Showing papers by "Michelle G. Craske published in 2013"

Fear Extinction and Relapse: State of the Art

Abstract: Exposure-based treatments for clinical anxiety generally are very effective, but relapse is not uncommon. Likewise, laboratory studies have shown that conditioned fears are easy to extinguish, but they recover easily. This analogy is striking, and numerous fear extinction studies have been published that highlight the processes responsible for the extinction and return of acquired fears. This review examines and integrates the most important results from animal and human work. Overall, the results suggest that fear extinction is relatively easy to “learn” but difficult to “remember.” It follows that treatments will benefit from an enhanced focus on the long-term retrieval of fear extinction. We review the available studies on the prevention of return of fear and the prospects of weakening fear memories forever. We show that the behavioral principles outlined in learning theory provide a continuous inspiration for preclinical (neurobiological) and clinical research on the extinction and return of fear.

The cortisol awakening response predicts major depression: predictive stability over a 4-year follow-up and effect of depression history.

Abstract: BackgroundThe cortisol awakening response (CAR) has been shown to predict major depressive episodes (MDEs) over a 1-year period. It is unknown whether this effect: (a) is stable over longer periods of time; (b) is independent of prospective stressful life events; and (c) differentially predicts first onsets or recurrences of MDEs.MethodA total of 270 older adolescents (mean age 17.06 years at cortisol measurement) from the larger prospective Northwestern-UCLA Youth Emotion Project completed baseline diagnostic and life stress interviews, questionnaires, and a 3-day cortisol sampling protocol measuring the CAR and diurnal rhythm, as well as up to four annual follow-up interviews of diagnoses and life stress.ResultsNon-proportional person-month survival analyses revealed that higher levels of the baseline CAR significantly predict MDEs for 2.5 years following cortisol measurement. However, the strength of prediction of depressive episodes significantly decays over time, with the CAR no longer significantly predicting MDEs after 2.5 years. Elevations in the CAR did not significantly increase vulnerability to prospective major stressful life events. They did, however, predict MDE recurrences more strongly than first onsets.ConclusionsThese results suggest that a high CAR represents a time-limited risk factor for onsets of MDEs, which increases risk for depression independently of future major stressful life events. Possible explanations for the stronger effect of the CAR for predicting MDE recurrences than first onsets are discussed.

Are flatter diurnal cortisol rhythms associated with major depression and anxiety disorders in late adolescence? The role of life stress and daily negative emotion.

Abstract: Alterations in hypothalamic-pituitary-adrenal (HPA) axis functioning have been associated with major depression disorder (MDD) and some anxiety disorders Few researchers have tested the possibility that high levels of recent life stress or elevations in negative emotion may partially account for the HPA axis alterations observed in these disorders In a sample of 300 adolescents from the Youth Emotion Project, we examined associations between MDD and anxiety disorders, dimensional measures of internalizing symptomatology, life stress, mood on the days of cortisol testing, and HPA axis functioning Adolescents with a past MDD episode and those with a recent MDD episode comorbid with an anxiety disorder had flatter diurnal cortisol slopes than adolescents without a history of internalizing disorders Higher reports of general distress, a dimension of internalizing symptomatology, were also associated with flatter slopes Negative emotion, specifically sadness and loneliness, was associated with flatter slopes and partially accounted for the associations between comorbid MDD and anxiety disorders and cortisol The associations between past MDD and cortisol slopes were not accounted for by negative emotion, dimensional variation in internalizing symptomatology, or levels of life stress, indicating that flatter cortisol slopes may also be a "scar" marker of past experiences of MDD

Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement.

Abstract: Objective The present study explored treatment dose and patient engagement as predictors of treatment outcome in cognitive behavioral therapy (CBT) for anxiety disorders. Method Measures of high versus low treatment dose and high versus low patient engagement in CBT were compared as predictors of 12- and 18-month outcomes for patients being treated for anxiety disorders with CBT (with or without concurrent pharmacotherapy) in primary care settings as part of a randomized controlled effectiveness trial of the Coordinated Anxiety Learning and Management (CALM) intervention. Measures of dose (attendance, exposure completion) and engagement in CBT (homework adherence, commitment) were collected throughout treatment, and blinded follow-up phone assessments of outcome measures (12-item Brief Symptom Inventory, Patient Health Questionnaire 8, Sheehan Disability Scale) were completed at 12 and 18 months. Propensity score weighting controlled for baseline differences in demographics and symptom severity between patients with high and low dose and engagement. These analyses included the 439 patients who selected CBT as treatment modality. Results Completing exposures, having high attendance, and being more adherent to completing homework predicted better outcomes across all measures at 12 and 18 months, and high CBT commitment predicted better outcomes on all measures at 18 months. Conclusions This study found that higher treatment dose and patient engagement in CBT for anxiety disorders were stable and robust predictors of greater reductions in anxiety symptoms, depression symptoms, and functional disability.

