Michelle L. Davis

A comparison of clinical features in Trichotillomania and obsessive-compulsive disorder

Trichotillomania (TM) recently has been conceptualized as a variant of obsessive-compulsive disorder (OCD). However, no systematic data have compared the clinical features of these two disorders. Here we report data from 8 TM and 13 OCD patients which suggest important clinical differences between groups. First, TM patients reported a significantly greater degree of pleasure during hair-pulling than OCD patients reported during performance of ritualistic behaviors. Second, TM was accompanied by significantly fewer associated obsessive-compulsive symptoms. Third, the groups differed with regard to other clinical features including anxiety, depression, and personality characteristics. We conclude that TM is not conceptualized best as a variant of OCD.

D-cycloserine Enhancement of Exposure Therapy for Social Anxiety Disorder Depends on the Success of Exposure Sessions

OBJECTIVE The evidence for the efficacy of D-cycloserine (DCS) for augmenting cognitive behavioral therapy (CBT) for anxiety disorders has been mixed. Guided by preclinical research and initial findings from a small-scale study involving humans, we tested the hypothesis that DCS enhancement of exposure therapy would be specific to successful exposure sessions. METHOD Medication-free adults with generalized social anxiety disorder (N = 145) received 50 mg of DCS or placebo 1 h before each of 5 exposure sessions that were part of a standardized 12-session group CBT protocol. Participants provided fear ratings at the beginning and just before the end of exposure exercises. Independent raters, blind to group assignment, administered the clinical global impression improvement and severity scales at each session and at posttreatment. RESULTS Mixed-effects analyses revealed that, among patients who reported low fear at the end of an exposure session, those who had received DCS evidenced significantly greater clinical improvement at the next session, relative to those who had received placebo. In contrast, when exposure end fear was high, patients receiving DCS exhibited less clinical improvement at the following session than patients receiving placebo. Similarly, patients who had received DCS evidenced lower clinical severity at posttreatment, relative to patients who had received placebo, only when their average end fear for medication-augmented sessions had been in the low to moderate range. Finally, these moderating effects of exposure success as indexed by end fear were not better accounted for by within-session extinction. CONCLUSIONS The efficacy of DCS for augmenting exposure-based CBT depends on the success of exposure sessions. These findings may help guide the development of an algorithm for the effective use of DCS for augmenting exposure-based CBT. TRIAL REGISTRY http://www.ClinicalTrials.gov, ID# NCT00633984, http://www.clinicaltrials.gov/ct2/show/NCT00633984.

Can the Yale-Brown Obsessive Compulsive Scale be used to assess trichotillomania? A preliminary report.

Given recent conceptualizations of trichotillomania (TM) as a variant of obsessive compulsive disorder (OCD), clinician-rated measures of obsessive compulsive symptoms have been adapted for use in the assessment of TM. Although the reliability and validity of these instruments have been well-documented in patients with OCD, psychometric properties have not been examined systematically in patients with TM. Here, we evaluate the reliability and validity of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in a sample of 11 patients with a primary diagnosis of TM. Data addressed the utility of the Y-BOCS for evaluating symptoms of TM, and provided information regarding the proposed overlap between OCD and TM. Initial analyses suggested that interrater reliability, internal consistency, and test-retest reliability for the total score were adequate. However, the range of scores was somewhat restricted, and suggested in particular that interference in daily functioning from TM symptoms is quite low. Both internal consistency and test-retest reliability for the Target Behaviors subscale were inadequate, suggesting that this combined score is inappropriate for use with TM patients. Concurrent validity data using the total score were mixed, although the Y-BOCS did appear to be sensitive to change in TM symptoms over treatment. Implications for the use of the Y-BOCS with TM patients and hypothesized phenomenological differences between TM and OCD are discussed.

Yohimbine enhancement of exposure therapy for social anxiety disorder: A randomized controlled trial

BACKGROUND Preclinical and clinical trials suggest that yohimbine may augment extinction learning without significant side effects. However, previous clinical trials have only examined adults with specific phobias. Yohimbine has not yet been investigated in the augmentation of exposure therapy for other anxiety disorders. METHODS Adults (n = 40) with a DSM-IV diagnosis of social anxiety disorder were randomized to placebo or yohimbine HCl (10.8 mg) 1 hour before each of four exposure sessions. Outcome measures were collected at baseline, each treatment session, posttreatment, and 1-month follow-up. RESULTS Yohimbine was well tolerated. Yohimbine augmentation, relative to placebo augmentation, resulted in faster improvement and better outcomes on self-report measures of social anxiety disorder severity (Liebowitz Social Anxiety Scale, d = .53) and depressed mood severity (Beck Depression Inventory, d = .37) but not on the clinician-rated measures (Clinical Global Impressions-Severity Scale, d = .09; Clinical Global Impressions-Improvement Scale, d = .25). Between-group differences on the Liebowitz Social Anxiety Scale were moderated by the level of fear reported at the end of an exposure exercise (end fear), such that the advantage of yohimbine over placebo was only evident among patients who reported low end fear. CONCLUSIONS The results provide moderate support for yohimbine as a therapeutic augmentation strategy for exposure therapy in social anxiety disorder, one that may be especially effective when coupled with successful exposure experiences. Beneficial effects for yohimbine were readily evident for self-report measures but not for clinician-rated outcomes of social anxiety severity and improvement.

