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Using cognitive therapy for PTSD when racism was part of the traumatic event(s): Case illustrations and practical considerations for therapists and supervisors
Cognitive therapy for post-traumatic stress disorder (PTSD) is recommended in a range of national and international guidelines. This clinical guidance paper specifically focuses on cognitive therapy for PTSD (CT-PTSD) where racism has been part of the index trauma event(s). It aims to support CBT therapists to maintain fidelity to the CT-PTSD model but also ensure that racism is integrated into the formulation and interventions in ways that are sensitive and validating. It explores barriers to this occurring ranging from societal factors (e.g. ongoing racism, discouragement from discussing racism), to therapist factors (e.g. lack of understanding of racism, lack of own understanding of racialised identity, anxiety, lack of knowledge, skills and confidence) and patient factors (e.g. shame, fear of therapist response). The paper aims to provide guidance on how these can be addressed alongside case illustrations and practical considerations for therapists and supervisors. Key learning aims (1) To understand how Ehlers and Clark's (2000) cognitive model and related treatment of PTSD can be applied when racism is part of the traumatic event. (2) To provide guidance, tips and examples on how to identify key personal meanings around the trauma index event involving racism. (3) The article will encourage therapists to reflect on their own identity and experiences (or lack of) around racism, considering how this might hinder or facilitate the appropriate inclusion of racist experience within CT-PTSD. (4) To provide suggestions on how to ensure that supervision of CT-PTSD supports the consideration and addressing of relevant experiences of racism and supports therapists where patient experiences may overlap with their own experience of racism.
Sudden Gains in Cognitive Behavioural Therapy and Metacognitive Therapy for Complex Anxiety Disorders.
The present study investigated the prevalence of sudden gains in a large sample of patients with complex anxiety disorders, that is, long-lasting and treatment-resistant anxiety disorders. The properties of these gains were explored in a longitudinal design from two treatment modalities: cognitive behavioural therapy (CBT) and metacognitive therapy (MCT). Participants were 404 adults with a primary diagnosis of anxiety disorder, receiving a standardized 8 weeks of inpatient treatment with CBT or MCT. Symptom severity was measured weekly with the Beck Anxiety Inventory (BAI) and additionally during the first assessment session, pre-treatment, post-treatment and 1-year follow-up. Sudden gains were identified as between-session symptom changes of ≥ 9 points on the BAI, which were relatively large (≥ 25% difference) and stable (did not reverse) in the weeks after the gain. The prevalence of sudden gains during treatment was 19%. Individuals experiencing sudden gains had significantly lower levels of anxiety immediately after treatment and at 1-year follow-up compared to those without. Sudden gains were present in both CBT and MCT, showing similar magnitudes and prevalence, but patients treated with MCT tended to experience sudden gains earlier than those with CBT. This study demonstrates that sudden gains also occur in a long-lasting and treatment-resistant anxiety disorder population treated with CBT and MCT.
The acceptability and usefulness of ambulatory assessment: A large-scale investigation of a daily diary study with 2,816 adults.
Despite the popularity of ambulatory assessment (AA), few studies have investigated how participants experience and perceive their participation, including the burdensomeness and utility of AA. This is important, as participants' experience in the measurement process can directly impact participants' well-being and data quality. In a 40-day diary study involving 2,816 individuals, participants reported their experience of the measurement process (acceptability) with six self-report items. We further investigated the demographic difference in acceptability using seemingly unrelated regression and logistic regression. We explored how compliance was related to acceptability and participant demographics with Poisson regression. Most participants found daily diary assessments to be beneficial in general (74.7%), specifically, for their self-understanding (60.0%) and self-reflection and experience sharing (68.5%). Most participants expressed willingness to participate in similar research again (83.9%). A minority of participants (11.7%) reported they felt participation worsened their problems, while twice as many (21.7%) participants reported that participation helped alleviate their mental health problems. Demographic predictors were predominantly insignificant, reflecting that the high acceptability of daily diary assessments was relatively stable across different populations. Adults across different subgroups predominantly found their participation in daily diary research to be beneficial for their mental health, with the majority of adults expressing reparticipation interest. One in five participants experienced an improvement in their psychiatric symptoms related to participation, while a minority of individuals expressed mental deterioration, presenting a critical avenue for future research to identify the characteristics of individuals who are more or less likely to benefit from AA research. (PsycInfo Database Record (c) 2025 APA, all rights reserved).