Panic Disorder and Agoraphobia

Abstract: Panic disorder is characterized by recurrent and unexpected panic attacks. Agoraphobia is defined as a marked fear or anxiety about actual and anticipated exposures to public spaces when the person believes that escape might be difficult or help might not be available if the person develops panic-like symptoms or other distressing signs or symptoms. A number of biological and psychological models of the disorders have been proposed. A prominent biological model, the suffocation alarm hypothesis, assumes that panic disorder is the result of a pathologically low threshold for firing of a suffocation alarm. The two most prominent psychological models are the cognitive model and the anxiety sensitivity model. Cognitive restructuring, interoceptive exposure practices, and in-vivo situational exposure exercises all seem to be important components for cognitive behavioral therapy of panic disorder and agoraphobia. The treatment is usually delivered in 12 weekly 60-minute individual sessions. The efficacy of this treatment protocol is well documented. Controlled studies show that this intervention is more effective than relaxation techniques and at least as effective as alprazolam or imipramine.

Who Gets the Most Out of Cognitive Behavioral Therapy for Anxiety Disorders

Abstract: OBJECTIVE The present study explored treatment dose and patient engagement as predictors of treatment outcome in cognitive behavioral therapy (CBT) for anxiety disorders. METHOD Measures of high versus low treatment dose and high versus low patient engagement in CBT were compared as predictors of 12- and 18-month outcomes for patients being treated for anxiety disorders with CBT (with or without concurrent pharmacotherapy) in primary care settings as part of a randomized controlled effectiveness trial of the Coordinated Anxiety Learning and Management (CALM) intervention. Measures of dose (attendance, exposure completion) and engagement in CBT (homework adherence, commitment) were collected throughout treatment, and blinded follow-up phone assessments of outcome measures (12-item Brief Symptom Inventory, Patient Health Questionnaire 8, Sheehan Disability Scale) were completed at 12 and 18 months. Propensity score weighting controlled for baseline differences in demographics and symptom severity between patients with high and low dose and engagement. These analyses included the 439 patients who selected CBT as treatment modality. RESULTS Completing exposures, having high attendance, and being more adherent to completing homework predicted better outcomes across all measures at 12 and 18 months, and high CBT commitment predicted better outcomes on all measures at 18 months. CONCLUSIONS This study found that higher treatment dose and patient engagement in CBT for anxiety disorders were stable and robust predictors of greater reductions in anxiety symptoms, depression symptoms, and functional disability.

Homework Compliance Counts in Cognitive-Behavioral Therapy

Abstract: Background: Prior research has demonstrated that there is some association between treatment engagement and treatment outcome in behavioral therapy for anxiety disorders However, many of these investigations have been limited by weak measurement of treatment engagement variables, failure to control for potentially important baseline variables, and failure to consider various treatment engagement variables simultaneously The purpose of the present study is to examine the relationship between two treatment engagement variables (treatment expectancy and homework compliance) and the extent to which they predict improvement from cognitive-behavioral therapy (CBT) for anxiety disorders Methods: 84 adults with a DSM-IV-defined principal anxiety disorder took part in up to 12 sessions of CBT or acceptance and commitment therapy Pre- and post-treatment disorder severity was assessed using clinical severity ratings from a semi-structured diagnostic interview Participants made ratings of treatment expectancy af

