Jordana Zwerling

An investigation of the role of intolerance of uncertainty in hoarding symptoms

BACKGROUND Hoarding disorder (HD) is a common, debilitating mental illness and public health burden. Understanding the factors that contribute to hoarding is critical for identifying treatment targets. As a relatively new diagnostic entity, this research remains in its initial stages. Intolerance of uncertainty (IU) is thought to be a vulnerability factor for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD), and may also be relevant to HD. We investigated the possible association between IU and hoarding in two sets of analyses. METHOD First, we administered self-report measures of IU and hoarding symptoms to unscreened undergraduate students (N=456) and used regressions to probe their association controlling for relevant covariates. Second, in a clinical sample, we compared IU across groups of patients with HD (N=26), GAD (N=26), OCD (N=51), other anxiety disorders (N=91) and healthy controls (N=29). RESULTS In the student sample, IU predicted hoarding symptoms above and beyond relevant covariates, including hoarding-related beliefs. In the clinical sample, HD patients evidenced greater IU relative to healthy individuals and the mixed anxiety group, and comparable levels of IU to the GAD and OCD groups. LIMITATIONS This study relied exclusively on self-report questionnaires and a cross-sectional design. CONCLUSIONS IU is associated with hoarding behavior and, as we discuss, conceptual models might benefit from the study of IU as a potentially contributing factor. Directions for future research are discussed.

Acceptability of treatments and services for individuals with hoarding behaviors

OBJECTIVE To explore the acceptability of currently available treatments and services for individuals who self-report hoarding behaviors. METHOD Between 10/2013 and 8/2014, participants were invited to complete an online survey that provided them descriptions of eleven treatments and services for hoarding behaviors and asked them to evaluate their acceptability using quantitative (0 [not at all acceptable] -10 [completely acceptable]) Likert scale ratings. The a priori definition of acceptability for a given resource was an average Likert scale score of six or greater. Two well-validated self-report measures assessed hoarding symptom severity: the Saving Inventory-Revised and the Clutter Image Rating Scale. RESULTS Two hundred and seventy two participants who self-reported having hoarding behaviors completed the questionnaire. Analyses focused on the 73% of responders (n=203) who reported clinically significant hoarding behaviors (i.e., Saving Inventory-Revised scores of ≥40). The three most acceptable treatments were individual cognitive behavioral therapy (6.2 ±3.1 on the Likert scale), professional organizing service (6.1 ±3.2), and use of a self-help book (6.0 ±3.0). CONCLUSION In this sample of individuals with self-reported clinically significant hoarding behaviors (n=203), only 3 out of 11 treatments and services for hoarding were deemed acceptable using an a priori score. While needing replication, these findings indicate the need to design more acceptable treatments and services to engage clients and maximize treatment outcomes for hoarding disorder.

Open-Label trial on the effects of memantine in adults with obsessive-compulsive disorder after a single ketamine infusion.

