This article reviews cigarette smoking in patients with psychiatric disorders (PD) and substance use disorders (SUD). Rates of smoking are approximately 23% in the U.S. population but approximately two-to four-fold higher in patients with PD and SUD. Many remaining smokers have had repeated smoking cessation failures, possibly due to the presence of co-morbid PD and SUDs. There is modest, evidence-based support for effective treatment interventions for nicotine addiction in PD and SUD. Further research is needed to increase our understanding of nicotine addiction in PD and SUD and develop more effective treatment interventions.Although smoking prevalence in the United States has decreased from 43.8% in 1965 to 23.3% in 2000, 1 there are many cigarette smokers who have been unable to quit. An important subset of refractory smokers are those with psychiatric disorders (PD) and substance use disorders (SUD), among whom smoking rates exceed those in the general population by two-to fourfold. 2 In a population-based study of smoking prevalence in the U.S., Lasser and colleagues found that smoking prevalence among persons with and without a psychiatric disorder were 41% and 22.5%, respectively. 2 The highest prevalence (67.9%) was found among persons with drug abuse. Consistent with these results, Degenhardt and Hall 3 reported similar findings in their study of smoking prevalence in Australia. The prevalence of smoking in various PD and SUD 4 is presented in Fig. 1. Other studies have found that individuals with PD and SUD are at higher risk for many tobacco-related diseases, including cardiovascular illness, respiratory disease, and cancer, than individuals in the general population. 5-8 Among "ever smokers," persons with PD or SUD are less likely to be former smokers than other smokers. Lasser et al. 2 found that the quit rate among ever smokers with no history of PD or SUD was 42.5%. Significantly lower quit rates were associated with several other PD and SUD, including alcohol use disorder (16.9%), bipolar disorder (25.9%), major depression (26.0%), and post-traumatic stress disorder (23.2%). Clearly, improved treatments for nicotine addiction are needed for these populations.Several explanations have been proposed for the high prevalence of smoking in individuals with PD and SUD. First, there may be intrinsic factors (eg, shared genes, abnormalities in brain

Smoking is highly prevalent across most anxiety disorders. Tobacco use increases risk for the later development of certain anxiety disorders, and smokers with anxiety disorders have more severe withdrawal symptoms during smoking cessation than smokers without anxiety disorders. The authors critically examined the relationships among anxiety, anxiety disorders, tobacco use, and nicotine dependence and reviewed the existing empirical literature. Future research is needed to better understand the interrelationships among these variables, including predictors, moderators, and mechanisms of action. Increased knowledge in these areas should inform prevention efforts as well as the development and improvement of smoking cessation programs for those with anxiety and other psychiatric disorders.

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are highly prevalent among Veterans of the conflicts in Iraq and Afghanistan. These conditions are associated with common and unique neuropsychological and neuroanatomical changes. This review synthesizes neuropsychological and neuroimaging studies for both of these disorders and studies examining their co-occurrence. Recommendations for future research, including utilizing combined neuropsychological and advanced neuroimaging techniques to study these disorders alone and in concert, are presented. It is clear from the dearth of literature that more attention in the literature should be given to examining temporal relationships between PTSD and mTBI, risk and resilience factors associated with both disorders and their co-occurrence, and mTBI-specific factors such as time since injury and severity of injury, utilizing comprehensive, yet targeted cognitive tasks.

