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Introduction: For over two decades school shootings have become a significant concern, especially in the United States. Following a rampage school shooting, extensive resources are devoted to gathering all of the information surrounding the event. To date, few studies have compared completed to averted, or near-miss, school shootings. This study utilized the largest known sample of cases based in the United States in an effort to identify potential targets for prevention. Method: Data were derived from the Averted School Violence database of incidents occurring between 1999 and 2020. Statistical analyses were conducted to determine how age, co-conspirator involvement, engagement in leakage warning behavior, and motives - in isolation and in combination - varied between groups. Results: In insolation, age, co-conspirator involvement, engagement in leakage warning behaviors, and motives were significantly different between groups. However, when these variables were combined into a logistic regression, co-conspirator involvement, engagement in leakage warning behaviors, and motives involving suicidal intent emerged as statistically significant predictors of group membership. Age no longer differentiated the two types of events. Conclusion: This study demonstrates that regardless of suspect age, threats of school violence must be taken seriously and investigated fully. Further, students reporting their peers' engagement in shooting-related behaviors (e.g., bringing a gun to school, mapping school, etc.) was one of the most significant predictors that a plot will be thwarted. While perpetrators who planned with others had increased odds of their plot being identified, those acting alone still demonstrated leakage behaviors. If individuals in the school environment are educated regarding warning behaviors, lone perpetrators can still be identified and reported to authorities. The perpetrator's emotional distress, in particular depressive or suicidal thoughts were also a significant predictor of a completed school shooting. Future research efforts should focus on the development and evaluation of peer training programs to assist in the detection of school shooting warning behaviors.

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BACKGROUND: Few studies have examined the prevalence of social anxiety disorder (SAD) among adolescents and the associated sex-specific fears. No previous studies have reported variance in SAD prevalence among adolescents based on a stepwise diagnostic approach. METHODS: Using various diagnostic thresholds from the Anxiety Disorders Interview Schedule child version, and the diagnostic criteria from both the 4th and 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), we explored the point prevalence of SAD among a population-based sample of 8216 adolescents aged 13-19 years. RESULTS: Overall, 2.6% of adolescents met the SAD diagnostic criteria. The prevalence varied from 2.0% to 5.7% depending on the criteria-set. Twice as many females met the overall SAD criteria. The DSM-IV generalized SAD subtype was assigned to 86.5% of the sample, while 3.5% met the DSM-5 performance-only subtype. Compared with males aged 16-19 years, significantly more of those aged 13-15 years met the SAD criteria; no significant age group differences were found among females. CONCLUSIONS: This is the first study to demonstrate variance in SAD prevalence among adolescents based on the diagnostic threshold method. Depending on the threshold applied, SAD prevalence among adolescents varied from 2.0% to 5.7%. Age and sex differences in social fear experiences highlight the importance of considering developmental heterogeneity in SAD, especially for adapting prevention and treatment interventions.

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In June 2021, a condominium in Florida collapsed, with the loss of 98 lives. Search and rescue teams spent 2 weeks, recovering the victims. This study's objective was to assess the presence of psychological symptoms that might emerge in the following months, using the PTSD Checklist for DSM-5 (PCL-5), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder - 7 (GAD-7), Suicide Cognitions Scale-Short (SCS-S), and the Insomnia Severity Index (ISI). A monthly survey conducted for 3 months found that overall, mean scores on these measures did not indicate significant emotional distress. We then compared the scores when the group was divided into responders who recovered human remains and those who did not. Scores were significantly higher among the subgroup that recovered human remains. Fifty-three percent (53%) of this sub-group met the cut-off score for a provisional diagnosis of PTSD, depressive disorder or generalized anxiety disorder-15% met the cut-off score criteria on the PCL-5 for probable PTSD, 36.8% for probable depressive disorder on the PHQ-9, and 26.3% for probable generalized anxiety disorder on the GAD-7. The results are consistent with other investigations examining mental health after mass disasters. Specifically, not all first responders will develop emotional distress but certain recovery activities may put some responders at higher risk, with a percentage displaying psychological distress. The results emphasize the need to assess the impact of these events on the mental health of first responders and to consider strategies to prevent or mitigate the development of impairing psychopathology.