History of Ketamine Response by Patient Age/Sex/ Ethnicity Duration of Illness (y) No. of Prior SRI Trials Prior EX/RP Trials KETAMINE Memantine Start ↓ MEMANTINE PreBaseline Y-BOCS Post– 1-Week Y-BOCS Days Post-Ketamine Infusion PreBaseline Y-BOCS Y-BOCS at Dropb Post– 6-Week Y-BOCS Memantine Continuation 12-Weekc Y-BOCS Ketamine responders 1 47/M/AA 19 3 Yes 26 14 84 25 14 22 2 53/M/W 15 1 No 29 12 28 11 12 ...d 3 32/M/H 25 3 Yes 29 17 21 21 19 25 4 24/F/AA 12 0 Yes 25 7 14 0 0 ... ... Ketamine nonresponders 5 24/M/H 5 0 No 24 27 73 27 23 ... 6 32/M/W 11 3 Yes 23 19 62 18 23 ... ... 7 38/F/A 22 2 No 36 31 25 31 28 ... 8 29/F/AA 14 4 No 29 30 14 31 23 ... 9 33/M/W 30 5 No 24 26 14 26 21 ... 10 22/F/AA 10 0 No 25 24 7 24 24 ... ... 11 33/M/AA 21 0 No 20 23 7 23 26 ... 12 36/M/W 20 1 Yes 23 20 7 20 23 ... ... aHistory of ketamine response in a prior study (see Koran et al1) was defined as a ≥ 35% Y-BOCS reduction 1 week after intravenous ketamine. bY-BOCS score at drop visit. Participant 4 dropped at week 4 due to no longer having OCD symptoms. Participants 6, 10, and 12, dropped at week 2 due to increased anxiety. cMemantine was continued to 12 weeks in those with treatment response (see Goodman et al12) either to ketamine (≥ 35% Y-BOCS reduction 1 week after intravenous ketamine) or to memantine (≥ 35% Y-BOCS reduction from pre– to post–6 weeks of memantine). dParticipant 2 reported continued low OCD symptoms while on his medication, but was unable to have week 12 independent evaluation until 2 weeks after his medications ran out. His Y-BOCS score at week 14 independent evaluation was 26. Abbreviations: A = Asian, AA = African American; EX/RP = Cognitive Behavioral Therapy with Exposure and Response Prevention; F = female; H = Hispanic, M = male; OCD = obsessive-compulsive disorder, SRI = serotonin reuptake inhibitor; W = white; Y-BOCS = Yale-Brown Obsessive Compulsive Scale. Symbol: ... = not applicable. Open-Label Trial on the Effects of Memantine in Adults With Obsessive-Compulsive Disorder After a Single Ketamine Infusion

Augmenting Buried in Treasures with in-home uncluttering practice: Pilot study in hoarding disorder

Hoarding disorder is characterized by difficulty parting with possessions and by clutter that impairs the functionality of living spaces. Cognitive behavioral therapy conducted by a therapist (individual or in a group) for hoarding symptoms has shown promise. For those who cannot afford or access the services of a therapist, one alternative is an evidence-based, highly structured, short-term, skills-based group using CBT principles but led by non-professional facilitators (the Buried in Treasures [BIT] Workshop). BIT has achieved improvement rates similar to those of psychologist-led CBT. Regardless of modality, however, clinically relevant symptoms remain after treatment, and new approaches to augment existing treatments are needed. Based on two recent studies - one reporting that personalized care and accountability made treatments more acceptable to individuals with hoarding disorder and another reporting that greater number of home sessions were associated with better clinical outcomes, we tested the feasibility and effectiveness of adding personalized, in-home uncluttering sessions to the final weeks of BIT. Participants (n = 5) had 15 sessions of BIT and up to 20 hours of in-home uncluttering. Reductions in hoarding symptoms, clutter, and impairment of daily activities were observed. Treatment response rate was comparable to rates in other BIT studies, with continued improvement in clutter level after in-home uncluttering sessions. This small study suggests that adding in-home uncluttering sessions to BIT is feasible and effective.

