Suzanne A. Meunier

Augmentation of Behavior Therapy With d -Cycloserine for Obsessive-Compulsive Disorder

OBJECTIVE This study examined whether d-cycloserine, a partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor, enhances the efficacy of behavior therapy for obsessive-compulsive disorder (OCD). METHOD A randomized, double-blind, placebo-controlled trial investigating D-cycloserine versus placebo augmentation of behavior therapy was conducted in 23 OCD patients. Patients first underwent a diagnostic interview and pretreatment evaluation, followed by a psychoeducational/treatment planning session. Then they received 10 behavior therapy sessions. Treatment sessions were conducted twice per week. One hour before each of the behavior therapy sessions, the participants received either D-cycloserine, 100 mg, or a placebo. RESULTS Relative to the placebo group, the D-cycloserine groups OCD symptoms were significantly more improved at mid-treatment, and the D-cycloserine groups depressive symptoms were significantly more improved at posttreatment. CONCLUSIONS These data provide support for the use of D-cycloserine as an augmentation of behavior therapy for OCD and extend findings in animals and other human disorders suggesting that behavior therapy acts by way of long-term potentiation of glutamatergic pathways and that the effects of behavior therapy are potentiated by an NMDA agonist.

Course of compulsive hoarding and its relationship to life events

Background: Compulsive hoarding is a common and debilitating, yet poorly understood, condition characterized by excessive acquisition of and failure to discard a large number of objects, resulting in cluttered and often hazardous living conditions. The aim of this study was to examine the onset and course of compulsive hoarding, and the relationships between stressful or traumatic life events and course of illness. Methods: Seven hundred fifty‐one adults with self‐reported hoarding symptoms completed an online survey regarding the severity of hoarding behavior over the lifespan and the incidence of stressful or traumatic life events. Results: Median age of onset was between 11 and 15 years, with most respondents reporting symptom onset before age 20. Late‐onset (e.g., after age 40) hoarding was rare. Most respondents described a chronic course of illness, with a significant minority describing an increasing or relapsing/remitting course. Stressful and traumatic events were common in this sample; changes in relationships and interpersonal violence were disproportionately associated temporally with periods of symptom onset or exacerbation. Conclusions: These results highlight the chronic nature of compulsive hoarding, its associated public health burden, and the potential impact of life stressors on symptom development. Directions for further research are discussed. Depression and Anxiety, 2010.

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.

Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania

Background: Not all hair pullers improve acutely with cognitive–behavioral treatment (CBT) and few maintain their gains over time. Methods: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM‐IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)‐enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self‐report measures of hair pulling severity and emotion regulation. Results: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. Conclusions: This study offers preliminary evidence for the efficacy of DBT‐enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment. Depression and Anxiety, 2010.

DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial

Background and aims Limited treatment options are available for trichotillomania (TTM) and most have modest outcomes. Suboptimal treatment results may be due to the failure of existing approaches to address all TTM styles. Methods Thirty-eight DSM-IV TTM participants were randomly assigned across two study sites to Dialectical Behavior Therapy (DBT) -enhanced cognitive-behavioral treatment (consisting of an 11-week acute treatment and 3-month maintenance treatment) or a minimal attention control (MAC) condition. MAC participants had active treatment after the 11-week control condition. Follow-up study assessments were conducted three and six months after the maintenance period. Results Open trial treatment resulted in significant improvement in TTM severity, emotion regulation (ER) capacity, experiential avoidance, anxiety and depression with changes generally maintained over time. In the randomized controlled trial, those with active treatment had greater improvement than those in the MAC condition for both TTM severity and ER capacity. Correlations between changes in TTM severity and ER capacity were not reported at post-treatment but did occur in maintenance and follow-up indicating reduced TTM severity with improved ER capacity. Conclusions DBT-enhanced cognitive-behavioral treatment is a promising treatment for TTM. Future studies should compare this approach to other credible treatment interventions and investigate the efficacy of this approach in more naturalistic samples with greater comorbidity.