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Disseminating efficacious psychological treatments remains a challenge for researchers and clinicians. In the case of social anxiety disorder (SAD), Social Effectiveness Therapy for Children (SET-C) has been demonstrated as an efficacious intervention, but elements of the protocol, such as peer generalization sessions, remain challenging to conduct in typical clinical settings. To address this need, we developed an artificially intelligent, web-based application, Pegasys-VR™, designed to replace peer generalization sessions and enhance homework compliance. The feasibility of Pegasys-VR™ was tested in a randomized controlled trial in comparison to SET-C. The results indicated that both programs were equally efficacious in decreasing anxiety and improving social skill in social encounters. Sixty-three percent (63%) of children treated with SET-C and 60% treated with Pegasys-VR™ did not meet diagnostic criteria for SAD at posttreatment. Pegasys-VR™ is a feasible, efficacious, and dissemination-friendly element of a comprehensive treatment program for social anxiety disorder in children.

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Adolescents' exposure to negative life events (NLEs) and potentially traumatic events is highly prevalent and increases their risk of developing psychological disorders considerably. NLE exposure has also been linked to the development of social anxiety disorder (SAD) among older children and young adolescents. Despite the relatively low treatment efficacy reported for children and adolescents suffering from SAD, few studies have addressed the extent to which resilience factors, such as social support and social self-efficacy, are associated with SAD symptoms. This study examined whether social support and social self-efficacy predict, and buffer against SAD symptoms using a large, population-based sample of adolescents, among whom a large proportion have experienced NLEs. The results reveal that NLEs are significantly associated with SAD symptoms, while social support and social self-efficacy are both negatively associated with SAD symptoms. Only the NLEs × social support interaction significantly predicted SAD symptoms, with social support attenuating the association between NLEs and SAD symptoms. Moreover, increases in both social self-efficacy and social support were associated with reduced SAD symptoms, over and above variance explained by social support alone. Our cumulative results suggest that interventions that can modify both social support and social self-efficacy may help reduce SAD symptoms in at-risk adolescents.

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Firefighters are at risk for chronic sleep disruption due to their rotating 24-hour on and 48-hour off work schedule and hazardous work conditions. Forty-five firefighters were assessed to determine the impact of their shift schedule on sleep duration, sleep quality, processing speed, sustained attention, vigilance, and mental health. Assessments were conducted at the start and end of shift. Firefighters endorsed sleeping 5 hours 21 minutes at work, and the results suggest that even minimal sleep disruption affected cognitive functioning (e.g. processing speed, visual-motor coordination, and reaction time), increasing the likelihood of poor work performance or injury.

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Given that first responders experience elevated rates of posttraumatic stress disorder and suicide, there is a need for evidence-based assessments and treatments to accurately assess, diagnose, and evaluate treatment outcome. This study examined the psychometric properties of the Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) in a sample of 133 firefighters/emergency medical technicians and police officers seeking treatment for PTSD. The results indicated that PCL-5 scores showed strong internal consistency and convergent and discriminant validity. Signal detection analyses indicated a good diagnostic accuracy and an optimal cutoff score of 41 for detecting PTSD. Consistent with recent studies, confirmatory factor analyses indicated that the anhedonia model of PTSD best fit the data. Overall, findings support use of the PCL-5 as a psychometrically sound measure of PTSD in individuals at high risk for exposure to trauma.

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BACKGROUND: An abundance of cross-sectional research links inadequate sleep with poor emotional health, but experimental studies in children are rare. Further, the impact of sleep loss is not uniform across individuals and pre-existing anxiety might potentiate the effects of poor sleep on children's emotional functioning. METHODS: A sample of 53 children (7-11 years, M = 9.0; 56% female) completed multimodal, assessments in the laboratory when rested and after two nights of sleep restriction (7 and 6 hr in bed, respectively). Sleep was monitored with polysomnography and actigraphy. Subjective reports of affect and arousal, psychophysiological reactivity and regulation, and objective emotional expression were examined during two emotional processing tasks, including one where children were asked to suppress their emotional responses. RESULTS: After sleep restriction, deleterious alterations were observed in children's affect, emotional arousal, facial expressions, and emotion regulation. These effects were primarily detected in response to positive emotional stimuli. The presence of anxiety symptoms moderated most alterations in emotional processing observed after sleep restriction. CONCLUSIONS: Results suggest inadequate sleep preferentially impacts positive compared to negative emotion in prepubertal children and that pre-existing anxiety symptoms amplify these effects. Implications for children's everyday socioemotional lives and long-term affective risk are highlighted.

