Levels of Anger Severity in Psychiatric Patients.

ABSTRACT: Given anger's clinical relevance and adverse impact on functioning, there is a need to examine diagnostically heterogeneous individuals at different levels of anger severity to provide a basis for considering anger severity in clinical research and practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined the validity of severity classifications based on the Clinically Useful Anger Outcome Scale (CUANGOS) in 1738 clinically heterogeneous psychiatric outpatients. We compared patients reporting no, mild, moderate, or severe anger with regard to demographics, psychosocial morbidity, functioning, and life satisfaction. Increasing anger severity was associated with elevated clinician-rated psychosocial morbidity and poorer self-rated functioning and life satisfaction. Results demonstrate that assessing anger severity yields crucial information about psychosocial functioning and morbidity. This provides additional validity evidence for self-reported anger in general and the CUANGOS in particular, in that the CUANGOS can validly distinguish among meaningfully different anger severity levels.

Emotion regulation difficulties link trait resilience and symptoms of depression and anxiety in psychiatric outpatients.

BACKGROUND: Despite negative associations of trait resilience with depression and anxiety symptoms, the mechanisms by which resilience may buffer against these symptoms remain underexplored. This study investigated emotion regulation difficulties as a potential link in the relationship between trait resilience and depression and anxiety severity in psychiatric outpatients (N = 353). METHODS: Participants diagnosed with primary depression or anxiety disorders were evaluated prior to treatment initiation with the Connor-Davidson Resilience Scale, Difficulties in Emotion Regulation Scale (DERS), Clinically Useful Depression Outcome Scale (CUDOS), and Clinically Useful Anxiety Outcome Scale (CUXOS). RESULTS: In the depression sample, the effect of resilience on CUDOS scores was fully mediated by total DERS scores. In the anxiety sample, the effect of resilience on CUXOS scores was partially mediated by total DERS scores. Exploratory parallel mediation analyses showed only the DERS subscale strategies had a significant effect on CUDOS scores, while only goals had a significant effect on CUXOS scores. CONCLUSIONS: Emotion regulation difficulties are a mediator of trait resilience in psychiatric outpatients. For patients seeking treatment for depression, difficulties with accessing emotion regulation strategies may be particularly relevant, while difficulties meeting one's goals may be most relevant for patients seeking treatment for anxiety.

Exploring the Optimal Factor Structure of the Five Facet Mindfulness Questionnaire: Associations Between Mindfulness Facets and Dimensions of Psychopathology.

Recent studies of the Five Facet Mindfulness Questionnaire (FFMQ) and its condensed version (FFMQ-SF) fail to replicate the initially proposed five-factor structure in clinical samples. Failure to adequately understand the dimensionality of common mindfulness measures within clinical samples, therefore, represents an important gap in the current literature. The increasing popularity of mindfulness-based interventions warrants further investigation of differential associations between facets of mindfulness and different forms of psychopathology. We examined (a) the underlying structure of the FFMQ and FFMQ-SF, and (b) associations between FFMQ and FFMQ-SF facets and dimensions of psychopathology (i.e., internalizing and substance use disorders) in two large clinical samples (N = 2,779). Results from bass-ackwards analyses suggested similarly defensible five- and six-factor model solutions in terms of fit. The five-factor model was optimal when factoring in parsimony. Exploratory structural equation modeling revealed that all FFMQ facets with the exception of observe were negatively associated with the internalizing factor. Associations with substance use disorders were more complex. In both samples, five-factor FFMQ and FFMQ-SF models were determined to best represent these data. Whereas deficits in all FFMQ facets with the exception of observe correspond with lower internalizing psychopathology, a more nuanced association was observed with substance use disorders.

A Clinically Useful Anger Outcome Scale.

In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the development and validation of the Clinically Useful Anger Outcome Scale (CUANGOS). Current anger measures vary in their psychometric quality, clinical utility, and clinically relevant content coverage, and no one scale addresses all three of these key considerations. We aimed to develop a brief, clinically useful anger scale that (a) assesses clinically relevant aspects of anger, (b) performs well across different patient populations, and (c) is brief, accessible, and easy to use in routine clinical practice either as a stand-alone measure or as part of an assessment battery. Analyses included data from 2710 psychiatric outpatients and 1397 partial hospitalization patients. We used data from randomly drawn subsamples to select items with good psychometric properties and sufficient distinction from measurements of other emotional dysfunction, resulting in a 5-item scale. In reliability and validity analyses using the remaining participants, CUANGOS scores showed high internal consistency and appropriate test-retest reliability, as well as excellent discriminant validity from measurements of depression and anxiety. CUANGOS scores converged strongly with clinician ratings of subjective and overt anger and differentiated across all or almost all levels of clinician-rated anger severity. CUANGOS scores were also significantly higher in patients with anger-related disorders versus patients with other psychiatric disorders. Results provide promising evidence for the CUANGOS as a reliable and valid measurement of anger in clinical populations. Moreover, the CUANGOS is brief and feasible to incorporate into routine clinical practice.

Impact of anxiety on dropping out of treatment for major depressive disorder at an intensive partial hospitalization program.

