Michael J. Gawrysiak

Brief Behavioral Activation and Problem-Solving Therapy for Depressed Breast Cancer Patients: Randomized Trial

OBJECTIVE Major depression is the most common psychiatric disorder among breast cancer patients and is associated with substantial impairment. Although some research has explored the utility of psychotherapy with breast cancer patients, only 2 small trials have investigated the potential benefits of behavior therapy among patients with well-diagnosed depression. METHOD In a primarily Caucasian, well-educated sample of women (age = 55.4 years, SD = 11.9) diagnosed with breast cancer and major depression (n = 80), this study was a randomized clinical trial testing the efficacy of 8 sessions of behavioral activation treatment for depression (BATD) compared to problem-solving therapy. Primary outcome measures assessed depression, environmental reward, anxiety, quality of life, social support, and medical outcomes. RESULTS Across both treatments, results revealed strong treatment integrity, excellent patient satisfaction with treatment protocols, and low patient attrition (19%). Intent-to-treat analyses suggested both treatments were efficacious, with both evidencing significant pre-post treatment gains across all outcome measures. Across both treatments, gains were associated with strong effect sizes, and based on response and remission criteria, a reliable change index, and numbers-needed-to-treat analyses, approximately ¾ of patients exhibited clinically significant improvement. No significant group differences were found at posttreatment. Treatment gains were maintained at 12-month follow-up, with some support for stronger maintenance of gains in the BATD group. CONCLUSIONS BATD and problem-solving interventions represent practical interventions that may improve psychological outcomes and quality of life among depressed breast cancer patients. Study limitations and future research directions are discussed.

The reward probability index: design and validation of a scale measuring access to environmental reward.

Behavioral models of depression implicate decreased response-contingent positive reinforcement (RCPR) as critical toward the development and maintenance of depression (Lewinsohn, 1974). Given the absence of a psychometrically sound self-report measure of RCPR, the Reward Probability Index (RPI) was developed to measure access to environmental reward and to approximate actual RCPR. In Study 1 (n=269), exploratory factor analysis supported a 20-item two-factor model (Reward Probability, Environmental Suppressors) with strong internal consistency (α=.90). In Study 2 (n=281), confirmatory factor analysis supported this two-factor structure and convergent validity was established through strong correlations between the RPI and measures of activity, avoidance, reinforcement, and depression (r=.65 to .81). Discriminant validity was supported via smaller correlations between the RPI and measures of social support and somatic anxiety (r=-.29 to -.40). Two-week test-retest reliability was strong (r=.69). In Study 3 (n=33), controlling for depression symptoms, hierarchical regression supported the incremental validity of the RPI in predicting daily diary reports of environmental reward. The RPI represents a parsimonious, reliable, and valid measure that may facilitate understanding of the etiology of depression and its relationship to overt behaviors.

Outcomes of Prolonged Exposure Therapy for Veterans With Posttraumatic Stress Disorder

Prolonged Exposure (PE) is an evidenced-based psychotherapy for posttraumatic stress disorder (PTSD) that is being disseminated nationally within the U.S. Department of Veterans Affairs (VA) with promising initial results. Empirical evidence, however, regarding the effectiveness of PE for treatment of PTSD in military veterans is limited. Building on previous treatment outcome research, the current study investigated the effectiveness of PE in a diverse veteran sample. One-hundred fifteen veterans were enrolled in PE at an urban VA medical center and its surrounding outpatient clinics. PTSD and depression symptoms as well as quality of life were measured before and after treatment. Several baseline patient characteristics were examined as predictors of treatment response. Eighty-four participants completed treatment. Participants experienced a 42% reduction in PTSD symptoms, a 31% reduction in depression symptoms, and an increase in quality of life following PE. Veterans not prescribed psychotropic medication reported greater PTSD symptom reduction than veterans prescribed such medication. The implications of these results for treatment programs targeting PTSD in veterans are discussed.