Objective-A substantial proportion of the more than 2 million service members who have served in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) have experienced a traumatic brain injury (TBI). Understanding the long-term impact of TBI is complicated by the non-specific nature of postconcussive symptoms (PCS) and the high rates of co-occurrence among TBI, posttraumatic stress disorder (PTSD), and depression. The goal of the present research was to examine the relations among TBI, persistent PCS, and symptoms of PTSD and depression among returning OEF/OIF Veterans.Design-Two-hundred and thirteen OEF/OIF Veterans (87% male) completed a semi-structured screening interview assessing deployment-related TBI and current, persistent PCS. Participants also completed self-report measures of combat exposure and current symptoms of PTSD and depression.Results-Nearly half (46%) of sampled Veterans screened positive for TBI, the majority of whom (85%) reported at least one persistent PCS after removing PCS that overlapped with PTSD and depression. Veterans with deployment-related TBI reported higher levels of combat exposure and symptoms of PTSD and depression. Structural equation modeling was used to assess the fit of three models of the relationships among TBI, combat exposure, persistent PCS, PTSD, and depression. Consistent with hypotheses, the best fitting model was one in which the effects of TBI on both PTSD and depression were fully mediated by non-overlapping persistent PCS.Implications-These findings highlight the importance of addressing persistent PCS in order to facilitate the functional recovery of returning war Veterans.Understanding the long-term effects of traumatic brain injury (TBI) has important public health implications. Estimates suggest that one to two million Americans sustain a TBI annually (Faul, Xu, Wald, & Coronado, 2010;Gerberding & Binder, 2003;Sosin, Sniezek, & Thurman, 1996;Thurman, Alverson, Dunn, Guerrero, & Sniezek, 1999;. Moreover, the large number of Veterans of the wars in Iraq and Afghanistan add to the global incidence of TBI. Since the inception of the current conflicts in Iraq and Afghanistan, more than two million U.S. troops have been deployed as part of (Stein & McAllister, 2009;Vanderploeg, Curtiss, Luis, & Salazar, 2007; Zaloshnja, Miller, Langlois, & Selassie, 2008). U.S. Department of Veterans AffairsIn general, following sports-related mTBI, post-injury cognitive effects (i.e., performance on neuropsychological tests) tend to resolve within 5-7 days (Guskiewicz et al., 2003), and PCS generally resolve within 2 weeks (Carroll et al., 2004). For mTBIs arising from non-sportsrelated events, post-injury cognitive effects tend to resolve within several weeks to 3 months (e.g., Belanger, Curtis, Demery, Lebowitz, & Vanderploeg, 2005;Carroll et al., 2004); however, PCS following mTBI may persist for one year post-injury or longer in adult civilian (Carroll et al., 2004) and Veteran (Stein & McAllister, 2009) samples. Despite the expectation of full recovery in most...

Although much is known regarding predictors of posttraumatic stress disorder (PTSD), little of this knowledge directly informs treatment. This study examined whether higher scores on the Acceptance and Action Questionnaire—II (AAQ–II), a self-report measure that purportedly assesses experiential avoidance and psychological inflexibility, accounted for unique variance in PTSD symptoms compared with personality factors and other established predictors of PTSD. In addition, this study examined whether the construct measured by the AAQ–II accounts for unique variance in PTSD severity over and above the avoidance symptoms of PTSD. A sample of 109 trauma-exposed veterans of the wars in Iraq and Afghanistan, approximately half of whom met current PTSD criteria on the Clinician-Administered PTSD Scale (CAPS), completed self-report measures of PTSD, combat exposure, perceived life threat, peritraumatic dissociation, recent life stress, perceived postdeployment social support, and personality. Higher AAQ–II scores, which indicate higher levels of psychological inflexibility and experiential avoidance, accounted for unique variance in PTSD symptom severity after controlling for all other predictors (small effect size [ES] on the CAPS; large ES on the self-report PTSD measure). Significant effects for AAQ–II scores remained after controlling for the avoidance symptoms of PTSD (small ES on the CAPS; medium ES on the self-report measure). Scores on the AAQ–II appears to be an important predictor of PTSD that warrants further investigation. Research should continue to examine the malleability of the constructs assessed by the AAQ–II, which may be useful targets in treatment.