BACKGROUND: Premature treatment discontinuation (dropout) is a common problem among patients seeking treatment for major depressive disorder (MDD). To prevent treatment dropout, it is important to identify its associated risk factors. The impact anxiety has on treatment dropout for MDD is especially critical to investigate due to the high rates of comorbidity between anxiety and depressive disorders. Evidence for the degree to which anxiety reliably predicts treatment dropout for MDD remains inconclusive and has yet to be investigated at an adult partial hospitalization program. Examining this can help elucidate which factors predict dropout among patients who need intensive treatment for their depression. METHODS: Participants were patients seeking treatment for MDD at an adult partial hospitalization program (N = 461). A series of Chi-square tests and t tests were conducted to assess for any differences in frequencies of anxiety disorder comorbidities or mean scores of dimensional anxiety among patients who dropped out of treatment and those who did not. RESULTS: No significant associations between high baseline anxiety and early dropout were found (all P > .05). CONCLUSIONS: Findings suggest that no specific actions need to be taken to prevent individuals with high baseline levels of anxiety from prematurely dropping out of a partial hospitalization program.

Emotion regulation accounts for associations between mindfulness and depression across and within diagnostic categories.

BACKGROUND: Previous research shows that mindfulness and emotion regulation (ER) are highly related to each other. Preliminary evidence in small clinical populations show that ER may partially account for the relationship between mindfulness and depressive symptoms. The present study aimed to investigate which diagnostic categories were associated with depressive symptoms after controlling for ER in a heterogeneous sample of treatment-seeking patients. METHODS: A large sample of psychiatric outpatients (N = 911) completed the Structured Clinical Interview for DSM-IV (SCID), Five Facet Mindfulness Questionnaire (FFMQ), Difficulties in Emotion Regulation Scale (DERS), and Clinically Useful Depression Outcome Scale (CUDOS). Partial correlations were conducted to evaluate to what degree the relationship between depression scores and facets of mindfulness were accounted for by ER scores. RESULTS: When controlling for baseline mindfulness, the relationship between emotion dysregulation and depression symptoms remained significant for all data points; however, when controlling for baseline emotion dysregulation, the association between mindfulness and depression was not significant in the majority of cases. Nonjudging was most resistant to this result. CONCLUSIONS: Although mindfulness is negatively associated with depressive symptoms, this association may be better accounted for by emotion dysregulation.

Is the DSM-5 Anxious Distress Specifier Interview a valid measure of anxiety in patients with generalized anxiety disorder: A comparison to the Hamilton Anxiety Scale.

DSM-5 includes criteria for an anxious distress specifier for major depressive disorder, and measures have been developed to assess these criteria. The validity of measures of the severity of anxious distress has been established in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether a severity measure of anxious distress was as valid as the Hamilton Anxiety Scale (HAMA) as a measure of the severity of anxiety in patients with generalized anxiety disorder (GAD). Eighty-five patients with GAD were interviewed by trained raters who administered the DSM-5 Anxious Distress Specifier Interview (DADSI), HAMA, and Hamilton Depression Rating Scale (HAMD). The patients completed self-report measures of depression, anxiety, and irritability. The DADSI and HAMA were significantly correlated (r  0.52, p < .001). Both the DADSI and HAMA were more highly correlated with measures of anxiety than with measures of the other symptom domains. The HAMD was significantly more highly correlated with the HAMA than with the DADSI. Both measures were significantly correlated with measures of positive mental health, functioning, life satisfaction, and general well-being. Both measures were sensitive to change in response to treatment. Both the DADSI and HAMA were valid measures of anxiety severity in patients with GAD, though the HAMA was more highly confounded with the HAMD than the DADSI. The DADSI is briefer than the HAMA, and thus may be more practical to use in research studies as well as clinical practice.

A comparison of the dimensionality of the Hamilton Rating Scale for anxiety and the DSM-5 Anxious-Distress Specifier Interview.

The Hamilton Rating Scale for Anxiety (HAM-A) is one of the most widely used measures for assessing anxiety in research settings. However, it has been criticized for its inclusion of items that assess depressive symptoms. The DSM-5 Anxious Distress Specifier Interview (DADSI), developed as one assessment tool for measuring anxiety among depressed patients, demonstrates similar validity when compared with the HAM-A. However, its underlying factor structure has never been explored. The goal of the current study, therefore, was to compare the underlying factor structures of the HAM-A and the DADSI among clinically depressed (n = 576) and non-depressed (n = 146) patient samples. While two- and three-factor structures of the HAM-A fit similarly well among patients with a current major depressive episode, the three-factor structure-with anxiety and depressive symptoms forming separate factors-fit best among patients without a current major depressive episode. The DADSI was best represented by a single-factor model in both groups. The DADSI showed stronger associations with anxiety and somatic symptoms than with depressive symptoms of the HAM-A. These findings add to the characterization of the DADSI, and further highlight an important consideration for the use of HAM-A as a measure of anxiety in outcome studies.

Risk of skin cancer in multiple myeloma patients: a retrospective cohort study.