Stimulation of the human ventral tegmental area increases strategic betting.
Learning is a fundamental aspect of human behaviour and is essential for adapting to new environments and situations. The ventral tegmental area is a critical brain area containing neurons that release dopamine to signal reward, drive learning, and bias decision-making. Human data on ventral tegmental area's effects on cognition are scarce, and no studies have causally manipulated the human ventral tegmental area. Here we studied a unique group of patients who had deep brain stimulation surgery in the ventral tegmental area, to improve pain due to trigeminal autonomic cephalalgias refractory to medical therapy. In this study, we asked how deep brain stimulation, which aimed to inhibit the ventral tegmental area, affected reward-related learning and decision-making. Patients performed a reversal learning task while their deep brain stimulation was switched on vs. off, in a powerful within-subject design. In the task, patients learned to choose between two options to win money, based on previous outcomes, but also made post-decision bets based on whether they thought they were likely to win. This allowed us to also investigate the effect of electrical stimulation within the ventral tegmental area on betting behaviour. We found that stimulation did not affect learning in this group of patients but led to a more strategic betting behaviour. First, stimulation reduced the bias where healthy people tend to bet similarly to the previous trial. Second, when on stimulation, bets were more strongly linked to the actual value of the choice. The data indicate that disrupting ventral tegmental area signals by electrical stimulation reduces the perseverative betting bias, permitting more strategic decision-making. We interpret this to mean that mesolimbic dopaminergic signals in humans may be important in producing persistence of reward-driven behaviours over time.
How well can commonly used anxiety scales detect treatment outcomes in the context of autism?
Anxiety is one of the most prevalent mental health challenges in autistic children, yet there is limited evidence on effective tools to measure treatment outcomes. Previous research with non-autistic children has found that the Child Anxiety Impact Scale, Parent Version achieved good diagnostic accuracy when measuring treatment outcomes and performed better than a commonly used symptom measure. However, this has not been evaluated for autistic children. The present study examined the psychometric properties of the Child Anxiety Impact Scale, Parent Version in autistic children and compared its utility against other anxiety symptom measures, to detect treatment outcomes as assessed by a gold-standard diagnostic interview, the Anxiety and Related Disorders Interview Schedule, Child Version, Parent Interview with the Autism Spectrum Addendum. Data were used from 212 children (aged 7-13 years) who participated in a randomised controlled trial. Receiver-operating characteristic curve analyses were conducted, and subsequent subgroup analyses were conducted using DeLong tests. Results demonstrated that the Child Anxiety Impact Scale, Parent Version had strong psychometric properties, with total scores significantly outperforming other measures in predicting post-treatment recovery from anxiety diagnoses. These findings have implications for future choices of treatment outcome measures in research and clinical practice.Lay abstractStudy on the utility of anxiety scales to detect anxiety diagnostic treatment outcomes in autistic childrenWhy was the study done? The importance of having valid and reliable anxiety measures for autistic children has been highlighted as a research priority by professionals and people with lived experience. Yet, while anxiety has been frequently assessed in autistic children, we do not currently know much about how well commonly used anxiety measures work, especially parent reports, in this context. This has significant implications for care planning and resource allocation for autistic children who experience significant anxiety problems.What did the researchers do? The research team studied data collected in a previously published multi-centred randomised controlled trial (RCT) testing an adapted cognitive behavioural therapy for anxiety (Wood et al., 2020) to better understand how different anxiety measures did, compared to gold-standard anxiety diagnostic assessments, in detecting treatment outcomes. They focused in particular on the Child Anxiety Impact Scale, Parent Version (CAIS-P).What did the researchers find? This study found that the CAIS-P did better than conventional anxiety symptom measures in detecting treatment outcomes for anxiety problems in autistic children.What do the findings mean? This study adds to the current evidence base to inform choices of measurement of anxiety problems in the context of autism.