Dimensions of distress tolerance and the moderating effects on mindfulness-based stress reduction

ABSTRACT Background and Objectives: This study examined the relationship between distress tolerance and psychosocial changes among individuals participating in Mindfulness-Based Stress Reduction (MBSR). The objective of the analysis was to discern whether individuals with lower distress tolerance measured before MBSR showed larger reductions in perceived stress following MBSR. Design and Methods: Data were collected from a sample of convenience (n = 372) using a quasi-experimental design. Participants completed self-report measures immediately prior to course enrollment and following course completion. Results: Perceived stress, distress tolerance, and mood states showed favorable changes from pre- to post-MBSR in the current study. Baseline distress tolerance significantly moderated reductions on perceived stress, supporting the primary hypothesis that individuals with lower baseline distress tolerance evidenced a greater decline in perceived stress following MBSR. For a one-unit increase on the self-reported baseline Distress Tolerance Scale, reported perceived stress scores decreased by 2.5 units (p < .0001). Conclusions: The finding that individuals with lower baseline distress tolerance evidenced a greater decline in perceived stress may offer hints about who is most likely to benefit from MBSR and other mindfulness-based treatments. Identifying moderators of treatment outcomes may yield important benefits in matching individuals to treatments that are most likely to work for them.

Emotional, physical and sexual abuse are associated with a heightened limbic response to cocaine cues

Drug‐reward cues trigger motivational circuitry, a response linked to drug‐seeking in animals and in humans. Adverse life events have been reported to increase sensitivity to drug rewards and to bolster drug reward signaling. Therefore, we hypothesized that cocaine‐dependent individuals with prior emotional, physical and sexual abuse might have a heightened mesolimbic brain response to cues for drug reward in a new brief‐cue probe. Cocaine‐dependent human individuals (N = 68) were stabilized in an inpatient setting and then completed an event‐related blood‐oxygen‐level dependent functional magnetic resonance imaging task featuring 500‐ms evocative (cocaine, sexual, aversive) and comparator (neutral) cues. Responses to three questions about emotional, physical and sexual abuse from the Addiction Severity Index were used to divide the patients into subgroups (history of Abuse [n = 40] versus No Abuse [n = 28]). When subjects were grouped by the historical presence or absence of emotional, physical or sexual abuse, the Abuse group showed a heightened midbrain, thalamic, caudate, and caudal orbitofrontal cortex response to cocaine cues; a similar result was found in other evocative cues, as well. These findings are the first reported for a 500‐ms cocaine‐cue probe, and they highlight the ability of very brief evocative cues to activate the brains motivational circuitry. Although all participants had severe cocaine use disorders, individuals reporting prior abuse had a heightened mesolimbic response to evocative cues. To our knowledge, this is the first study in humans linking a history of abuse to a brain vulnerability (heightened mesolimbic response to drug cues) previously shown to contribute to drug‐seeking.

Neural Changes following Behavioral Activation for a Depressed Breast Cancer Patient: A Functional MRI Case Study

Functional neuroimaging is an innovative but at this stage underutilized method to assess the efficacy of psychotherapy for depression. Functional magnetic resonance imaging (fMRI) was used in this case study to examine changes in brain activity in a depressed breast cancer patient receiving an 8-session Behavioral Activation Treatment for Depression (BATD), based on the work of Hopko and Lejuez (2007). A music listening paradigm was used during fMRI brain scans to assess reward responsiveness at pre- and posttreatment. Following treatment, the patient exhibited attenuated depression and changes in blood oxygenation level dependence (BOLD) response in regions of the prefrontal cortex and the subgenual cingulate cortex. These preliminary findings outline a novel means to assess psychotherapy efficacy and suggest that BATD elicits functional brain changes in areas implicated in the pathophysiology of depression. Further research is necessary to explore neurobiological mechanisms of change in BATD, particularly the potential mediating effects of reward responsiveness and associated brain functioning.

Multi-site exploration of sex differences in brain reactivity to smoking cues: Consensus across sites and methodologies

