anxiety disorders. Future research directions are suggested.

Usefulness of a run-in period to reduce drop-outs in a randomized controlled trial of a behavioral intervention

OBJECTIVES We evaluated the usefulness of a simple run-in period to reduce drop-outs in a behavioral intervention to improve blood pressure (BP). In a pilot study where a run-in period was not used, we had a 25% drop-out rate. METHODS A prospective evaluation was performed in the context of a blinded 3-arm randomized trial. Participants are eligible if they have uncontrolled BP on 2 consecutive visits. Potential participants are approached during a routine visit, informed, consented and enrolled. After a 1-month run-in period during which all participants receive a phone call to: i) verify phone availability, ii) get basic information on treatment, and iii) confirm the baseline visit, participants return for a baseline visit. They are then randomized to one of the three treatment arms: usual care, non-tailored counseling, or tailored counseling. Participants make return visits at 3, 6 and 12 months. RESULTS Of the 1275 potential participants who received detailed study information, 301 consented to participate, of whom 226 were enrolled. During the run-in period, 73 withdrew consent and 153 participants were randomized; 7 subsequently dropped out. There were no differences (p>.1) between the 73 cancelled and the 153 randomized patients. There were fewer drop-outs than in the pilot study (5% vs. 25%, p<.0001). CONCLUSIONS The run-in period reduces the number of drop-outs after randomization and improves statistical power. In order to retain external validity, it is important to compare participants who remain in the study and those that cancel, and incorporate that in generalizing from the study.

Does attachment avoidance help people cope with loss? The moderating effects of relationship quality.

Previous research has been inconsistent about the role of attachment avoidance in coping with loss. The present study sought to resolve this issue by examining the potential moderating role of relationship quality with the deceased. The authors used longitudinal data on bereaved spouses (N=50) collected at 4 and 18 months postloss. Three-way effects emerged among attachment avoidance, attachment anxiety, and marital quality in the prediction of complicated grief (CG) symptoms at 18 months, controlling for 4-month symptoms. Findings indicated that, in the context of high but not low marital quality, persons with a dismissingly avoidant attachment style (high avoidance, low anxiety) experienced marked reductions in CG symptoms from 4 to 18 months. Findings clarify the role of attachment avoidance in coping with loss and underscore that relationship quality is a critical factor in the attachment-grief relationship.

Remembering the Past and Envisioning the Future in Bereaved Adults With and Without Complicated Grief

Complicated grief (CG) is associated with impairment in the ability to retrieve specific autobiographical memories. However, previous research suggests that this impairment may not occur for memories related to the deceased. We recruited conjugally bereaved adults and assessed autobiographical memory specificity for events with and without the deceased. In addition, we examined the specificity of imagined future events both with the deceased and without. Individuals with CG were no less specific than were bereaved comparison subjects when generating events that included the deceased. However, they did exhibit difficulty recalling specific past events and imagining specific future events that did not include the deceased. Difficulty generating events without the deceased may underlie the sense of lost identity and hopelessness observed in CG. Relative ease of envisioning a counterfactual future with the deceased may provide the cognitive basis for yearning. Accordingly, memory and prospection may be important targets for CG treatments.