Troy A. Webber

Pediatric misophonia with comorbid obsessive-compulsive spectrum disorders.

OBJECTIVE Misophonia is a potentially debilitating condition characterized by increased sensitivity to specific sounds, which cause subsequent behavioral and emotional responses. The nature, clinical phenomenology and etiology of misophonia remain unclear, and misophonic clinical presentations are not currently accounted for by existing psychiatric or audiological disorders. METHOD We present a case of pediatric misophonia in the context of comorbid obsessive-compulsive disorder and Tourettes syndrome. RESULTS Given the interrelationships among obsessive-compulsive spectrum disorders and misophonia, these disorders may share underlying pathophysiology, particularly within the dopaminergic and serotonergic neural systems. Clinical (i.e., treatment) and theoretical implications are discussed.

Toward a theoretical model of misophonia

Improvement Across Minnesota (DIAMOND) program in over 80 primary care clinics throughout Minnesota and the Washington state Mental Health Integration Program, inwhichmajor insurance companies agreed to implement and pay for collaborative care in over 100 community health clinics and30 communitymental health centers [5]. However, health policy changes will be necessary to widely implement this evidence-based model. Several recent policies could improve depression quality of care. These include mental health policies, such as the Medicare Improvements for Patients and Providers Act of 2008 [which eliminated by 2014 unequal copayments previously required for psychotherapy (50%) and othermedical services inMedicare (20%)], theMental Health Parity and Addiction Equity Act of 2008 (which prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits), and broader health policies included in the ACA: Medicaid expansion, employer mandate, health insurance exchanges with low income subsidies, PCMHs, Medicaid health homes, ACOs, and inclusion of mental health in essential benefits packages. Some policies have a greater likelihood than others to improve depression care. For example, mental health parity and insurance expansion alone are unlikely to solve the problem, as challenges with access to mental health services, which is already difficult, are likely to worsen (i.e., demandwill increase but provider supplywill not). However, some policy changes, such as credentialing requirements based on 2014 National Committee for Quality Assurance criteria for PCMH designation, incentivize integrated models with population-based requirements, CM requirements, and ways to better integrate mental health as key components to achieve level 3 credentialing, which will lead to better payments frommany insurers. Demonstration models such as the Comprehensive Primary Care initiative provide financial incentives as well as educational opportunities and technical assistance to encourage integrated care practices. ACOs incentivize decreasing emergency room visits and hospitalizations, and people with comorbid mental and physical illness are disproportionately represented in these populations. Increasing evidence demonstrates that depression predicts 30-day rehospitalizations and ambulatory care-sensitive hospitalizations. CMS tracks and penalizes hospitals in the bottom25%of 30-day rehospitalizations. CMS also recently finalized a separate payment, outside of a face-to-face visit, for managing care ofMedicare patientswith two ormore chronic conditions (which could include depression) beginning in 2015. One might question how new policies could improve depression outcomes, particularly due to limited focus of broader policies on mental health conditions (e.g., only 1 of 33 ACO quality measures focuses on mental healthwith depression screening). However, strengths of recent policies may lie in encouraging more thoughtful applications of integrating evidence-based models to enhance depression treatment. These policies potentially incentivize a more nuanced, systematic, and integrated approach to depression management. Financial incentives provided by policies generate motivation for clinicians and healthcare systems to engage in the practice redesign work to identify which patients have depression, what treatments are needed, how treatments fit into overall treatment plans (rather than addressing mental and physical disorders separately), and provide increased intensity of care and systematic follow-up for patients with persistent symptoms. We recommend that to enhance integration of this evidence-based model, payers need to develop billing codes for care management contacts, includingphone contacts and in-person contacts, codes forweekly psychiatrist systematic caseload review, and incentives for processmeasures tightly linked to depressive outcomes (e.g., changing ineffective treatments by 8 weeks) and improved outcomes (e.g., percent of patients reaching at least a 50% symptom reduction by 8 weeks and 6 months) [5]. Quality indicators or fidelity measures are needed to provide either a financial disincentive for systems that have attempted to implement care managed with little fidelity to evidence-based models or to provide an incentive for systems implementing higher fidelity models. Incentives should also be provided for groups to participate in collaborative endeavors to improve the dissemination process and createmore sustainable improvements. Both performance criteria and outcomes monitoring are important. Don Berwick said that the American system gets what it pays for by incentivizing high-cost procedures and tests rather than care quality and time with practitioners. It is time to change financial incentives to improve quality of care and outcomes for depression using evidencebased ways to deliver treatments.