Hoarding among patients seeking treatment for anxiety disorders

The aim of the present study was to examine the prevalence of hoarding symptoms among individuals presenting for treatment of anxiety symptoms. Participants included 130 adults who were seeking treatment at an outpatient anxiety disorders clinic between January 2004 and February 2006. During their initial assessment, participants (31 with panic disorder, 15 specific phobia, 27 social phobia, 36 obsessive-compulsive disorder, 21 generalized anxiety disorder, mean age 37 years, 57% female, 88% White) completed the Saving Inventory-Revised, a self-report measure of hoarding symptoms, and several measures of anxiety symptoms, depressive symptoms, and functional impairment. Approximately 12-25% of anxious patients reported significant hoarding symptoms. Patients diagnosed with generalized anxiety disorder and obsessive-compulsive disorder were more likely to report significant hoarding symptoms than were those with panic disorder or specific phobia. Hoarding symptoms were positively correlated with trait anxiety, depressive symptoms, and functional impairment. These findings suggest that hoarding symptoms may be associated with anxiety disorders other than obsessive-compulsive disorder. The findings further suggest that hoarding symptoms may be underreported by anxious populations since typical intake assessments do not include specific questions about hoarding and individuals with hoarding symptoms may be unlikely to spontaneously report them.

DBT‐enhanced habit reversal treatment for trichotillomania: 3‐and 6‐month follow‐up results

Background: Maintenance of gains with cognitive‐behavioral treatment for trichotillomania (TTM) has historically been problematic. Methods: We conducted follow‐up assessments 3 and 6 months after completion of a 3‐month maintenance phase on 10 individuals with DSM‐IV‐TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)‐enhanced habit reversal treatment (HRT). Results: Significant improvement from baseline was reported at 3‐and 6‐month follow‐up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6‐month follow‐up, five and four participants were full and partial responders, respectively. Significant correlations were reported at both follow‐up time points between changes in hair pulling severity and emotion regulation capacity. Conclusions: DBT‐enhanced HRT offers promise for improved long‐term treatment results in TTM. Changes in TTM severity from baseline to 3‐and 6‐month follow‐up is correlated with changes in emotion regulation capacity. Depression and Anxiety, 2011.   © 2010 Wiley‐Liss, Inc.

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.

Affective and Sensory Correlates of Hair Pulling in Pediatric Trichotillomania

Hair pulling in pediatric populations has not received adequate empirical study. Investigations of the affective and sensory states contributing to the etiology and maintenance of hair pulling may help to elucidate the classification of trichotillomania (TTM) as an impulse control disorder or obsessive-compulsive spectrum disorder. The current study aimed to examine childrens self-reported affective and sensory states associated with hair pulling. Fifteen participants completed a questionnaire assessing childrens experiences during first and recent hair pulling episodes. Results revealed that pulling hair for the first time was associated with pleasure and pain whereas recent hair pulling was associated with pleasure only, suggesting that the punishing quality of hair pulling may diminish over time. The findings also support the notion that hair pulling may be maintained primarily through positive reinforcement, which is consistent with its classification as an impulse control disorder.

Extending Cognitive-Behavioral Therapy for Late-Life Anxiety to Home Care: Program Development and Case Examples.

Data suggesting that cognitive-behavioral therapy (CBT) is efficacious for late-life anxiety are accumulating; however, effectiveness has not been well established. Incorporating CBT for anxiety into home care is needed to facilitate access to evidenced-based treatment for a growing population of community-dwelling, functionally impaired elderly people. In this article, the authors describe the development of a home-based CBT program for late-life anxiety, outlining their experience partnering with a community care management organization. They also describe the CBT protocol and present data form two participants who completed the treatment. The two case examples illustrate multiple barriers to achieving successful treatment outcomes with this population. Future research needs to determine the extent to which adaptations are necessary to optimize the success of CBT for anxiety in a home care setting.