Generalized Anxiety Disorder

Abstract: Therapists and clinical scientists involved in the study, assessment, and treatment of generalized anxiety disorder (GAD) undoubtedly encounter individuals preoccupied with intense and pervasive worry and anxiety. Whereas worry is a universal experience, common in both nonpathological and anxious populations, individuals with GAD stand apart, as their worry is more pervasive and less controllable, thereby engendering greater distress and life interference. Typically describing themselves as lifelong worriers, these individuals perceive their worrisome thinking and associated anxiety as facets of their personality, enduring traits rather than phenomena prone to fluctuations that can be monitored, targeted, and effectively changed. In fact, worry may be viewed as such a central part of life, a primary coping strategy used to avoid perceived threat and changes in emotional reactivity, that treatment may not even be considered (Newman, Crits-Christoph, & Szkodny, in press). GAD has been referred to as the “basic” anxiety disorder (Brown, Barlow, & Liebowitz, 1994), an appellation that suggests understanding the development and maintenance of GAD is important for understanding all anxiety disorders. Given GAD’s course and documented resistance to change, research has centered not only on elucidating the nature and etiology of this disorder, but also on developing treatments that improve upon standard versions of cognitive behavioral therapy (CBT). This has been most critical since worry is a means to avoid anticipated threats, as opposed to tangible, anxiety-provoking stimuli, and thus is not as easily addressed with exposure interventions commonly executed in the treatment of other anxiety disorders (Newman & Borkovec, 2002). The principal objective of this chapter is to present an overview of CBT for GAD. First, the symptomatology of GAD is discussed, followed by a presentation of the cognitive behavioral treatment rationale and CBT techniques. Additionally, empirical evidence supporting the efficacy of CBT for GAD

Web-based therapist training on cognitive behavior therapy for anxiety disorders: a pilot study.

Abstract: The need for clinicians to use evidence-based practices (such as cognitive behavior therapy [CBT]) is now well recognized. However, a gap exists between the need for empirically based treatments and their availability. This is due, in part, to a shortage of clinicians formally trained on CBT. To address this problem, we developed a Web-based therapist CBT training program, to increase accessibility to this training. The program uses a two-step approach: an interactive multimedia online tutorial for didactic training on CBT concepts, followed by live remote observation through a videoconference of trainees conducting CBT, with immediate feedback in real time during critical moments to enhance learning through iterative guidance and practice. Thirty-nine clinicians from around the county completed the online didactic training and 22 completed the live remote training. Results found a significant increase in knowledge of CBT concepts and a significant increase in clinical skills, as judged by a blind rater. User satisfaction was high for both the online tutorial and the videoconference training. Utilization of CBT by trainees increased after training. Results support the acceptability and effectiveness of this Web-based approach to training.

Age differences in treatment response to a collaborative care intervention for anxiety disorders

Abstract: Background Some data suggest that older adults with anxiety disorders do not respond as well to treatment as do younger adults. Aims We examined age differences in outcomes from the Coordinated Anxiety Learning and Management (CALM) study, an effectiveness trial comparing usual care to a computer-assisted collaborative care intervention for primary care patients with panic disorder, generalised anxiety disorder, post-traumatic stress disorder (PTSD), and/or social anxiety disorder. This is the first study to examine the efficacy of a collaborative care intervention in a sample that included both younger and older adults with anxiety disorders. We hypothesised that older adults would show a poorer response to the intervention than younger adults. Method We examined findings for the overall sample, as well as within each diagnostic category ([clinicaltrials.gov][1] identifier: [NCT00347269][2]). Results The CALM intervention was more effective than usual care among younger adults overall and for those with generalised anxiety disorder, panic disorder and social anxiety disorder. Among older adults, the intervention was effective overall and for those with social anxiety disorder and PTSD but not for those with panic disorder or generalised anxiety disorder. The effects of the intervention also appeared to erode by the 18-month follow-up, and there were no significant effects on remission among the older adults. Conclusions These results are consistent with the findings of other investigators suggesting that medications and psychotherapy for anxiety disorders may not be as effective for older individuals as they are for younger people. [1]: http://clinicaltrials.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00347269&atom=%2Fbjprcpsych%2F203%2F1%2F65.atom

Postpartum GAD is a risk factor for postpartum MDD: the course and longitudinal relationships of postpartum GAD and MDD.

Abstract: Background: The objective was to examine the course and longitudinal associations of generalized anxiety disorder (GAD) and major depressive disorder (MDD) in mothers over the postpartum 2 years. Method: Using a prospective naturalistic design, 296 mothers recruited from a large community pool were assessed for GAD and MDD at 3, 6, 10, 14, and 24 months postpartum. Structured clinical interviews were used for diagnoses, and symptoms were assessed using self-report questionnaires. Logistic regression analyses were used to examine diagnostic stability and longitudinal relations, and latent variable modeling was employed to examine change in symptoms. Results: MDD without co-occurring GAD, GAD without co-occurring MDD, and co-occurring GAD and MDD, displayed significant stability during the postpartum period. Whereas MDD did not predict subsequent GAD, GAD predicted subsequent MDD (in the form of GAD + MDD). Those with GAD + MDD at 3 months postpartum were significantly less likely to be diagnosis free during the follow-up period than those in other diagnostic categories. At the symptom level, symptoms of GAD were more trait-like than those of depression. Conclusions: Postpartum GAD and MDD are relatively stable conditions, and GAD is a risk factor for MDD but not vice versa. Given the tendency of MDD and GAD to be persistent, especially when comorbid, and the increased risk for MDD in mothers with GAD, as well as the potential negative effects of cumulative exposure to maternal depression and anxiety on child development, the present findings clearly highlight the need for screening and treatment of GAD in addition to MDD during the postpartum period. Depression and Anxiety 30:506–514, 2013. C � 2013 Wiley Periodicals, Inc.

