Gretchen J. Diefenbach

Pediatric Trichotillomania: Descriptive Psychopathology and an Open Trial of Cognitive Behavioral Therapy

In study 1, 46 children and adolescents with trichotillomania who sought treatment at 2 specialty outpatient clinics were assessed. Most children reported pulling hair from multiple sites on the body, presented with readily visible alopecia, reported spending 30–60 minutes per day pulling or thinking about pulling, and reported experiencing significant distress about their symptoms. Most were described by their parents as having significant problems in school functioning. Few children met criteria for obsessive‐compulsive disorder or tic disorder. Child and family rates of other forms of psychopathology were high. In study 2, 22 of these children were enrolled in an open trial of individual cognitive behavioral therapy with particular attention to relapse prevention. Trichotillomania severity decreased significantly and 77% of children were classified as treatment responders at post‐treatment and 64% at 6‐month follow‐up.

Quality of life and anxiety and depressive disorder comorbidity

The present investigation evaluated the relations among anxiety and depressive disorder comorbidity and quality of life (QOL) by utilizing self-report measures of life satisfaction and functional disability. Participants were 94 individuals who were presented for treatment at an outpatient anxiety disorders clinic and 26 nonclinical participants. Results indicated that participants diagnosed with anxiety disorders reported lower QOL than did nonclinical participants. Anxiety disorder comorbidity did not additionally impact QOL; however, presence of a depressive disorder comorbid with an anxiety disorder did negatively impact QOL as these individuals reported significantly more functional disability and less life satisfaction than did individuals with anxiety disorders alone or those without a psychiatric diagnosis. These results highlight the negative nature of anxiety disorders and improve clarification on the role of diagnostic comorbidity on QOL among those with an anxiety disorder.

Stepped care versus standard cognitive–behavioral therapy for obsessive–compulsive disorder: A preliminary study of efficacy and costs

Background: Exposure and response prevention (ERP) for obsessive–compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low‐intensity, low‐cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention. Methods: Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low‐intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist‐administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist‐administered ERP with no lower‐intensity lead‐in. Results: The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third‐party payers than did standard ERP, with large effect sizes. Conclusions: These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long‐term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings. Depression and Anxiety 0:1–10, 2011.  © 2011 Wiley‐Liss, Inc.

The association between self-reported anxiety symptoms and suicidality

This cross-sectional study assessed the association between self-reported anxiety symptoms and self-reported suicidality among a mixed diagnostic sample of psychiatric outpatients. Data were obtained from chart review of 2,778 outpatients who completed a routine diagnostic clinical interview and a standardized self-report of psychiatric symptoms on admission. Bivariate analyses indicated that those with ≥ moderate anxiety symptoms were over three times as likely to report ≥ moderate difficulty with suicidality. Self-reported anxiety symptoms were associated with a 2-fold increased likelihood of reporting suicidality after controlling for confounding (demographics, depressive symptoms, and diagnoses). These data are consistent with a growing literature demonstrating an association between anxiety symptoms and suicidality, and suggest that this association is not accounted for by coexisting mood symptoms or diagnoses. A single item, self-report may be a useful screening tool for symptoms that are pertinent to assessment of suicide risk.

The Trichotillomania Scale for Children: Development and Validation

Trichotillomania (TTM) is a chronic impulse control disorder characterized by repetitive hair-pulling resulting in alopecia. Although this condition is frequently observed in children and adolescents, research on pediatric TTM has been hampered by the absence of validated measures. The aim of the present study was to develop and test a new self-report measure of pediatric TTM, the Trichotillomania Scale for Children (TSC), a measure that can be completed by children and/or their parents. One hundred thirteen children meeting self-report criteria for TTM, and 132 parents, provided data over the internet. An additional 41 child–parent dyads from an outpatient clinic also provided data. Replicated principal components analysis, with elimination of poorly-loading items, yielded two components, which we labeled Severity (five items) and Distress/Impairment (seven items). The TSC total score and subscales showed adequate internal consistency and test-retest reliability. Parent–child agreement was good in the internet sample, but more modest in the clinic sample. Children’s TSC scores correlated significantly with other measures of TTM severity, although some exceptions were noted. Parents’ TSC scores correlated significantly with other measures of parent-rated TTM severity in the internet sample, but showed more attenuated relationships with child- and interviewer-rated TTM severity in the clinic sample. The present results suggest that the TSC may be a useful measure of TTM for child and adolescent samples, although additional clarification of convergent validity is needed.