CAN EXPOSURE-BASED CBT EXTEND IV KETAMINE’S EFFECTS IN OCD? AN OPEN-LABEL TRIAL

Abtract Introduction A single subanesthetic intravenous (IV) dose of ketamine leads to rapid anti-obsessional effects in obsessive-compulsive disorder (OCD) patients with near-constant intrusive obsessions, but these effects usually do not persist. We tested whether a brief course of exposure-based cognitive behavioral therapy (CBT) could extend ketamine’s effects in a two week pilot open trial and if this effect was maintained (without additional treatment) two weeks later. Our rationale was: 1) ketamine is reported to enhance plasticity and extinction learning in rodents, and 2) enhanced extinction learning may facilitate CBT gains, as reported in trials that combined CBT with agents thought to facilitate extinction learning (e.g. D-cycloserine). Mimicking those trials, CBT was abbreviated (i.e. 10 one-hour exposure sessions) but delivered during the putative time interval when ketamine facilitates extinction learning (within 14 days). Methods Ten unmedicated OCD outpatients (aged 18-55) with near-constant intrusive obsessions (>8 hours/day) and at least moderate symptoms (Y-BOCS score ≥16) were recruited. Exclusion criteria included severe depression (HDRS >25), current CBT, and comorbid psychiatric or medical conditions that made participation unsafe. In an open-label design, participants received a single 40-minute IV infusion of ketamine (dose=0.5 mg/kg), followed by 10 one-hour exposure sessions delivered over two weeks. The CBT treatment was planned in a 90-minute session the day before the ketamine infusion. At baseline, during the infusion, at 20, 90, 110, 230 minutes post-infusion, patients rated their obsessional severity using the OCD-VAS. At baseline and weekly for four weeks post-ketamine, an independent evaluator, blind to study design, evaluated patients using the Y-BOCS, which appraises obsessive and compulsive symptoms over the prior week. Treatment response was defined a priori as ≥35% Y-BOCS reduction at week 2. Y-BOCS outcomes were analyzed using mixed-effects regression to model symptoms as a function of time. Results Of the 10 patients who started ketamine, nine completed the infusion. Eight reported a rapid reduction in obsessive severity as measured by the OCD-VAS, which persisted up to 230 minutes post-infusion in seven patients. Eight completed the 10 hours of exposure and the two week follow-up and were included in the Y-BOCS analyses. From baseline to four weeks post-infusion, OCD severity, as measured by the YBOCS, was significantly decreased over time (F=14.36, df=4,28, p Conclusions These results corroborate prior findings that IV ketamine can rapidly reduce obsessions in unmedicated OCD patients. The data suggest that a brief course of CBT may help some individuals maintain the improvement they experienced from ketamine; however, this needs to be formally tested in a randomized controlled trial to determine whether the improvement seen after two weeks of CBT is due to the addition of CBT, or whether the effects of ketamine persist longer in some than previously described.

Bridging the Divide: Advances and Challenges in Understanding the Impact of Race and Ethnicity on the Mental Health of Older Adults

This issue of the American Journal of Geriatric Psychiatry features six articles focusing on aspects of race and ethnicity in the mental health of older adults, ranging from racial-ethnic disparities to culturally informed interventions. This collection illustrates how race and ethnicity are important considerations across psychiatric disorders and neurologic conditions, including depression, schizophrenia, and dementia, as well as factors that cut across diagnoses as traditionally defined (e.g., cognition, perceptions of illness). Addressing racial-ethnic disparities in mental healthcare is a continued challenge in the field of psychiatry. We know African Americans and other underserved minority groups underuse traditional mental health services, compared with white Americans. 1 Identifying culturally relevant health promotion interventions is one approach to engaging older African Americans in utilization of mental health services. Jimenez et al. 2 analyzed data from a randomized depression prevention trial in which 247 adults (154 non-Latino whites, 90 African Americans, 3 Asian) were randomly assigned to either problem-solving therapy or coaching in healthy dietary practices. Participants were age 50 or older who met criteria for subsyndromal depression. African Americans in both conditions had greater improvements in mental healtherelated quality of life compared with non-Latino whites. The authors’ findings shed light on how mental health services can design programs using problemsolving techniques or culturally relevant health promotion interventions (e.g., obesity, which is more prevalent in older African Americans than in older non-Latino whites) to engage older African Americans with subsyndromal depression in mental healthcare. Another strategy for engaging African Americans in mental healthcare involves engagement with local churches. 1 Given the high rate of religious service attendance and the central role of church-based social supports in many African American communities, 1 Chatters et al. 3 examined the influences of church and family informal support networks on depressive symptoms among older African Americans. Crosssectional data were included from 686 African Americans (age 55 years or older) who endorsed attending religious services in the National Survey of American Life. The authors found that social support from church networks were protective against depressive symptoms and psychological distress. A strength of this study was the use of a validated measure to control for the influence of both positive and negative aspects of family support networks. This study contributes to the emerging literature that emotional support from church members is