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OBJECTIVE: U.S. military special operation forces represent the most elite units of the U.S. Armed Forces. Their selection is highly competitive, and over the course of their service careers, they experience intensive operational training and combat deployment cycles. Yet, little is known about the health-care needs of this unique population. METHOD: Professional consultations with over 50 special operation forces operators (and many spouses or girlfriends) over the past 6 years created a naturalistic, observational base of knowledge that allowed our team to identify a unique pattern of interrelated medical and behavioral health-care needs. RESULTS: We identified a consistent pattern of health-care difficulties within the special operation forces community that we and other special operation forces health-care providers have termed "Operator Syndrome." This includes interrelated health and functional impairments including traumatic brain injury effects; endocrine dysfunction; sleep disturbance; obstructive sleep apnea; chronic joint/back pain, orthopedic problems, and headaches; substance abuse; depression and suicide; anger; worry, rumination, and stress reactivity; marital, family, and community dysfunction; problems with sexual health and intimacy; being "on guard" or hypervigilant; memory, concentration, and cognitive impairments; vestibular and vision impairments; challenges of the transition from military to civilian life; and common existential issues. CONCLUSIONS: "Operator Syndrome" may be understood as the natural consequences of an extraordinarily high allostatic load; the accumulation of physiological, neural, and neuroendocrine responses resulting from the prolonged chronic stress; and physical demands of a career with the military special forces. Clinical research and comprehensive, intensive immersion programs are needed to meet the unique needs of this community.

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Theoretical models of posttraumatic stress disorder (PTSD) as well as exposure therapy (EXP) methodology suggest that trauma recall is crucial to altering the conditioned fear response associated with PTSD. However, it is unclear whether limited recall of the trauma event attenuates treatment outcomes. This study examined whether the extent of difficulty recalling aspects of a traumatic event affected fear activation, habituation, number of sessions, session length, and diagnostic outcomes in 166 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans. Extent of trauma recall difficulty neither attenuated veterans' ability to achieve fear activation and habituation nor affected treatment outcomes. Findings suggest that even veterans who reported greater difficulty recalling their trauma event can engage successfully and benefit from EXP. This research is the first to examine trauma event recall in the context of the EXP process and contributes to the current body of literature that aims to address the question: "For whom do treatments work?"

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Posttraumatic stress disorder (PTSD) resulting from military service is a common, yet often chronic condition. Treatment outcome often is attenuated by programs that are (a) lengthy in nature and (b) constricted in their target outcomes. These limitations leave much of the emotional and behavioral impairment that accompanies PTSD unaddressed and/or unassessed. Typical PTSD treatment programs are 3-4 months in length, which is challenging for the pace of the nation's military. In this investigation, we will compare two treatments, Trauma Management Therapy (TMT) and Prolonged Exposure (PE), both redesigned to address the needs of active duty personnel (300 participants at 3 military installations). Specifically, we will compare the TMT Intensive Outpatient Program (IOP; 3 weeks) to PE's compressed (2 week) format. Both interventions will be compared to a standard course of PE (12 weeks). In addition to PTSD symptomatology, outcome measurement includes other aspects of psychopathology as well as changes in social, occupational, and familial impairment. Potential negative outcomes of massed treatment, such as increased suicidal ideation or increased alcohol use, will be assessed, as will genetic predictors of PTSD subtype and treatment outcome. This study will inform the delivery of care for military-related PTSD and particularly the use of intensive or compressed treatments for active duty personnel.