Suicidal ideation and risk factors in primary care patients with anxiety disorders

Abstract: The presence of an anxiety disorder is associated with greater frequency of suicidal thoughts and behaviors. Given the high personal and societal costs of suicidal behaviors, suicide prevention is a priority. Understanding factors present within individuals with anxiety disorders that increase suicide risk may inform prevention efforts. The aims of the present study were to examine the prevalence of suicidal ideation and behaviors, as well as factors associated with suicide risk in patients with anxiety disorders in primary care. Data from a large scale randomized controlled study were analyzed to assess prevalence of suicidal thoughts and behaviors, as well as factors associated with suicide risk. Results revealed that suicidal ideation and behaviors were relatively common in this group. When examining mental and physical health factors jointly, presence of depression, mental health-related impairment, and social support each uniquely accounted for variance in suicide risk score. Methodological limitations include cross-sectional data collection and lack of information on comorbid personality disorders. Moreover, patients included were from a clinical trial with exclusion criteria that may limit generalizability. Results highlight the complex determinants of suicidal behavior and the need for more nuanced suicide assessment in this population, including evaluation of comorbidity and general functioning.

CBT competence in novice therapists improves anxiety outcomes.

Abstract: Therapist competence in and adherence to delivering mental health treatment are important markers of the integrity of a therapeutic package(1). Competence refers to the skill of a clinician in delivering a particular therapeutic intervention and to act as an “agent of psychological change”(2) whereas adherence indicates the degree to which therapists follow a prescribed manual without deviation(3). Competence and adherence are distinct but related concepts. In order for therapists to be competent in a therapeutic modality they must be adherent to the intervention protocol, but adherence to the intervention provides no guarantee of competence(4). The correlation between competence and adherence ranges from r= .5 to r=.85(5). It is essential to measure both competence and adherence in treatment outcome research in order to understand their respective contribution to outcomes. Investigations of the relationship between therapist competence and outcome provide contradictory evidence. On the one hand, higher competency is related to better outcomes for depression, generalized anxiety disorder, and panic disorder(6–12) and better child-reported (though not parent- or clinician-reported) anxiety outcomes(13). On the other hand, competence only predicted clinician-rated outcomes after adherence to the protocol and rapport were added as covariates in another study, and did not predict self-reported depression(14). In addition, therapists whose panic disorder clients achieved higher than average improvement did not differ from therapists whose clients achieved lower than average improvement on competence(15), and competence did not predict substance abuse outcomes(16). Many of these studies use the Cognitive Therapy Scale(17)as their measure of cognitive behavioral therapy (CBT) competence. Higher therapist adherence ratings predict subsequent improvements in depression(18), especially early in treatment(3), and substance abuse(19, 20). However, there are contradictory findings as well(21, 22). Furthermore, one study suggested that therapist adherence occurring early in treatment is not predictive of adherence later in treatment, and measures of adherence late in treatment do not predict depression outcomes(23). A recent meta-analysis by Webb et al.(1) concluded that neither competence nor adherence were significant predictors of therapeutic outcome; however, there was large variability in the effect sizes across studies. Most prior research has relied on therapists who were already deemed highly competent in cognitive behavioral therapy by the study investigators(9, 24) and who underwent extensive training to meet criteria for “study therapists.” This selection bias is likely to produce a ceiling effect, thereby mitigating a full analysis of the effects of therapist competence and adherence. With an increased emphasis on dissemination of evidence-based practice, it is important to understand the effect of competency and adherence in mental health providers, most likely with expertise in areas other than psychology who are likely to be delivering services in primary care practices(25). However, research to date has not examined competence and adherence in therapists who are non-expert CBT clinicians. The current study examined competency and adherence of novice, non-expert clinicians who provided treatment in the Coordinated Anxiety Learning and Management (CALM) study, an effectiveness trial of a treatment for anxiety disorders in primary care. Full details on the methodology of the multi-site study can be found in Roy-Byrne et al.(26) and Sullivan et al(27). The CALM study provided a unique opportunity to examine competence and adherence in a relatively naive sample of clinicians delivering behavioral health, typical of real world settings such as primary care. Based on the available literature, we hypothesized that competence and adherence would predict treatment outcome. In addition, given the novice sample of therapists, we explored the degree to which competence and adherence changed as a function of time (i.e., from initial training to the later stages of the study). Prior research shows that CBT therapists increase their competence and adherence with more experience(12, 28–34). However, it is unclear if the same pattern of improvement occurs with non-expert or novice clinicians. This is a relevant question since it pertains to the value of booster training following initial training in CBT for novice therapists.