Stability and change in distress tolerance and its prospective relationship with borderline personality features: a short-term longitudinal study.

Distress tolerance (DT), or the ability to withstand psychological distress, has been proposed as a mechanism underlying multiple forms of psychopathology. However, research on DT is limited in several areas. First, stability and change of DT over time has never been assessed in adults. Second, it is unclear whether alternative conceptualizations of DT yield differences in longitudinal stability and change. Third, gender differences in DT have yet to be examined in nonclinical adult samples. And fourth, longitudinal predictive utility of DT has not been adequately assessed. The purpose of this study was to investigate these 3 questions using data collected at 3 time points over a 6-month period, examining borderline personality disorder (BPD) features as an outcome. Using 3 different measures of DT, results indicated that there is no mean level change in DT. Similarly, there was moderate rank-order stability in DT and no significant individual level change across measures. These findings suggest that DT is similar to other stable, trait-like constructs, as has been previously theorized. Next, a series of cross-lagged panel models revealed that although DT had a cross-sectional relationship with BPD features across all time points, DT did not predict BPD traits longitudinally. These findings have implications for treatments for BPD.

Validity of the alcohol purchase task: a meta-analysis

BACKGROUND AND AIMS Behavioral economists assess alcohol consumption as a function of unit price. This method allows construction of demand curves and demand indices, which are thought to provide precise numerical estimates of risk for alcohol problems. One of the more commonly used behavioral economic measures is the Alcohol Purchase Task (APT). Although the APT has shown promise as a measure of risk for alcohol problems, the construct validity and incremental utility of the APT remain unclear. This paper presents a meta-analysis of the APT literature. METHODS Sixteen studies were included in the meta-analysis. Studies were gathered via searches of the PsycInfo, PubMed, Web of Science and EconLit research databases. Random-effects meta-analyses with inverse variance weighting were used to calculate summary effect sizes for each demand index-drinking outcome relationship. Moderation of these effects by drinking status (regular versus heavy drinkers) was examined. Additionally, tests of the incremental utility of the APT indices in predicting drinking problems above and beyond measuring alcohol consumption were performed. RESULTS The APT indices were correlated in the expected directions with drinking outcomes, although many effects were small in size. These effects were typically not moderated by the drinking status of the samples. Additionally, the intensity metric demonstrated incremental utility in predicting alcohol use disorder symptoms beyond measuring drinking. CONCLUSIONS The Alcohol Purchase Task appears to have good construct validity, but limited incremental utility in estimating risk for alcohol problems.

Genetic and environmental influences on the codevelopment among borderline personality disorder traits, major depression symptoms, and substance use disorder symptoms from adolescence to young adulthood

Although borderline personality disorder (BPD) traits decline from adolescence to adulthood, comorbid psychopathology such as symptoms of major depressive disorder (MDD), alcohol use disorder (AUD), and drug use disorders (DUDs) likely disrupt this normative decline. Using a longitudinal sample of female twins (N = 1,763), we examined if levels of BPD traits were correlated with changes in MDD, AUD, and DUD symptoms from ages 14 to 24. A parallel process biometric latent growth model examined the contributions of genetic and environmental factors to the relationships between developmental components of these phenotypes. Higher BPD trait levels predicted a greater rate of increase in AUD and DUD symptoms, and higher AUD and DUD symptoms predicted a slower rate of decline of BPD traits from ages 14 to 24. Common genetic influences accounted for the associations between BPD traits and each disorder, as well as the interrelationships of AUD and DUD symptoms. Both genetic and nonshared environmental influences accounted for the correlated levels between BPD traits and MDD symptoms, but solely environmental influences accounted for the correlated changes between the two over time. Results indicate that higher levels of BPD traits may contribute to an earlier onset and faster escalation of AUD and DUD symptoms, and substance use problems slow the normative decline in BPD traits. Overall, our data suggests that primarily genetic influences contribute to the comorbidity between BPD features and substance use disorder symptoms. We discuss our data in the context of two major theories of developmental psychopathology and comorbidity.

