Heart failure (HF) is a major public health problem throughout the world. It accounts for one death certificate among nine in the United States. Heart failure and sudden death combined are responsible for the largest number of deaths in America. The total costs of HF in the United States are estimated to be $37 billion each year. Despite substantial medical and surgical advances related to treatment of HF, it remains a very costly condition with high mortality and morbidity rates. Although biological factors contribute to high morbidity and mortality in HF, there are many unexplored psychosocial factors that also likely contribute to these rates. Thus, the purpose of this dissertation was to examine the association between some of the psychosocial factors (i.e. depression, anxiety, comorbid depression and anxiety, stress, cognitive appraisal, and coping) and health outcomes as defined by rehospitalisation and mortality among HF patients. The first paper is a report of longitudinal study of 1,260 patients with HF. The purpose of the study was to determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. Anxiety and depression were treated first as continuous level variables, then as categorical variables using standard published cut points. Patients were then divided into four groups based on the presence of symptoms of anxiety and depression. When depression and anxiety were treated as continuous level variables, both comorbid depression and anxiety, and depression alone were significant predictors of all-cause mortality. However, when depression and anxiety were treated as categorical variables, comorbid depression and anxiety was a predictor of all-cause mortality, while anxiety and depressive symptoms considered alone were not independent predictors of the same outcome. None of those variables were significant predictors of cardiac rehospitalization outcome, regardless of whether entered as continuous or categorical level variables. The second paper is a report of a study that was conducted to (1) examine the association of stress with 6-month cardiac event-free survival; (2) examine the relationship of stress with salivary cortisol; and (3) examine the association of salivary cortisol level with 6-month cardiac event-free survival. The study sample was 81 HF patients. A prospective design was used in which patients were followed for 6 months to determine occurrence of 6-month cardiac event-free survival, defined as time to the combined endpoint of cardiac rehospitalization or all-cause death. Stress was not a significant predictor of event-free survival in HF, salivary cortisol was a significant predictor of event-free survival in the unadjusted model, but not in the adjusted model, and stress was not a significant predictor of salivary cortisol level. The final paper is a report of prospective design study that aimed to describe self-reported stress level, cognitive appraisal and coping among patients with HF, and to examine the association of cognitive appraisal and coping strategies with event-free survival based on a proposed model of HF patients’ response to stressors that been suggested according to literature to date. The study sample consisted of 88 HF patients who been followed for 6 months to determine occurrence of the combined endpoint of rehospitalization for cardiac causes or all-cause death. The study showed that stress level was associated with harm and loss cognitive appraisal. Harm/loss and threat cognitive appraisals were associated with avoidant emotional coping. Furthermore, harm/loss cognitive appraisal was a significant predictor of avoidant emotional coping and event free survival. Finally avoidant emotional coping was a significant predictor of event free survival among HF patients in the unadjusted model, but not in the adjusted model. The findings from this dissertation provided further evidence of the importance of psychosocial factors to health outcomes in HF patients. It also filled important gaps in the body of knowledge related to health outcomes among those with HF by demonstrating the need for cognitive and behavioral therapy among HF patients who negatively appraise their health condition.

The purpose of this quantitative study was to examine whether the post-deployment screening instrument currently utilized to assess active-duty Marines for symptoms of PTSD upon their return from a combat deployment can be solely relied upon to accurately assess for PTSD. Additionally, this study sought to compare the number of Marines who have sought trauma-related mental health treatment based on their answers on the Post-Deployment Health Assessment (PDHA) to the number who have sought trauma-related mental health treatment based on their answers on their PTSD Checklist â?? Military Version (PCL-M). The participants in this study were comprised of a sample of active-duty Marines that had recently returned from a combat deployment. A quantitative secondary data analysis used Item Response Theory (IRT) to examine the answers provided by the participants on both the PDHA and PCL-M. Both instruments proved to be effective when assessing symptoms of PTSD and the participants identified as having symptoms of PTSD were referred for mental health services as required. According to the results, more Marines were identified as having symptoms of PTSD using both assessment instruments (PDHA and PCL-M) compared to those identified using just the PDHA. The result was a better understanding of predictors of Marines who may later develop PTSD. The results of this study can also assist the Marine Corps with its post-deployment screening for symptoms of PTSD which in turn can provide appropriate mental health referrals for Marines if deemed appropriate.