Differentiating anxiety and depression in older adults with generalized anxiety disorder

To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.

Assessment of Anxiety in Older Home Care Recipients

PURPOSE This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services. DESIGN AND METHODS Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD). RESULTS Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified). IMPLICATIONS These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.

Cognitive-behavioral therapy for late-life generalized anxiety disorder : Who gets better?

The authors pooled data from three independently conducted treatment outcome studies to examine predictors of outcome from group-administered cognitive-behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD). Data were collected from 65 patients with a mean age of 67.7 years (SD = 6.6). Average reliable change indices (RCI) based on 3 outcome measures were calculated at posttreatment and at 6-month follow-up. Approximately half of patients achieved a significant RCI at posttreatment and two-thirds achieved a significant RCI at follow-up. Factors associated with better outcomes included better homework adherence, higher baseline GAD severity, and presence of a comorbid psychiatric diagnosis. Results suggest that at-home practice is associated with better and longer-lasting outcomes from CBT in older adults with GAD.

Stepped care for obsessive-compulsive disorder: A pilot study

Cognitive-behavioral therapy incorporating exposure and ritual prevention (EX/RP) is the first-line psychosocial treatment of choice for obsessive-compulsive disorder (OCD). However, several barriers to care prevent many OCD patients from receiving this treatment. Previous research has indicated that some OCD patients may benefit from less intensive treatment options, such as bibliotherapy; however, it is not clear how to assign patients to their appropriate level of treatment. We suggest that an optimal approach may be to use a stepped care protocol, in which patients begin with a low-intensity treatment and then progress to more costly (but perhaps more efficacious) treatments as needed. In this pilot study, 11 adults with OCD initially received bibliotherapy EX/RP treatment; 20% of patients completing this treatment met stringent responder criteria. The remaining patients were then assigned to a therapist who provided brief education and EX/RP advice but did not actually assist patients with exposure exercises. Twenty-nine percent of patients who completed this treatment were classified as responders. The remaining patients then received the more traditional therapist-administered EX/RP; 67% of patients completing this treatment were responders. Across the entire protocol, 86% of treatment completers and 80% of the intent-to-treat sample were rated as “much improved” or “very much improved.” Cost-effectiveness analyses, in which the total cost of treatment was divided by the degree of symptom reduction, showed that stepped care compared favorably to other forms of EX/RP delivery. We provide a detailed case discussion that illustrates the clinical decision-making process and one patients response to different levels of treatment.

The Nature of Generalized Anxiety in Older Primary Care Patients: Preliminary Findings

Clinical features of older primary care patients with GAD (PC-GAD; n = 22) were examined relative to older patients with GAD recruited for two academic clinical trials (M. A. Stanley, J. G. Beck, et al., 2003; J. L. Wetherell, M. Gatz, & M. G, Craske, 2003) and to a sample of older primary care patients without psychiatric diagnoses (No Dx; n = 10). Comparisons revealed similar levels of worry, anxiety, depressive symptoms, quality of life, and functional status between the PC-GAD subsample and patients recruited for academic trials, although primary care patients were older, less well educated, and more ethnically diverse. The PC-GAD subgroup, however, reported greater symptom severity, reduced quality of life, and poorer perceived general health, mental health, and vitality than the No Dx subgroup (η2 = .23–.43). Service utilization was not different between PC-GAD and No Dx subgroups, with the exception of psychotropic medication use. The Penn State Worry Questionnaire (PSWQ) and an abbreviated version of this measure may be useful for identifying late-life GAD in primary care. Cutoff scores of 50 and 22 on the full and abbreviated versions of the PSWQ, respectively, demonstrated excellent specificity, sensitivity, and positive predictive value. Negative predictive value was less impressive, probably as a result of high base rates for GAD in this sample.