BACKGROUND Biological sex influences cigarette smoking behavior. More men than women smoke, but women have a harder time quitting. Sex differences in smoking cue (SC) reactivity may underlie such behavioral differences. However, the influence of sex on brain reactivity to SCs has yielded inconsistent findings suggesting the need for continued study. Here, we investigated the effect of sex on SC reactivity across two sites using different imaging modalities and SC stimulus types. METHODS Pseudo-continuous arterial spin-labeled (pCASL) perfusion functional magnetic resonance imaging (fMRI) was used to assess brain responses to SC versus non-SC videos in 40 smokers (23 females) at the University of Pennsylvania. BOLD fMRI was used to assess brain responses to SC versus non-SC still images in 32 smokers (18 females) at McLean Hospital. Brain reactivity to SCs was compared between men and women and was correlated with SC-induced craving. RESULTS In both cohorts, males showed higher SC versus non-SC reactivity compared to females in reward-related brain regions (i.e., ventral striatum/ventral pallidum, ventral medial prefrontal cortex). Brain activation during SC versus non-SC exposure correlated positively with SC-induced subjective craving in males, but not females. CONCLUSIONS The current work provides much needed replication and validation of sex differences in SC-reactivity. These findings also add to a body of literature showing that men have greater reward-related brain activation to drug cues across drug classes. Such sex differences confirm the need to consider sex not only when evaluating SC-reactivity but when examining nicotine dependence etiology and treatment.

The relationship between dispositional mindfulness, borderline personality features, and suicidal ideation in a sample of women in residential substance use treatment

Borderline personality disorder (BPD), which is characterized by unstable moods, behavior, and relationships, is also associated with heightened suicidal ideation. Prior research has demonstrated that BPD and suicidal ideation are prevalent among women in substance use treatment. Efforts to treat substance use in this population are made difficult due to the severity of BPD, and it is possible that mindfulness-based interventions specific to substance use could be an effective approach for this population. However, basic research is needed on the relationship between dispositional mindfulness, BPD, and suicidal ideation among women in treatment for substance use to support their associations, which was the purpose of the present study. Pre-existing medical records were reviewed from a residential substance use treatment center. A total of 81 female patients were included in the current study. Patients completed self-report measures of mindfulness, BPD, suicidal ideation, substance use, and impression management at treatment intake. Findings demonstrated dispositional mindfulness to be negatively associated with BPD features and suicidal ideation. With the exception of self-harm, this negative relationship was found even after controlling for age, substance use, and impression management. Future research should examine whether mindfulness-based interventions are an effective treatment for comorbid substance use and BPD.

Functional neuroimaging of personally-relevant stimuli in a paediatric case of impaired awareness

Abstract Background: Functional neuroimaging studies have observed preserved neural activation to personally relevant stimuli in patients within the disorders of consciousness (DOC) spectrum. As the majority of studies have focused on adult DOC patients, little is known about preserved activation in the developing brain of children with impaired consciousness. Case study: The aim of this study is to use fMRI to measure preserved neural activation to personally relevant stimuli (subject’s own name and familiar voice) in a paediatric patient who sustained a traumatic brain injury and anoxic-ischaemia following a motor vehicle accident at 18 months of age rendering her probable for minimally conscious state. Contrasts revealed activation in the right middle frontal gyrus when hearing the subject’s own name and the anterior supramarginal gyrus when hearing a familiar voice. Conclusion: This study provides preliminary support for fMRI as a method to measure preserved cognitive functioning in paediatric DOC patients.

A Randomized Controlled Trial of a Mindfulness and Acceptance Group Therapy for Residential Substance Use Patients

ABSTRACT Background: Substance use disorders are understood as a chronically relapsing condition that is difficult to treat. However, in recent years there have been promising developments in the treatment of substance use disorders, specifically with interventions based on mindfulness and acceptance and commitment therapy. Little research has examined whether these types of interventions may positively impact residential substance use treatment outcomes. Objectives: Thus, in the current study we developed and examined, in a randomized controlled trial, a 4-week, eight-session, adjunctive mindfulness and acceptance group therapy for patients in residential substance use treatment. Our primary outcomes were substance use cravings, psychological flexibility, and dispositional mindfulness at treatment discharge. Methods: Patients (N = 117) from a private residential substance use facility were randomized to receive the adjunctive mindfulness and acceptance group or treatment-as-usual. Patients were assessed at treatment intake and at discharge from a 28–30-day residential program. Results: Although treatment groups did not statistically differ at discharge on any primary outcome, small effect sizes favored the mindfulness and acceptance group on cravings and psychological flexibility. Conclusions/Importance: Continued research is needed to determine whether the addition of mindfulness and acceptance-based interventions improve outcomes long term following residential substance use treatment.