Neural outcome processing of peer-influenced risk-taking behavior in late adolescence: Preliminary evidence for gene × environment interactions.

Adolescent brains are particularly susceptible to the rewarding properties of risky decisions in social contexts. Individual differences in genetic influences on dopamine transmission moderate neural outcome processing of risky decisions and may exert pronounced effects on adolescent risk-taking behavior (RTB) and corresponding neural outcome processing in peer contexts, a process called gene-environment interaction (G × E). Eighty-five undergraduate students completed a behavioral risk task alone and in the presence of a confederate peer providing “risky” feedback. We tested for G × E effects using a polygenic risk index that included 3 candidate genetic variations associated with high dopamine transmission efficiency, as well as the moderating role of family history of behavioral disinhibition. Difference waves for the P300 and FRN (i.e., feedback-related negativity) were examined as indices of neural outcome processing. A G × E effect was observed for RTB and the P300, but not the FRN. Family history of behavioral disinhibition also interacted with peer influence to predict P300 amplitude. These data provide preliminary evidence for G × E for peer-influenced RTB and neural outcome processing during late adolescence. Genetic influences on dopaminergic function may be particularly relevant for attentional and motivational neural systems, as indexed by the P300, which exert downstream effects on peer-influenced RTB.

Unidirectionality Between Borderline Personality Disorder Traits and Psychopathology in a Residential Addictions Sample: A Short-Term Longitudinal Study

Borderline personality disorder (BPD) is a barrier to treatment, yet the relationship between BPD features and other psychopathology symptoms in residential addictions treatment samples is understudied. Using a sample of adults enrolled in a residential drug treatment facility measured at baseline and 2-3 month follow-up, the authors examined the prospective relationship between BPD features and five indices of psychopathology: depression, anxiety, interpersonal sensitivity, hostility, and psychoticism, as well as psychopathology global severity. There was no effect of time on any of the forms of psychopathology, but females reported higher levels of BPD features, anxiety symptoms, and interpersonal sensitivity than males. A series of latent change score models indicated that BPD features predicted increases in all psychopathology scales at follow-up, while the reverse was not true. These results suggest that targeting BPD features in residents of drug treatment facilities may reduce the emergence of new psychopathology in the short term.

Preliminary Evidence that Digit Length Ratio (2D:4D) Predicts Neural Response to Delivery of Motivational Stimuli

Reduced relative length of the 2nd to 4th digits (2D:4D) is thought to partially reflect fetal testosterone (FT) exposure, a process suspected to promote relatively permanent effects on the brain and behavior via structural and functional neuroadaptations. We examined the effect of 2D:4D on neural response - assessed by P2a and feedback-related negativity (FRN) event-related potentials (ERPs) - to motivational stimuli (reward or punishment) using two counterbalanced conditions of a passive S1/S2 outcome prediction design. P2a to expected and unexpected delivered rewards or punishments (

When selective audiovisual stimuli become unbearable: a case series on pediatric misophonia

1 or white noise burst, respectively) and FRN to withheld rewards or punishments (

When selective audiovisual stimuli become unbearable: a case series on pediatric

0 or silence, respectively) were observed in undergraduates. Lower left 2D:4D and greater 2D:4DR-L predicted amplified P2a to the delivery (but not FRN to the omission) of motivationally salient stimuli, regardless of valence and probability. These preliminary findings suggest that FT may organize dopamine neurons to respond more strongly to the delivery of motivational stimuli.