Behavioral therapies for treatment-seeking cannabis users: a meta-analysis of randomized controlled trials.

Narrative reviews conclude that behavioral therapies (BTs) produce better outcomes than control conditions for cannabis use disorders (CUDs). However, the strength and consistency of this effect has not been directly empirically examined. The present meta-analysis combined multiple well-controlled studies to help clarify the overall impact of behavioral interventions in the treatment of CUDs. A comprehensive literature search produced 10 randomized controlled trials (RCTs; n = 2,027) that were included in the final analyses. Analyses indicated an effect of BTs (including contingency management, relapse prevention, and motivational interviewing, and combinations of these strategies with cognitive behavioral therapy) over control conditions (including waitlist [WL], psychological placebo, and treatment as usual) across pooled outcomes and time points (Hedges’ g = 0.44). These results suggest that the average patient receiving a behavioral intervention fared better than 66% of those in the control conditions. BT also outperformed control conditions when examining primary outcomes alone (frequency and severity of use) and secondary outcomes alone (psychosocial functioning). Effect sizes were not moderated by inclusion of a diagnosis (RCTs including treatment-seeking cannabis users who were not assessed for abuse or dependence vs. RCTs including individuals diagnosed as dependent), dose (number of treatment sessions), treatment format (either group vs. individual treatment or in-person vs. non-in-person treatment), sample size, or publication year. Effect sizes were significantly larger for studies that included a WL control comparison versus those including active control comparisons, such that BT significantly outperformed WL controls but not active control comparisons.

The Efficacy of Vigorous-Intensity Exercise as an Aid to Smoking Cessation in Adults With High Anxiety Sensitivity: A Randomized Controlled Trial.

Objectives High anxiety sensitivity predicts poor smoking cessation outcomes. Aerobic exercise reduces anxiety sensitivity and aspects of the risk conferred by anxiety sensitivity. In the current study, we examined whether exercise can aid smoking cessation in adults with high anxiety sensitivity. Methods Participants were sedentary and low-activity adult daily smokers (n = 136) with elevated prescreen anxiety sensitivity. Participants received 15 weeks of standard smoking cessation treatment (ST; cognitive behavioral therapy plus nicotine replacement therapy). In addition, participants were simultaneously randomized to 15 weeks of either an exercise intervention (ST + EX; n = 72) or a wellness education control condition (ST + CTRL; n = 64). Self-reported smoking abstinence was assessed weekly during the intervention, at the end of treatment (10 weeks after the target quit date), and at 4 and 6 months after the target quit date. Abstinence was verified by expired carbon monoxide readings and saliva cotinine. Results Results indicated that point prevalence abstinence (PPA) and prolonged abstinence (PA) rates were significantly higher for ST + EX than for ST + CTRL at each of the major end points among persons with high anxiety sensitivity (PPA: b = −0.91, standard error [SE] = 0.393, t(1171) = −2.33, p = .020; PA: b = −0.98, SE = 0.346, t(132) = −2.84, p = .005), but not among those with low anxiety sensitivity (PPA: b = −0.23, SE = 0.218, t(1171) = −1.06, p = .29; PA: b = −0.31, SE = 0.306, t(132) = −1.01, p = .32). Conclusions The present results suggest that exercise facilitates the odds of quit success for smokers with high levels of anxiety sensitivity and therefore may be a useful therapeutic tactic for this high-risk segment of the smoking population. Trial Registration: ClinicalTrials.gov, NCT01065506.

