Integrated PTSD and Smoking Treatment

描述(由申请人提供)：我的主要研究兴趣集中在为创伤后应激障碍(PTSD)成年人的药物使用问题开发有效和有效的行为干预。在这里，我的临床和研究经验指导我把重点放在戒烟上。在临床上，我观察到吸烟在接受创伤后应激障碍治疗的患者中很普遍，焦虑过程通常会导致吸烟。越来越多的研究支持这些观察结果。此外，现有的戒烟干预措施往往无法带来持久的临床变化。这些观察结果相互融合，表明在一个总体模型中开发针对焦虑过程和创伤后应激障碍的干预措施具有科学和临床价值。到目前为止，我的研究经验主要是在焦虑症的性质、原因和治疗方面。因此，我提议的研究路线需要在物质使用障碍方面进行进一步培训。短期内，我的职业目标为进一步培训提供了明确的方向。我想利用K01机制在我以前的经验和培训的基础上，通过三个有意义的方式。首先，我选择了两位导师[施密茨博士(小学)和兹沃伦斯基博士(联合导师)]，他们可以指导我努力开发一个专注于戒烟的独立研究计划。Smitts博士和Zvolensky博士带来了针对焦虑和相关物质使用问题的干预措施的开发和评估方面的专业知识。其次，在国际公认的创伤后应激障碍专家福阿博士的帮助下，我开发了一套课程，以建立我在创伤后应激障碍方面的专业知识。第三，我计划了一系列课程和与生物统计学家罗森菲尔德博士的会议，以了解统计方法，因为它与测试中介和调节有关。总而言之，这些综合培训经验将帮助我实现我的长期目标，即在心理学系从事这一独立的工作，成为一名终身教员。此次K01应用的研究计划与我向物质使用障碍研究的过渡是一致的。这项K01研究计划旨在开发和测试一种综合干预措施，以改善患有创伤后应激障碍的成年人戒烟的认知行为疗法(CBT)的结果。创伤后应激障碍与吸烟增加和戒烟尝试失败有关。2-7创伤后应激障碍患者的吸烟率为44.6%，而没有精神障碍的人为22.5%。8创伤后应激障碍患者更有可能依赖，4大量吸烟(每天25支)，2有更严重的戒烟症状，并在戒烟尝试后复发。2事实上，患有创伤后应激障碍的吸烟者的戒烟率(23.2%)是所有精神障碍中最低的之一。8因此，绝大多数试图戒烟的创伤后应激障碍患者并没有从现有的干预方案中受益。显然，有必要为这一群体制定专门的或个性化的战略。 可能导致吸烟者发展为尼古丁依赖和戒烟复发的创伤后应激障碍的特征包括负面情绪、恐惧、觉醒增加、易怒、愤怒、痛苦不耐受和焦虑敏感。除惊恐障碍外，创伤后应激障碍患者的焦虑敏感度比任何其他焦虑症患者都要高。9高焦虑敏感度与戒烟尝试期间犯错误10和复发11-13的几率更高有关。13痛苦不耐受，一种无法忍受痛苦的感知或行为倾向，14与创伤后应激障碍的维持和戒烟问题有关。15基于恐惧消退的治疗(即长期暴露[PE]、相互感觉暴露[IE])已显示出降低PTSD16和痛苦不耐受和焦虑敏感性的有效性17-19，因此成为有希望加强针对创伤后应激障碍患者的标准戒烟干预措施的候选对象。本申请建议对患有创伤后应激障碍的吸烟者进行综合和专门治疗的试点试验。这一综合创伤后应激障碍和吸烟治疗(IPST)结合了认知行为疗法和戒烟尼古丁替代疗法(标准护理；SC)和PE，针对创伤后应激障碍症状(例如，负面情绪、恐惧、觉醒增加、易怒、愤怒)和IE，以减少焦虑敏感性和痛苦不耐受。为此，80名患有创伤后应激障碍的成年吸烟者将被随机分配到：(1)IPST或(2)SC。戒烟后2周、4周、8周、10周、16周和24周将对吸烟结果进行评估。在退出日期之前和之后，将反复评估可能的调解人的衡量标准。

DESCRIPTION (provided by applicant): My primary research interests center around developing efficacious and effective behavioral interventions for substance use problems among adults with post-traumatic stress disorder (PTSD). Here, my clinical and research experiences have guided me to focus on smoking cessation. Clinically, I have observed that smoking is prevalent among patients who present for the treatment of PTSD, and that anxiety processes often serve to smoking. A growing body of research supports these observations. Moreover, extant smoking cessation interventions have often failed to yield lasting clinical change. These observations converge with one another to suggest that there is scientific and clinical merit to developing interventions that target anxiety processes and PTSD in one overarching model. My research experience to date is primarily in the area of the nature, causes, and treatment of anxiety disorders. Thus, my proposed line of research requires further training in substance use disorders. In the short- term, my professional goals provide clear direction for further training. would like to use the K01 mechanism to build upon my previous experience and training in three meaningful ways. First, I selected two mentors [Drs. Smits (Primary) and Zvolensky (Co-Mentor)] who can guide me in my efforts to develop an independent research program focusing on smoking cessation. Dr. Smits and Zvolensky bring expertise in the development and evaluation of interventions for anxiety and related substance use problems. Second, with help of Dr. Foa, an internationally-recognized