The Placental Steroid Hypothesis of Human Brain Evolution.
The evolution of the human brain has long been framed in terms of sexual selection, with an emphasis on consistent but small on-average volumetric differences between males and females. In this review, we present new molecular, genetic and clinical findings regarding neurodevelopment, cortical expansion and the production of sex steroid hormones, such as testosterone and oestradiol, by the placenta during pregnancy. We discuss converging evidence that on-average sex differences are relevant for human evolution but are characterised by significant overlap between the sexes and more adaptations in female, rather than male, physiology. We also consider recent accounts and modelling of evolutionary pressures in large social groups, regarding competition and fertility. Finally, we bring these findings together and present a novel hypothesis for understanding human brain development and evolution, which emphasises the role of sex steroid hormones, their prenatal production by the placenta and their roles in regulating physiology, fertility and cognition.
Target selection signals causally influence human perceptual decision making.
The ability to form decisions is a foundational cognitive function which is impaired across many psychiatric and neurological conditions. Understanding the neural processes underpinning clinical deficits may provide insights into the fundamental mechanisms of decision making. The N2c has been identified as an EEG signal indexing the efficiency of early target selection, which subsequently influences the timing of perceptual reports through modulating neural evidence accumulation rates. Evidence for the contribution of the N2c to human decision making however has thus far come from correlational research in neurologically healthy individuals. Here, we capitalised on the superior temporal resolution of EEG to show that unilateral brain lesions in male and female humans were associated with specific deficits in both the timing and strength of the N2c in the damaged hemisphere, with corresponding deficits in the timing of perceptual reports contralaterally. The extent to which the N2c influenced clinical deficits in perceptual reporting speed depended on neural rates of evidence accumulation. This work provides causal evidence that the N2c indexes an early, hemisphere-specific process supporting human decision making. This non-invasive EEG marker could be used to monitor novel approaches for remediating clinical deficits in perceptual decision making across a range of brain disorders.Significance Statement Understanding how particular brain processes contribute to decision-making is crucial for our treatment of psychiatric and neurological disorders. This study provides causal evidence linking deficits in speed of visual processing to specific well-delineated EEG signals representing early target selection and evidence accumulation, in individuals with brain lesions. By showing how these lesions disrupt perceptual decisions, this work identifies a potential biomarker for decision-making deficits. This EEG measure offers a promising, non-invasive tool to track and refine treatments aimed at restoring decision-making abilities in affected patients.
Experiences of Help-Seeking for Severe Mental Health Problems in Young Pakistani Women: A Preliminary Qualitative Study.
Almost three quarters of mental illnesses start by the age of 25, yet youth (18-25-year-olds) are often underrepresented in U.K. services. This is particularly true for those of ethnic minorities. In this study, we aimed to understand how young Pakistani women and their parents make decisions to seek help for severe mental health problems, and the barriers and facilitators to accessing professional help. Young Pakistani women with experience of severe mental health problems and their parents were recruited from a community sample. Semi-structured interviews were conducted with six young people and two parents. Data were analyzed using reflexive thematic analysis. Pakistani culture and its interplay with British culture strongly influenced the decisions and ability of young Pakistani women and their parents to help-seek, largely through the role of stigma. Low mental health literacy, stigma, and a lack of culturally informed services were identified as the most common barriers to accessing care. These barriers fed into the internalized stigma these young women experienced which, through fear of damaged reputation and personal prejudices, posed further barriers to seeking help. Participants highlighted recommendations for both individual-level (e.g., increased education and awareness) and service-level (e.g., greater choice over care) change to facilitate accessibility of professional help. Young Pakistani women face multiple culturally related challenges to accessing care for severe mental health problems at both the individual- and service-level. Novel suggestions to address these challenges, such as including youth peer support workers in services, may facilitate more inclusive and accessible services.