Effects of medical comorbidity on anxiety treatment outcomes in primary care.

Abstract: Objective To evaluate the effects of medical comorbidity on anxiety treatment outcomes. Methods Data were analyzed from 1004 primary care patients enrolled in a trial of a collaborative care intervention for anxiety. Linear-mixed models accounting for baseline characteristics were used to evaluate the effects of overall medical comorbidity (two or more chronic medical conditions [CMCs] versus fewer than two CMCs) and specific CMCs (migraine, asthma, and gastrointestinal disease) on anxiety treatment outcomes at 6, 12, and 18 months. Results At baseline, patients with two or more CMCs (n = 582; 58.0%) reported more severe anxiety symptoms (10.5 [95% confidence interval {CI} = 10.1–10.9] versus 9.5 [95% CI = 9.0–10.0], p = .003) and anxiety-related disability (17.6 [95% CI = 17.0–18.2] versus 16.0 [95% CI = 15.3–16.7], p = .001). However, their clinical improvement was comparable to that of patients with one or zero CMCs (predicted change in anxiety symptoms = −3.9 versus −4.1 at 6 months, −4.6 versus −4.4 at 12 months, −4.9 versus −5.0 at 18 months; predicted change in anxiety-related disability = −6.4 versus −6.9 at 6 months, −6.9 versus −7.3 at 12 months, −7.3 versus −7.5 at 18 months). The only specific CMC with a detrimental effect was migraine, which was associated with less improvement in anxiety symptoms at 18 months (predicted change = −4.1 versus −5.3). Conclusions Effectiveness of the anxiety intervention was not significantly affected by the presence of multiple CMCs; however, patients with migraine displayed less improvement at long-term follow-up. Conclusions Trial Registration: ClinicalTrials.com Identifier: NCT00347269

Race and beliefs about mental health treatment among anxious primary care patients.

Abstract: Large racial disparities in the use of mental health care persist. Differences in treatment preferences could partially explain the differences in care between minority and nonminority populations. We compared beliefs about mental illness and treatment preferences between adult African-Americans, Hispanics, Asian Americans, Native Americans, and White Americans with diagnosed anxiety disorders. Measures of beliefs about mental illness and treatment were drawn from the National Comorbidity Survey Replication and from our previous work. There were no significant differences in beliefs between the African-Americans and the White Americans. The beliefs of the Hispanics and the Native Americans were most distinctive, but the differences were small in magnitude. Across race/ethnicity, the associations between beliefs and service use were generally weak and statistically insignificant. The differences in illness beliefs and treatment preferences do not fully explain the large, persistent racial disparities in mental health care. Other crucial barriers to quality care exist in our health care system and our society as a whole.

Trajectories of Change in Anxiety Severity and Impairment During and After Treatment with Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care

Abstract: Background Coordinated Anxiety Learning and Management (CALM) is a model for delivering evidence-based treatment for anxiety disorders in primary care. Compared to usual care, CALM produced greater improvement in anxiety symptoms. However, mean estimates can obscure heterogeneity in treatment response. This study aimed to identify (1) clusters of participants with similar patterns of change in anxiety severity and impairment (trajectory groups); and (2) characteristics that predict trajectory group membership. Methods The CALM randomized controlled effectiveness trial was conducted in 17 primary care clinics in four US cities in 2006–2009. 1,004 English- or Spanish-speaking patients age 18–75 with panic, generalized anxiety, social anxiety, and/or posttraumatic stress disorder participated. The Overall Anxiety Severity and Impairment Scale was administered repeatedly to 482 participants randomized to CALM treatment. Group-based trajectory modeling was applied to identify trajectory groups and multinomial logit to predict trajectory group membership. Results Two predicted trajectories, representing about two-thirds of participants, were below the cut-off for clinically significant anxiety a couple of months after treatment initiation. The predicted trajectory for the majority of remaining participants was below the cut-off by 9 months. A small group of participants did not show consistent improvement. Being sicker at baseline, not working, and reporting less social support were associated with less favorable trajectories. Conclusions There is heterogeneity in patient response to anxiety treatment. Adverse circumstances appear to hamper treatment response. To what extent anxiety symptoms improve insufficiently because adverse patient circumstances contribute to suboptimal treatment delivery, suboptimal treatment adherence, or suboptimal treatment response requires further investigation.