Borderline Personality Disorder (BPD) is a disabling condition characterized by chronic emotion dysregulation and behavioral impulsivity. Prospective studies that test proposed mechanisms of within-person change in BPD hold the key to improving symptom predictability and control in this disorder. A small body of evidence suggests that fluctuations in estradiol such as those occurring naturally at ovulation during the monthly female reproductive cycle may increase symptoms in women with BPD (DeSoto et al., 2003). Furthermore, there is preliminary evidence that both self-esteem and feelings of social rejection are highest at ovulation, when estradiol peaks (Durante and Hill, 2009; Eisenlohr-Moul et al., under review). Such feelings have been reliably linked to increases in BPD-related behavior in all individuals (e.g., Twenge et al., 2002). The purpose of this dissertation was to test a cyclical vulnerability model for women with BPD in which ovulatory estradiol shifts are associated with reductions in felt social acceptance, which in turn are associated with increased BPD symptom expression. 40 women, sampled to achieve a flat distribution of BPD symptoms, completed 28 daily diaries online, as well as four 1-hour weekly visits to the laboratory to complete longer assessments and provide saliva samples, which were assayed for estradiol. In addition, participants underwent the Structured Clinical Interview for the Diagnosis of BPD at the end of the study. Results of multilevel models revealed the opposite of the predicted effects of within-person changes in estradiol and their interaction with trait BPD. The data suggest a pattern in which women high in trait BPD show increases in felt acceptance and reductions in BPD symptom expression at higher levels of conception probability and higher-than-usual levels of estradiol. Women low in trait BPD show the opposite pattern in some cases. Several alternative moderators were tested, and results suggest that some risk factors for BPD (e.g., Neuroticism, Sexual Abuse) interact with high trait levels of estradiol to predict greater symptoms. Both average levels of estradiol and monthly fluctuations in estradiol may have relevance for women with BPD. It is recommended that future studies utilize clinical samples and additional physiological measures to further elucidate the mechanisms through which estradiol exerts clinically-relevant change.

In 1869 the General Assembly of the Commonwealth of Virginia passed legislation that established the first asylum in the United States to care exclusively for African-American patients. Then known as Central Lunatic Asylum for the Colored Insane and located in Richmond, Virginia, the asylum began to admit patients in 1870. This thesis explores three aspects of Central State Hospital's history during the nineteenth century: attitudes physicians held toward their patients, the involuntary commitment of patients, and life inside the asylum. Chapter One explores the nineteenth-century belief held by southern white physicians, including those at Central State Hospital, that freed people were mentally, emotionally, and physically unfit for freedom. Chapter Two explains the involuntary commitment of African Americans to Central State Hospital in 1874. Chapter Three considers patient life at the asylum by contrasting the expectation of “Moral Management” care with the reality of daily life and treatment.

Qualitative phenomenological methodology was used to explore the lived experiences of African American women diagnosed with breast cancer. Phenomenology focuses on the meaning of the lived experiences of individuals experiencing a concept, structure, or phenomenon (Creswell, 2007). The purpose of phenomenological research is to identify phenomena as perceived by the individual. Utilizing an existential perspective, the focus of this study was to uncover meaning which defined the essence of the participants’ experiences. Seven African American women diagnosed with breast cancer participated in this study. The participants’ ages ranged from 33-63 years. A semi-structured interview process with open-ended questions was utilized to gain an understanding of the participants’ personal experiences related to the phenomenon. Data was analyzed using Interpretative Phenomenological Analysis (Smith, 2004) to ascertain emergent themes and to interpret the meaning of the participants’ breast cancer experience. Seven common themes emerged from the cases. Those themes included: spirituality; support systems; self-care; resiliency; existential meaning; education; and perception of counseling. These seven themes will help to provide insight into how counselors can help to facilitate emotional wellness within this particular population. Implications and recommendations for counselor educators, counselors, and counselors-in-training with this population are also addressed.

Parental responses to their children are crucially influenced by stress. However, brain-based mechanistic understanding of the adverse effects of parenting stress and benefits of therapeutic interventions is lacking. We studied maternal brain responses to salient child signals as a function of Mom Power (MP), an attachment-based parenting intervention established to decrease maternal distress. Twenty-nine mothers underwent two functional magnetic resonance imaging brain scans during a baby-cry task designed to solicit maternal responses to child's or self's distress signals. Between scans, mothers were pseudorandomly assigned to either MP (n = 14) or control (n = 15) with groups balanced for depression. Compared to control, MP decreased parenting stress and increased child-focused responses in social brain areas highlighted by the precuneus and its functional connectivity with subgenual anterior cingulate cortex, which are key components of reflective self-awareness and decision-making neurocircuitry. Furthermore, over 13 weeks, reduction in parenting stress was related to increasing child- versus self-focused baby-cry responses in amygdala–temporal pole functional connectivity, which may mediate maternal ability to take her child's perspective. Although replication in larger samples is needed, the results of this first parental-brain intervention study demonstrate robust stress-related brain circuits for maternal care that can be modulated by psychotherapy.