Mindfulness and self-compassion are overlapping, but distinct constructs that characterize how people relate to emotional distress. Both are associated with posttraumatic stress disorder (PTSD) and may be related to functional disability. Although self-compassion includes mindful awareness of emotional distress, it is a broader construct that also includes being kind and supportive to oneself and viewing suffering as part of the shared human experience--a potentially powerful way of dealing with distressing situations. We examined the association of mindfulness and self-compassion with PTSD symptom severity and functional disability in 115 trauma-exposed U.S. Iraq/Afghanistan war veterans. Mindfulness and self-compassion were each uniquely, negatively associated with PTSD symptom severity. After accounting for mindfulness, self-compassion accounted for unique variance in PTSD symptom severity (f(2) = .25; medium ES). After accounting for PTSD symptom severity, mindfulness and self-compassion were each uniquely negatively associated with functional disability. The combined association of mindfulness and self-compassion with disability over and above PTSD was large (f(2) = .41). After accounting for mindfulness, self-compassion accounted for unique variance in disability (f(2) = .13; small ES). These findings suggest that interventions aimed at increasing mindfulness and self-compassion could potentially decrease functional disability in returning veterans with PTSD symptoms.

U.S. combat veterans of the Iraq and Afghanistan wars have elevated rates of posttraumatic stress disorder (PTSD) compared to the general population. Self-compassion, characterized by self-kindness, a sense of common humanity when faced with suffering, and mindful awareness of suffering, is a potentially modifiable factor implicated in the development and maintenance of PTSD. We examined the concurrent and prospective relationship between self-compassion and PTSD symptom severity after accounting for level of combat exposure and baseline PTSD severity in 115 Iraq and Afghanistan war veterans exposed to 1 or more traumatic events during deployment. PTSD symptoms were assessed using the Clinician Administered PTSD Scale for DSM-IV (CAPS-IV) at baseline and 12 months (n =101). Self-compassion and combat exposure were assessed at baseline via self-report. Self-compassion was associated with baseline PTSD symptoms after accounting for combat exposure (β = -.59; p < .001; ΔR(2) = .34; f(2) = .67; large effect) and predicted 12-month PTSD symptom severity after accounting for combat exposure and baseline PTSD severity (β = -.24; p = .008; ΔR(2) = .03; f(2) = .08; small effect). Findings suggest that interventions that increase self-compassion may be beneficial for treating chronic PTSD symptoms among some Iraq and Afghanistan war veterans.

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co‐occur and are associated with worse outcomes together than either disorder alone. A lack of consensus regarding recommendations for treating PTSD–AUD exists, and treatment dropout is a persistent problem. Acceptance and Commitment Therapy (ACT), a transdiagnostic, mindfulness‐ and acceptance‐based form of behavior therapy, has potential as a treatment option for PTSD–AUD. In this uncontrolled pilot study, we examined ACT for PTSD–AUD in 43 veterans; 29 (67%) completed the outpatient individual therapy protocol (i.e., ≥ 10 of 12 sessions). Clinician‐assessed and self‐reported PTSD symptoms were reduced at posttreatment, ds = 0.79 and 0.96, respectively. Self‐reported symptoms of PTSD remained lower at 3‐month follow‐up, d = 0.88. There were reductions on all alcohol‐related outcomes (clinician‐assessed and self‐reported symptoms, total drinks, and heavy drinking days) at posttreatment and 3‐month follow‐up, dmean = 0.91 (d range: 0.65–1.30). Quality of life increased at posttreatment and follow‐up, ds = 0.55–0.56. Functional disability improved marginally at posttreatment, d = 0.35; this effect became significant by follow‐up, d = 0.52. Fewer depressive symptoms were reported at posttreatment, d = 0.50, and follow‐up, d = 0.44. Individuals experiencing suicidal ideation reported significant reductions by follow‐up. Consistent with the ACT theoretical model, these improvements were associated with more between‐session mindfulness practice and reductions in experiential avoidance and psychological inflexibility. Recommendations for adapting ACT to address PTSD–AUD include assigning frequent between‐session mindfulness practice and initiating values clarification work and values‐based behavior assignments early in treatment.