expert in PTSD, I have developed a curriculum to build my expertise in PTSD. Third, I have planned a series of courses and meetings with Dr. Rosenfield, a biostatistician, to learn about statistical methods as it relates to testing mediatio and moderation. Together, these integrated training experiences will help me reach my long-term goal, which is to pursue this independent line of work as a tenured faculty member in a psychology department. The research plan of this K01 application is consistent with my transition to substance use disorder research. This K01 research plan aims to develop and test an integrated intervention for improving the outcome of cognitive-behavioral therapy (CBT) for smoking cessation in adults with PTSD. PTSD is associated with increased smoking and failed cessation attempts.2-7 The prevalence of smoking in persons with PTSD is 44.6 %, compared to 22.5% in persons with no psychiatric disorder.8 Smokers with PTSD are more likely to be dependent,4 smoke heavily (> 25 cigarettes per day),2 experience more severe withdrawal symptoms, and relapse following a quit attempt.2 In fact, the quit rate in smokers with PTSD (23.2%) is one of the lowest of all mental disorders.8Thus, the vast majority of persons with PTSD attempting to quit smoking do not benefit from existing intervention protocols. Clearly, there is a need for the development of specialized or personalized strategies for this population. Features of PTSD that may contribute to smokers' progression to nicotine dependence and cessation relapse include negative affect, fear, increased arousal, irritability, anger, distress intolerance, and anxiety sensitivity. Anxiety sensitivity is higher in persons with PTSD than in any other anxiety disorder except for panic disorder.9 High anxiety sensitivity is uniquely associated with greater odds of lapse10 and relapse11-13 during quit attempts.13 Distress intolerance, a perceived or behavioral tendency to not tolerate distress,14 is related to both the maintenance of PTSD and problems in quitting smoking.15 Fear extinction-based treatments (i.e., prolonged exposure [PE], interoceptive exposure [IE]) have shown efficacy for reducing PTSD16 and distress intolerance and anxiety sensitivity17-19 and therefore emerge as promising candidates to augment standard smoking cessation interventions for individuals with PTSD. The present application proposes to pilot test an integrated and specialized treatment for smokers with PTSD. This Integrated PTSD and Smoking Treatment (IPST) combines cognitive-behavioral therapy and nicotine replacement treatment for smoking cessation (standard care; SC) with PE to target PTSD symptoms (e.g., negative affect, fear, increased arousal, irritability, anger) and IE to reduce anxiety sensitivity and distress intolerance. To thi end, 80 adult smokers with PTSD will be randomly assigned to either: (1) IPST or (2) SC. Smoking outcomes will be assessed 2, 4, 8, 10, 16, and 24 weeks after quit date. Measure of putative mediators will be assessed repeatedly prior and following the quit date.