The purpose of this dissertation was to evaluate the association of psychological distress with cardiac disease, events, and mortality. Specific aims were to: 1) to evaluate the association between hostility level and recurrence of acute coronary syndrome (ACS) and all-cause mortality in patients with coronary heart disease (CHD); 2) to evaluate the psychometric properties of the Brief Symptom Inventory (BSI) hostility and anxiety subscales in a group of incarcerated participants at high risk of cardiovascular disease; and 3) to evaluate the association of patient and caregiver psychological state with quality of life in both patient and caregiver, and postoperative complications after cardiac surgery. Specific aim one was addressed through a secondary analysis of data collected during the Patient Response to Myocardial Infarction following a Teaching Intervention Offered by Nurses trial to determine whether hostility was a predictor of ACS recurrence and mortality. Hostility was common after ACS and predicted all-cause mortality. Hostility did not predict recurrent ACS. Specific aim 2 was addressed in a secondary analysis of baseline data from a randomized controlled trial in male prisoners. Participants completed the BSI at baseline prior to the intervention. Internal consistency reliability was good for both subscales (Cronbach’s alpha - hostility 0.83, anxiety 0.81). Items from the two dimensions were analyzed together using exploratory factor analysis with varimax rotation. Two dimensions, anxiety and hostility, were identified. Construct validity was supported; those with high anxiety and hostility reported a greater number of days where their self-reported health was rated as fair or poor. Those prisoners with less perceived control had higher levels of anxiety and hostility. Specific aim 3 was addressed through a prospective, descriptive correlational study that measured patient and caregiver anxiety, hostility and depressive symptoms, at baseline to determine whether these predicted quality of life using a multilevel dyadic analysis; and to evaluate the association of baseline anxiety, hostility and depressive symptoms and quality of life with postoperative complications and mortality. Anxiety, hostility, and depressive symptoms were common in both cardiac patients and their caregiver. Psychological state influenced quality of life in both dyad members, but was not associated with complications.

This purpose of this study was to explore social workers’ perspectives of drug-induced psychosis. More specifically, it sought to determine how knowledgeable clinical social workers are on the impact illicit drug use on the development of psychotic disorders. The study also aimed to discover clinical social workers’ perspectives regarding the influence of illicit drug use on the development of psychotic illnesses. This study used mixed methods approach in attempt to solve the research question. The quantitative portion of the research, an anonymous survey, allowed for the assessment of social workers’ knowledge of drug-induced psychosis. The qualitative portion of the research, individual interviews and a focus group, allowed for a comparison of social workers’ experiences from having encountered drug-induced psychosis in clinical practice. The qualitative findings produced insight that highlighted common themes that can be explored further in future research within the context of clinical social work practice.

Trauma-informed care (TIC) is an approach to service delivery based on the understanding of the prevalence of psychological trauma among service users, knowledge about the impact trauma has on engagement to services, and recognition that service settings can be re-traumatizing. For more than a decade, momentum has been building on this topic. Practitioners are pursuing the knowledge and skills needed to implement trauma-informed service delivery, while organizations are building infrastructure and processes aimed at supporting this approach. Disciplines across many human service sectors are eager to incorporate TIC into policy and practice. Despite this enthusiasm, implementation efforts are slow. Acquiring foundational knowledge about TIC has typically been recommended as a first step when implementing a trauma-informed approach. However, slow progress in implementation suggests knowledge may not be enough. This study investigated the individual characteristics that impact a commitment to TIC, with specific attention to the relationship between foundational knowledge about trauma-informed care and commitment to TIC. Other variables of interest included perceived principal support, TIC self-efficacy, beliefs about trauma and its impact, and organizational strain. Survey data were collected from 118 participants working in mental health, public health, and early childhood. Results from structural equation modeling suggest that foundational knowledge predicts affective commitment to TIC both directly and with the partially mediated paths through principal support, TIC self-efficacy, and beliefs about trauma. Organizational strain does not moderate these effects. However, group differences based on high and low levels of perceived organizational strain were observed and discussed. These findings add to the growing literature on TIC and should be considered as organizations strive to implement TIC.

This study was conducted to comparatively examine child specific expulsion rates and parent satisfaction of children who received early childhood mental health consultation (ECMHC) services delivered in 2 states for the 2012 program year: Maryland (unlicensed) and Delaware (licensed) . This current study examined secondary data to determine whether unlicensed (Maryland) ECMHC professionals are equally or more effective than licensed (Delaware) ECMHC professionals. Of the total number of child specific consultations or cases referred for services in Maryland (unlicensed), N = 370, n = 266 children avoided expulsion and were able to remain at their childcare placements while n = 17 children were expulsed. Of the total number of child specific consultations or cases referred for services in Delaware (licensed), N = 135, n = 119 children were able to remain in their childcare placements while n = 3 children were expulsed. The results of this study revealed that there is no statistically significant difference in expulsion rates between Unlicensed (Maryland) professionals and Licensed (Delaware) professionals. Results suggest that licensure status of ECMHC professionals has no affect on expulsion rate outcomes and should receive further examination. Additionally, results could support policy changes that could lead to a national credentialing process that would address the current gap in ECMHC services due to the shortage of qualified ECMHC professionals. This study was unable to determine the outcome of parent satisfaction due to missing data. Future direction should include replication using a mixed longitudinal study.