Christopher B. Donahue

D-Cycloserine Augmented Exposure Therapy for Obsessive-Compulsive Disorder

BACKGROUND D-cycloserine (DCS), a glutamatergic partial N-methyl-d-aspartate (NMDA) agonist, can facilitate extinction learning related to cued fear in animals and humans. We predicted that DCS would accelerate obsession-related distress reduction in patients with obsessive-compulsive disorder (OCD) undergoing extinction-based exposure therapy. METHODS We administered DCS (125 mg) or placebo in a double-blind fashion to individuals with OCD approximately 2 hours before each exposure session. RESULTS D-cycloserine decreased both the number of exposure sessions required to achieve clinical milestones and the rate of therapy dropout. After four exposure sessions, patients in the DCS group reported significantly greater decreases in obsession-related distress compared with the placebo group; however, after additional sessions, the placebo group tended to catch up. CONCLUSIONS D-cycloserine augmentation has the potential to increase the efficiency, palatability, and overall effectiveness of standard exposure therapy for OCD.

Imaginal desensitisation plus motivational interviewing for pathological gambling: randomised controlled trial

Sixty-eight individuals were randomised to either six sessions of imaginal desensitisation plus motivational interviewing (IDMI) or Gamblers Anonymous. Individuals assigned to IDMI had significantly greater reductions in Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling total scores, gambling urges and gambling behaviour. People who failed to respond to Gamblers Anonymous reported significantly greater reduction in pathological gambling symptoms following later assignment to IDMI. Abstinence was achieved by 63.6% during the acute IDMI treatment period.

Urge to Gamble in Problem Gamblers Exposed to a Casino Environment

Cue-reactivity has received increased attention in addiction research, though not for gambling in particular. We examined cue reactivity in 18 problem gamblers by accompanying them to a gaming casino and measuring their subjective urge to gamble over a 1-h period. Half of the sample was additionally exposed to a gambling-specific negative mood induction (NMI) manipulation via guided imagery. Overall, about two-thirds of the sample reported moderate to high-gambling urges during the casino exposure. Additionally, the NMI reduced cue-reactivity. Finally, gambling urges in both groups decreased over the course of the exposure sessions. These findings suggest that a majority of problem gamblers experience the urge to gamble when exposed to gambling cues and that the intensity of these urges decrease with time, especially in the presence of a gambling-relevant NMI. Cue exposure should be studied further as a potential tool in the treatment of problem gambling.

A randomized, placebo-controlled trial of N-acetylcysteine plus imaginal desensitization for nicotine-dependent pathological gamblers

OBJECTIVE Pathological gambling is associated with elevated proportions of nicotine dependence, and tobacco smoking in pathological gamblers has been associated with increased problem-gambling severity. This study examined the addition of N-acetylcysteine to imaginal desensitization in adults with co-occurring nicotine dependence and pathological gambling. METHOD Twenty-eight individuals with co-occurring DSM-IV nicotine dependence and pathological gambling who were receiving behavioral therapy were recruited from December 2009 to February 2012 and randomized to augmentation with N-acetylcysteine or placebo in an 12-week, double-blind trial. Subjects were assessed with measures of nicotine and gambling severity and followed for 3 months after treatment. The primary outcomes were the Fagerström Test for Nicotine Dependence and the pathological gambling adaptation of the Yale-Brown Obsessive-Compulsive Scale. RESULTS During the first 6 weeks, there was a significant benefit of N-acetylcysteine treatment versus placebo on Fagerström Test for Nicotine Dependence total scores (t = -2.224; P = .031). After the initial 6 weeks, all subjects significantly (P < .001) benefited from imaginal desensitization. During the 3-month follow-up, there was a significant additional benefit for N-acetylcysteine versus placebo on measures of problem-gambling severity (t = 2.069; P = .043). CONCLUSIONS N-acetylcysteine treatment during therapy facilitates long-term application of behavioral therapy techniques once patients are in the community after therapy has been completed. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00967005.

Cognitive behavioral treatment of comorbid anxiety disorder in alcoholism treatment patients: Presentation of a prototype program and future directions

Background: Anxiety disorders frequently co-occur with alcohol use disorders (comorbidity). Among alcoholism treatment patients, comorbid anxiety disorders often do not improve without specific treatment and can increase the risk for relapse to drinking. Aims: In this paper we describe evolving work on treatment approaches for individuals with alcohol dependence and comorbid anxiety disorder. Method:  We overview issues related to comorbidity and its treatment. We describe a prototype of an integrated CBT treatment protocol that integrates CBT treatment for panic disorder with content focusing on the interaction of alcohol use and panic symptoms. We discuss practical lessons learned over the course of this research program and how we are incorporating them into our ongoing work. Results:  Preliminary findings show that this program is well accepted by patients undergoing an intensive alcoholism treatment and offers significant clinical advantages over alcoholism treatment alone. Conclusions:  We conclude that integrated CBT treatments for comorbid anxiety disorder can be a practical and efficacious adjunct to standard alcoholism treatment.

Effect of quetiapine vs. placebo on response to two virtual public speaking exposures in individuals with social phobia

OBJECTIVE Clinical practice and open-label studies suggest that quetiapine (an atypical anti-psychotic) might improve symptoms for individuals with social anxiety disorder (SAD). The purpose of this study was to provide a rigorous test of the acute impact of a single dose of quetiapine (25mg) on SAD symptoms. METHOD Individuals with SAD (N=20) were exposed to a 4-min virtual reality (VR) public speaking challenge after having received quetiapine or placebo (double-blind) 1h earlier. A parallel VR challenge occurred 1 week later using a counter-balanced cross-over (within subject) design for the medication-placebo order between the two sessions. RESULT There was no significant drug effect for quetiapine on the primary outcome measures. However, quetiapine was associated with significantly elevated heart rate and sleepiness compared with placebo. CONCLUSION Study findings suggest that a single dose of 25mg quetiapine is not effective in alleviating SAD symptoms in individuals with fears of public speaking.

