Heather W. Murray

Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions.

Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.

Shared Variance Among Self-Report and Behavioral Measures of Distress Intolerance

Distress intolerance may be an important individual difference variable in understanding maladaptive coping responses across diagnostic categories. However, the measurement of distress intolerance remains inconsistent across studies and little evidence for convergent validity among existing measures is available. This study evaluated the overlap among self-report and behavioral measures of distress intolerance in four samples, including an unselected sample, a sample of patients with drug dependence, and two samples of cigarette smokers. Results suggested that the self-report measures were highly correlated, as were the behavioral measures; however, behavioral and self-report measures did not exhibit significant associations with each other. There was some evidence of domain specificity, with anxiety sensitivity demonstrating strong associations with somatic distress intolerance, and a lack of association between behavioral measures that elicit affective distress and those that elicit somatic distress. These findings highlight a potential divergence in the literature relative to the conceptualization of distress intolerance as either sensitivity to distress or as the inability to persist at a task when distressed. Further research is needed to elucidate the conceptualization and measurement of distress intolerance to facilitate future clinical and research applications of this construct.

Anxiety Sensitivity and Interoceptive Exposure: A Transdiagnostic Construct and Change Strategy

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N=54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS.

Predictors of Dropout from Psychosocial Treatment in Opioid-Dependent Outpatients

BACKGROUND AND OBJECTIVES Early dropout is common in substance abuse treatment settings and may lead to poorer outcomes relative to those completing a full course of treatment. Attempts to identify predictors of dropout have yielded mixed results, highlighting the need for additional research in this area to clarify risk and protective factors to guide intervention and retention efforts. This study evaluated predictors of dropout from psychosocial treatment among opioid-dependent patients on methadone maintenance therapy. METHODS Participants included 78 patients who had failed to respond to at least 4 months of methadone maintenance plus group counseling with clinic substance abuse counselors, and were enrolled in a study of randomized psychosocial treatment in addition to treatment-as-usual. Several factors that have been implicated in previous studies as well as two affective variables (distress intolerance and coping motives for drug use) were examined. RESULTS Results indicated that when controlling for various risk factors, age was the only significant predictor of dropout, with younger patients more likely to discontinue treatment early. CONCLUSIONS This study replicates previous findings in opioid-dependent samples that younger patients are at an increased risk of early treatment dropout. CONCLUSIONS AND SIGNIFICANCE Targeted intervention may be needed to retain young patients in drug abuse treatment.

Anxiety sensitivity and illicit sedative use among opiate-dependent women and men.

Objectives: Research has suggested that individuals with elevated anxiety sensitivity (AS) (the fear of benign bodily sensations associated with anxiety) are more likely to use substances to cope with distress, particularly substances with arousal-dampening effects such as benzodiazepines and other sedatives. Such coping motives may also vary as a function of gender, with women more likely to use substances for coping (self-medicating) purposes. Given these findings, we hypothesized that AS would be associated with illicit sedative use in an opioid-dependent sample and that gender would moderate this relationship, with a greater association among women. Method: Participants were 68 opioid-dependent patients recruited from a methadone maintenance clinic. A logistic regression was used to determine whether AS was associated with presence or absence of a history of illicit sedative use. Results: AS was significantly associated with sedative use and this relationship was moderated by gender; elevated AS was associated with greater sedative use only in women. Conclusion: The presence of elevated AS is related to greater illicit use of sedatives in women but not in men. Women may be more susceptible to seek sedatives as a means of coping with unpleasant, anxious sensations.

Personality factors associated with methadone maintenance dose.

Objectives: Methadone is the most frequently prescribed medication for the treatment of opioid dependence in the U.S., and questions relating to appropriate dosing of methadone remain an important issue. Given accumulating evidence suggesting an elevated prevalence of personality pathology in opioid dependent populations, as well as evidence of an association between Cluster B characteristics and substance use severity, we hypothesized that patients with such pathology would have elevated methadone dose prescriptions. Methods: Participants were 54 opioid dependent individuals recruited from a methadone maintenance clinic. Results: Results indicated that participants with symptoms consistent with Cluster B pathology had a significantly higher mean prescribed methadone dose relative to participants without Cluster B pathology. Conclusion: The presence of personality traits appears to influence methadone maintenance. Implications of this finding are discussed.

A Randomized, Controlled Trial of the Efficacy of an Interoceptive Exposure-Based CBT for Treatment-Refractory Outpatients with Opioid Dependence

Abstract Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.

Development and validation of the smoking cue appeal survey.

In this two-study investigation, a measure of sensory smoking cue appeal was developed and evaluated relative to smoking behavior, smoking severity, and craving. In the first study, 101 participants completed the Smoking Cue Appeal Survey (SCAS) and self-reported smoking status (current, former, or non-smoker). In the second study, 54 participants completed the SCAS and craving was measured following a cue exposure procedure. Data were collected between 2008 and 2009. The SCAS demonstrated good psychometric properties and was associated with smoking status. Additionally, craving was significantly associated with the SCAS, but there was no association with frequency of smoking or severity of nicotine dependence. Limitations include a cross-sectional design, small sample size, and focus on trait factors. Future directions are discussed.

Psychometric Analysis of the Perceptions of Computerized Therapy Questionnaire-Patient Version (PCTQ-P)

Dissemination and implementation science (DIS) in psychology is a growing area of research, with the potential to increase access to evidence based care. However, the field is characterized by a paucity of validated measures of DIS constructs. The present study aimed to fill this gap in the literature by examining the psychometric properties of the Perceptions of Computerized Therapy Questionnaire-Patient Version (PCTQ-P), a self-report questionnaire for potential consumers based on Diffusion of Innovations theory. Undergraduate students participated in this two-study design, and were instructed to complete a battery of self-report measures, including the PCTQ-P. Internal consistency reliability, retest reliability, and discriminant validity were evaluated. Results provide evidence that the PCTQ-P is a psychometrically sound instrument for assessing potential consumers’ perceptions of computer-based psychological treatments that are distinct from general help-seeking attitudes. With slight adaptation, the PCTQ-P can be used to examine other therapeutic modalities. Potential applications of the measure are discussed.

Avoiding Treatment Failures in Panic Disorder

Panic disorder (PD) is characterized by recurrent panic attacks accompanied by worry about future attacks, worry about the consequences of the attacks (e.g., having a heart attack), or substantial behavioral changes in response to the attacks (American Psychiatric Association, 1994).Panic attacks themselves are distinct periods of intense fear accompanied by four or more physical symptoms which begin suddenly and reach a peak of intensity within 10 min.Panic attacks are ubiquitous to a wide range of anxiety disorders, but in PD the focus of the phobic concern is on the anxiety symptoms themselves and the feared consequences of these symptoms