The efficacy of vigorous-intensity exercise as an aid to smoking cessation in adults with elevated anxiety sensitivity: study protocol for a randomized controlled trial

BackgroundAlthough cigarette smoking is a leading cause of death and disability in the United States (US), over 40 million adults in the US currently smoke. Quitting smoking is particularly difficult for smokers with certain types of psychological vulnerability. Researchers have frequently called attention to the relation between smoking and anxiety-related states and disorders, and evidence suggests that panic and related anxiety vulnerability factors, specifically anxiety sensitivity (AS or fear of somatic arousal), negatively impact cessation. Accordingly, there is merit to targeting AS among smokers to improve cessation outcome. Aerobic exercise has emerged as a promising aid for smoking cessation for this high-risk (for relapse) group because exercise can effectively reduce AS and other factors predicting smoking relapse (for example, withdrawal, depressed mood, anxiety), and it has shown initial efficacy for smoking cessation. The current manuscript presents the rationale, study design and procedures,and design considerations of the Smoking Termination Enhancement Project (STEP).MethodsSTEP is a randomized clinical trial that compares a vigorous-intensity exercise intervention to a health and wellness education intervention as an aid for smoking cessation in adults with elevated AS. One hundred and fifty eligible participants will receive standard treatment (ST) for smoking cessation that includes cognitive behavioral therapy (CBT) and nicotine replacement therapy (NRT). In addition, participants will be randomly assigned to either an exercise intervention (ST+EX) or a health and wellness education intervention (ST+CTRL). Participants in both arms will meet 3 times a week for 15 weeks, receiving CBT once a week for the first 7 weeks, and 3 supervised exercise or health and wellness education sessions (depending on randomization) per week for the full 15-week intervention. Participants will be asked to set a quit date for 6 weeks after the baseline visit, and smoking cessation outcomes as well as putative mediator variables will be measured up to 6 months following the quit date.DiscussionThe primary objective of STEP is to evaluate whether vigorous-intensity exercise can aid smoking cessation in anxiety vulnerable adults. If effective, the use of vigorous-intensity exercise as a component of smoking cessation interventions would have a significant public health impact. Specifically, in addition to improving smoking cessation treatment outcome, exercise is expected to offer benefits to overall health, which may be particularly important for smokers. The study is also designed to test putative mediators of the intervention effects and therefore has the potential to advance the understanding of exercise-anxiety-smoking relations and guide future research on this topic.Clinical trials registryClinicalTrials.gov, NCT01065506, http://clinicaltrials.gov/ct2/show/NCT01065506

Psychometric analyses of the Leyton Obsessional Inventory in patients with obsessive-compulsive and other anxiety disorders.

This study evaluated the psychometric properties of the Leyton Obsessional Inventory (LOI). In particular, internal consistency and intercorrelation of subscales were examined, as well as convergent, divergent, and discriminative validity

Predictors of PTSD symptoms in adults admitted to a Level I trauma center: a prospective analysis

Trauma centers are an ideal point of intervention in efforts to prevent posttraumatic stress disorder (PTSD). In order to assist in the development of prevention efforts, this study sought to identify early predictors of PTSD symptoms among adults admitted to a Level I trauma center using a novel analytic strategy (Fournier et al., 2009). Upon admission, participants (N=327) were screened for PTSD symptoms and provided information on potential predictor variables. Their PTSD symptoms were assessed again 3 months later (N=227). Participants were classified as symptomatic (positive PTSD screen) or asymptomatic (negative PTSD screen) at the follow-up assessment. Multinomial logistic regression showed that age, depression, number of premorbid psychiatric disorders, gunshot wound, auto vs. pedestrian injury, and alcohol use predicted who had PTSD symptoms at FU with 76.3% accuracy. However, when controlling for PTSD severity at baseline, only age, number of premorbid psychiatric disorders, and gunshot wounds predicted PTSD symptoms at FU but with 78.5% accuracy. These findings suggest that psychological prevention efforts in trauma centers may be best directed toward adults who are young, have premorbid psychiatric disorders, and those admitted with gunshot wounds.

Emotion dysregulation explains relations between sleep disturbance and smoking quit-related cognition and behavior

Poor sleep quality and tobacco use are common and co-occurring problems, although the mechanisms underlying the relations between sleep disturbance and smoking are poorly understood. Sleep disturbance lowers odds of smoking cessation success and increases odds of relapse. One reason may be that sleep loss leads to emotion dysregulation, which in turn, leads to reductions in self-efficacy and quit-related problems. To address this gap, the current study examined the explanatory role of emotion dysregulation in the association between sleep disturbance and smoking in terms of (1) self-efficacy for remaining abstinent in relapse situations, (2) the presence of a prior quit attempt greater than 24h, and (3) the experience of quit-related problems among 128 adults (Mage=40.2; SD=11.0; 52.3% female) seeking treatment for smoking cessation. Results suggested that increased levels of sleep disturbance are related to emotion dysregulation which, in turn, may lead to lower levels of self-efficacy for remaining abstinent, more quit-related problems, and being less likely to have had a quit attempt of 24h or greater. Further, these indirect effects were present above and beyond variance accounted for by theoretically-relevant covariates (e.g., gender and educational attainment), suggesting that they may maintain practical significance. These findings suggest that this malleable emotional risk factor (emotion dysregulation) could serve as a target for intervention among those with poor sleep and tobacco use.