Stress and Impulsive Behaviors

Publisher Summary This chapter explores the complex relationship between stress, impulsivity, and substance use disorders (SUDs). A representative sample of individual impulse control disorders is reviewed to include pathological gambling (PG), trichotillomania (TTM), and intermittent explosive disorder (IED), and categorized as problems of reward seeking (PG), habit (TTM), and a lack of premeditation (IED). Factors that mediate the disorders include tension reduction and affective regulation and can be further complicated by, and hold many similarities to, SUDs. Individuals with impulse control disorders can engage in the problem behavior as a means to immediately reduce tension or urge intensity and also seek to regulate affective states, particularly negative states (e.g., depression, boredom, and anxiety), which there is low tolerance for. Individuals with impulse control disorders suffer numerous negative psychosocial stressors as a result of their acting on the impulses. Impulsivity, aggression, and sensation seeking are common features of SUD and impulse control disorders (PG and IED) leading to problems in managing either comorbid disorders. Treatment of the differing impulse control problems requires multimodal approaches (psychosocial, behavioral, and pharmacological) in order to address unique qualities of each problem. Promising psychological treatment approaches include components of cognitive behavioral therapy (CBT) such as cognitive retraining, behavioral modification, cue exposure, and self-control training.

Adolescent stealing treated with motivational interviewing and imaginal desensitization — Case report

Background Adolescent shoplifting occurs in an estimated 15% of the United States population. Although adolescent stealing is associated with significant psychosocial consequences there is limited research concerning efficacious treatments. Case study A 17-year-old male with a history of compulsive stealing was treated using a six-session, individualized cognitive-behavioral therapy protocol which included motivational interviewing, psycho-education, behavioral modification, and an exposure script using imaginal desensitization. After the six-session therapy, the patient continued for eight further sessions of therapy to maintain treatment gains. His Yale-Brown Obsessive Compulsive Scale scores dropped from a 22 pre-treatment to a 3 at the end of the 14 sessions of therapy and he remained abstinent from stealing. Discussion This case reports on the successful use of an individualized, cognitive behavioral therapy on an adolescent with compulsive shoplifting and other antisocial behaviors. This treatment provides a promising step towards the treatment of a relatively common adolescent behavior.

Stress, Anxiety, and Addiction: Intervention Strategies

Publisher Summary This chapter explores the relationship between anxiety symptoms, stress responding, and substance use disorders (alcohol and drug), with special emphasis on treatment approaches. Having an anxiety disorder increases the probability of having substance use disorder (SUD) with research showing the short-term effects of alcohol and drug use dampening stress responding. Factors that can contribute to individuals developing SUD include stress reduction alcohol and drug outcome expectancies, and avoidant and impulsive personality styles. Individuals with an SUD are at an increased risk for relapse following standard substance abuse treatment. This observation provides the basis for developing treatment approaches that specifically target SUD. Different treatment approaches for dual diagnosis are discussed, including parallel, sequential, and hybrid strategies. It concludes that hybrid treatment approaches that focus on the interactive aspects of stress, anxiety, and substance use are the most promising approaches for future study.Publisher Summary This chapter explores the relationship between anxiety symptoms, stress responding, and substance use disorders (alcohol and drug), with special emphasis on treatment approaches. Having an anxiety disorder increases the probability of having substance use disorder (SUD) with research showing the short-term effects of alcohol and drug use dampening stress responding. Factors that can contribute to individuals developing SUD include stress reduction alcohol and drug outcome expectancies, and avoidant and impulsive personality styles. Individuals with an SUD are at an increased risk for relapse following standard substance abuse treatment. This observation provides the basis for developing treatment approaches that specifically target SUD. Different treatment approaches for dual diagnosis are discussed, including parallel, sequential, and hybrid strategies. It concludes that hybrid treatment approaches that focus on the interactive aspects of stress, anxiety, and substance use are the most promising approaches for future study.

Chapter 15 – Stress, Anxiety, and Addiction: Intervention Strategies

Publisher Summary This chapter explores the relationship between anxiety symptoms, stress responding, and substance use disorders (alcohol and drug), with special emphasis on treatment approaches. Having an anxiety disorder increases the probability of having substance use disorder (SUD) with research showing the short-term effects of alcohol and drug use dampening stress responding. Factors that can contribute to individuals developing SUD include stress reduction alcohol and drug outcome expectancies, and avoidant and impulsive personality styles. Individuals with an SUD are at an increased risk for relapse following standard substance abuse treatment. This observation provides the basis for developing treatment approaches that specifically target SUD. Different treatment approaches for dual diagnosis are discussed, including parallel, sequential, and hybrid strategies. It concludes that hybrid treatment approaches that focus on the interactive aspects of stress, anxiety, and substance use are the most promising approaches for future study.Publisher Summary This chapter explores the relationship between anxiety symptoms, stress responding, and substance use disorders (alcohol and drug), with special emphasis on treatment approaches. Having an anxiety disorder increases the probability of having substance use disorder (SUD) with research showing the short-term effects of alcohol and drug use dampening stress responding. Factors that can contribute to individuals developing SUD include stress reduction alcohol and drug outcome expectancies, and avoidant and impulsive personality styles. Individuals with an SUD are at an increased risk for relapse following standard substance abuse treatment. This observation provides the basis for developing treatment approaches that specifically target SUD. Different treatment approaches for dual diagnosis are discussed, including parallel, sequential, and hybrid strategies. It concludes that hybrid treatment approaches that focus on the interactive aspects of stress, anxiety, and substance use are the most promising approaches for future study.