The effect of early‐life stress on memory systems supporting instrumental behavior

Abstract: People experiencing early-life stress (ELS) exhibit increased incidence of behaviors that lead to addiction and obesity as adults. Many of these behaviors may be viewed as resulting from an overreliance on habits as opposed to goal-directed instrumental behavior. This increased habitization may result from alterations in the interactions between dorsolateral striatum-dependent and hippocampus-dependent learning systems. As an initial examination of this idea, we investigated the effect of ELS on instrumental learning and extinction. In Experiment 1, we examined the effect of ELS in two groups of people, one trained on a continuous reinforcement schedule and one trained on a partial reinforcement schedule. We found that people who experienced ELS had a diminished effect of the partial reinforcement schedule on extinction. In Experiment 2, we again manipulated reinforcement schedule and also challenged declarative memory by requiring subjects to perform a concurrent task. We found that the declarative challenge did not affect extinction responding in the non-ELS group. In a moderate-ELS group, we observed a diminished sensitivity to the reinforcement schedule during extinction only under divided attention. In the high-ELS group, we observed a reduced sensitivity to reinforcement schedule even in the absence of the declarative memory challenge, consistent with Experiment 1. Our results suggest that ELS reduces the tendency to use declarative, hippocampus-dependent memory in instrumental tasks in favor of habits. ELS may affect hippocampal development, thus altering the interaction between memory systems and potentially contributing to poor health outcomes.

Effects of Pain and Prescription Opioid Use on Outcomes in a Collaborative Care Intervention for Anxiety

Abstract: Objective:To determine the effects of pain and opioid pain medication use on clinical and functional outcomes in 1004 primary care patients with an anxiety disorder randomized to receive the Coordinated Anxiety Learning and Management (CALM) collaborative care intervention (cognitive-behavioral ther

Does a Quality Improvement Intervention for Anxiety Result in Differential Outcomes for Lower-Income Patients?

Abstract: ObjectiveThe authors examined the effects of a collaborative care intervention for anxiety disorders in primary care on lower-income participants relative to those with higher incomes. They hypothesized that lower-income individuals would show less improvement or improve at a lower rate, given that they would experience greater economic stress over the treatment course. An alternative hypothesis was that lower-income participants would improve at a higher rate because the intervention facilitates access to evidence-based treatment, which typically is less available to persons with lower incomes.MethodBaseline demographic and clinical characteristics of patients with lower (N=287) and higher (N=717) income were compared using t tests and chi-square tests for continuous and categorical variables, respectively. For the longitudinal analysis of intervention effects by income group, the outcome measures were jointly modeled at baseline and at 6, 12, and 18 months by study site, income, time, intervention, time...

Trauma Exposure in Anxious Primary Care Patients

Abstract: The present study examined rates of trauma exposure, clinical characteristics associated with trauma exposure, and the effect of trauma exposure on treatment outcome in a large sample of primary care patients without posttraumatic stress disorder (PTSD). Individuals without PTSD (N = 1,263) treated as part of the CALM program (Roy-Byrne et al., Journal of the American Medical Association 303(19)1921–1928, 2010) were assessed for presence of trauma exposure. Those with and without trauma exposure were compared on baseline demographic and diagnostic information, symptom severity, and responder status six months after beginning treatment. Trauma-exposed individuals (N = 662, 53 %) were more likely to meet diagnostic criteria for Obsessive Compulsive Disorder and had higher levels of somatic symptoms at baseline. Individuals with and without trauma exposure did not differ significantly on severity of anxiety, depression, or mental health functioning at baseline. Trauma exposure did not significantly impact treatment response. Findings suggest that adverse effects of trauma exposure in those without PTSD may include OCD and somatic anxiety symptoms. Treatment did not appear to be adversely impacted by trauma exposure. Thus, although trauma exposure is prevalent in primary care samples, results suggest that treatment of the presenting anxiety disorder is effective irrespective of trauma history.