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BACKGROUND & OBJECTIVES: Social anxiety disorder (SAD) is a debilitating condition, and approximately half of adults who stutter have SAD. Cognitive-behavioral therapy (CBT) has shown promise in decreasing social anxiety symptoms among adults who stutter, but exposure, arguably the essential component for successful CBT for SAD, has been understudied and underemphasized. Aims of this study were to develop an exposure therapy protocol designed specifically for people who stutter and have SAD and evaluate its potential efficacy in reducing social anxiety and stuttering severity using a multiple baseline design. METHODS: Six participants received ten sessions of exposure therapy. Participants reported daily social anxiety, and social distress and stuttering severity were evaluated at major assessment points. RESULTS: There were substantial reductions in social anxiety and considerable improvements in affective, behavioral, and cognitive experiences of stuttering. No consistent change was observed for stuttering frequency. Gains were mostly maintained after six-months. CONCLUSIONS: Results suggest that the novel exposure approach may decrease social distress, but not necessarily influence speech fluency. These findings underscore the importance of the assessment and treatment of SAD among adults who stutter and suggest that the integration of care between clinical psychologists and speech-language pathologists may prove beneficial for this population.

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Virtual reality exposure therapy (VRET) realistically incorporates traumatic cues into exposure therapy and holds promise in the treatment of combat-related posttraumatic stress disorder (PTSD). In a randomized controlled trial of 92 Iraq and Afghanistan veterans and active duty military personnel with combat-related PTSD, we compared the efficacy of Trauma Management Therapy (TMT; VRET plus a group treatment for anger, depression, and social isolation) to VRET plus a psychoeducation control condition. Efficacy was evaluated at mid- and post-treatment, and at 3- and 6-month follow-up. Consistent with our hypothesis, VRET resulted in significant decreases on the Clinician Administered PTSD Scale and the PTSD Checklist-Military version for both groups. Also consistent with our hypothesis, significant decreases in social isolation occurred only for those participants who received the TMT group component. There were significant decreases for depression and anger for both groups, although these occurred after VRET and before group treatment. All treatment gains were maintained six-months later. Although not part of the original hypotheses, sleep was not improved by either intervention and remained problematic. The results support the use of VRET as an efficacious treatment for combat-related PTSD, but suggest that VRET alone does not result in optimal treatment outcomes across domains associated with PTSD.

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Selective mutism (SM) is an anxiety disorder marked by withdrawal of speech in particular social situations. Treatment is often difficult, requiring attention to several characteristics particular to the disorder. Therapeutic tools and activities such as games and mobile applications (apps) may be particularly advantageous to behavioral therapy for SM. A 2-session hierarchy for shaping successive approximations of speech in SM was piloted with 15 children, 5 to 17 years old, who were randomly assigned to shaping while using mobile apps, other therapeutic tools/activities, and reinforcement alone. Very strong treatment gains were observed: 13 of 15 (88.7%) children completed the hierarchy during the first session and 14 (93.3%) did so during the second session, with the final child completing all but the final step (i.e., to ask and respond to at least 5 open-ended questions). Moreover, all 15 children spoke to the clinician within 59 minutes of treatment (M = 17 minutes), and 14 (93.3%) children held five, 5-minute conversations with additional unknown adults during the second session. This occurred regardless of the inclusion of therapeutic tools/activities, although preliminary patterns of responding were observed such that children shaped while using mobile apps tended to show less self-reported and physiologically measured anxious distress. The utility of therapeutic activities and mobile apps when treating SM is discussed as well as areas for future research.

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Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.

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There is a need for a better understanding of underlying pathology in posttraumatic stress disorder (PTSD) to develop more effective treatments. The late positive potential (LPP) amplitude from electroencephalogram has been used to assess individual differences in emotional reactivity. There is evidence that olfaction is particularly important in emotional processing in PTSD. The current study examined LPP amplitudes in response to olfactory stimuli in 24 combat veterans with PTSD and 24 nonmilitary/non-PTSD controls. An olfactometer delivered three negatively valenced odorants, with 12 trials of each delivered in a random order. The groups did not differ in LPP amplitude across odorants. However, within the PTSD group, higher Clinician-Administered PTSD Scale scores related to an increased LPP amplitude after diesel fuel and rotten egg, but not n_butanol, odorants. Results provide specific targets and theory for further research into clinical applications such as selection of idiographic odorants for use in virtual-reality exposure therapy.

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Exposure therapy (EXP) is one of the most widely used and empirically supported treatments for PTSD; however, some researchers have questioned its efficacy with specific populations and in targeting specific symptoms. One such symptom, guilt, has garnered increased attention in the PTSD treatment literature, as it is associated with worse symptomatology and outcomes. The current study examined cognitive changes in guilt in response to Intensive (3-week) and Standard (17-week) Trauma Management Therapy (TMT), and the potential mechanisms underlying TMT treatment. TMT is an exposure based intervention that does not include an emotional processing component after the imaginal exposure session. A portion of the sample completed measures of guilt. As a result, sample size for these analyses ranged from 39 to 102 and varied by the domain and measure. Of the 102 individuals that completed the PTSD Checklist- Military Version, 42 completed the Trauma Related Guilt Inventory, and 39 completed the Clinician Administered PTSD Scale supplemental guilt items. Participants reported significant reductions in trauma-related guilt symptoms over the course of the TMT interventions. Greater reductions in avoidance and prior session general arousal predicted the reduction of guilt symptoms. Exposure therapy may be effective in reducing trauma-related guilt even in the absence of the emotional processing component of treatment.

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The prevalence of posttraumatic stress disorder (PTSD) among U.S. veterans deployed to Iraq or Afghanistan necessitates the need for comprehensive assessment and treatment strategies. This study investigated the utility of a combat-related PTSD symptom provocation paradigm to elicit unique neurological responses across three groups: combat veterans with PTSD, combat veterans without PTSD, and nonmilitary participants without PTSD. Using functional near-infrared spectroscopy (fNIRS) the results indicated that combat veterans with PTSD demonstrated significant activation to a trauma-related sound compared with nonmilitary personnel, channel 14: d = 1.03, 95% confidence interval (CI) [0.28, 1.76]; channel 15: d = 1.30, 95% CI [0.53, 2.06]; and combat veterans without PTSD, channel 14: d = 0.87, 95% CI [0.14, 1.59]. Specifically, this increased neural activation was approximately located in the right medial superior prefrontal cortex (Brodmann areas 9/10), an area associated with experiencing negative or threatening stimuli and emotional detachment. There were no differences across the groups for nontrauma-related sounds. Results were less clear with respect to a combat-related odor. These results suggest a specific neurophysiological response to trauma-related cues and, if replicated, may offer a biomarker for combat-related PTSD. Such a response could provide incremental validity over diagnostic assessments alone and assist in planning and monitoring of treatment outcome.

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An estimated 18.5% of veterans returning from Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn are suffering from posttraumatic stress or posttraumatic stress disorder (PTSD). The number of veterans and service duty personnel requesting VA health care services is increasing, and the VA's ability to handle requests is dwindling. Thus, both the content of interventions and the format by which these services are delivered need to be reconceptualized. The authors present a multicomponent intervention program known as Trauma Management Therapy (TMT), a comprehensive, empirically supported treatment that can be delivered in an intensive, 3-week outpatient format. TMT combines individual exposure therapy with group social and emotional rehabilitation skills training to address specific aspects of the combat-related PTSD syndrome. The authors present the format of this novel intensive outpatient program, describe the components, and address implementation factors such as treatment compliance, dropout rates, and administrative considerations.

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Despite the 8-18.5% of returning Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) veterans who are suffering from posttraumatic stress disorder (PTSD), few receive empirically supported treatments. Among those that do, the dropout rate is high and more than 50% retain their diagnosis after treatment. This study evaluated the efficacy of Trauma Management Therapy (TMT), delivered in a 3-week intensive outpatient (IOP) format. TMT combines virtual-reality augmented individual exposure therapy with a group intervention to address social isolation, anger, and depression. One hundred twelve (112) OIF/OEF/OND veterans and active duty personnel participated. Assessment included measures of PTSD, sleep, depression, anger, guilt, and social isolation, administered at post-treatment, 3-month, and 6-month follow-up. The effect size for TMT delivered in an IOP format was 2.06, with 65.9% no longer meeting diagnostic criteria for PTSD. There were similar positive effects in other domains and treatment gains were maintained at 6-month follow-up. The results are discussed regarding the need for efficacious, multi-component interventions that can be delivered safely and rapidly, and the potential of this approach towards that end.

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