Immunosuppressed patients are known to have an increased incidence of skin cancer. Patients with multiple myeloma (MM) show impaired immune function. In the past, because of poor survival, the incidence of specific secondary primary malignancies such as skin cancer among these patients was difficult to establish. With more effective MM therapies that have emerged in recent years, these patients are living markedly longer, and therefore, it becomes of increasing importance to determine whether their risk of developing other medical problems such as skin cancer is increased. We performed a retrospective cohort study of 205 myeloma patients and 193 age-, race-, and gender-matched control subjects to assess the incidence of skin cancers among patients with MM and determine the specific types of and risk factors for skin cancer. We found that there is an increased occurrence of skin cancer among patients with MM compared to control subjects (26.8% vs. 16.1% in controls; P = 0.009). Among specific types of skin cancer, the proportion of patients with squamous cell carcinoma (SCC) was higher than controls (P = 0.016). In addition to MM diagnosis, older age and Caucasian ethnicity were predictors of skin cancer of any type. Furthermore, older age was also a predictor of SCC.

Association Between Mohs Surgery Wait Times and Surgical Defect Size in Patients With Squamous Cell or Basal Cell Carcinoma of the Skin.

BACKGROUND: Consequences of delays in treatment of nonmelanoma skin cancers (NMSCA) are largely unstudied. OBJECTIVE: To determine the relationship between Mohs micrographic surgery (MMS) delay time and final MMS defect size. METHODS: A retrospective chart review was performed to identify patients who underwent MMS for biopsy-proven basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) between 2004 and 2006. Time delay between date of biopsy and date of surgery and lesion diameter increase between biopsy and surgical defect were calculated. RESULTS: Two hundred eighty-three lesions qualified for inclusion in the study. No significant difference in mean change of major diameter between primary and recurrent tumors (1.0 vs 1.1 cm, p = .67), between BCCs and SCCs (both were 1.0 cm, p = .99), and between tumor size at presentation <1.0 versus ≥1.0 cm (1.1 vs 0.8 cm, p = .11) were found. However, the mean number of MMS layers taken was significantly different between BCCs and SCCs (1.9 vs 1.5, respectively; p = .0022). Linear regression analysis of major diameter change versus time delay to MMS showed no significant increasing trend over time. CONCLUSION: No evidence was found that time delays of up to 1 year from biopsy to MMS impact the growth of NMSCA.

Promising alternative clinical uses of prostaglandin F2α analogs: beyond the eyelashes.

Prostaglandin F2α analogs, commonly prescribed for glaucoma treatment, have been shown to induce side effects such as cutaneous hypertrichosis and hyperpigmentation. Therefore, these medications have theoretic applications in the treatment of alopecia and disorders of hypopigmentation. We reviewed the literature to find original studies assessing the use of prostaglandin F2α analogs in these settings. Studies and reports were analyzed in regards to androgenic alopecia, alopecia areata, chemotherapy-induced alopecia, vitiligo, and hypopigmented scarring. Based on the results of these studies, and consideration of pathophysiologic mechanism, the most promising applications for prostaglandin F2α analogs include androgenic alopecia, chemotherapy-induced alopecia, and alopecia areata concurrently treated with corticosteroids.

Update on tanning: More risks, fewer benefits.

The tanning response, classically defined as increased cutaneous pigmentation after solar ultraviolet light exposure, encompasses a variety of protective, reparative, and cosmetic issues. The tanning story is continuously evolving as basic science, clinical research, and public health studies shed light on topics involving: the physiologic mechanisms of tanning, the medical benefits of tanning, the role of sunscreens, the development of "sunless" self-tanners, the use of photocarcinogenic indoor tanning services, and the relatively recent development and promulgation of α-melanocyte-stimulating hormone analogues. High-risk tanning behaviors have become increasingly popular and the incidence of melanoma has risen more rapidly than any other cancer. This review will focus on the risks and benefits of each type of tanning, with an emphasis on issues pertinent to dermatologists who care for adolescents and young adults.

Dyshidrotic mycosis fungoides.

Mycosis fungoides (MF) represents the most common type of cutaneous T-cell lymphoma (CTCL). CTCL often progresses through patch, plaque and tumor stages but can also manifest with varied clinical presentations. MF rarely presents in vesiculobullous fashion, in which vesicles or bullae develop in pre-existing plaques or on the trunk or proximal extremities. We report a patient who presented with a vesiculobullous eruption on the palms and soles, resembling dyshidrotic dermatitis, which we believe represents dyshidrotic MF.

Effects of ambient sunlight and photoprotection on vitamin D status.

Ultraviolet B radiation exposure is responsible for the majority of natural vitamin D stores in humans. The physiologic role of vitamin D in health and disease is continually expanding, and at the same time the population that is vitamin D deficient is increasing. The environmental characteristics and personal physical traits that contribute to vitamin D3 synthesis from sun exposure are discussed, and the effects of photoprotection on vitamin D status are examined. It is concluded that sunscreen, in the manner used by the general public, does not cause vitamin D insufficiency. Implementing guidelines suggesting sun exposure duration for sufficient vitamin D3 production is limited by the complex interaction of contributory factors, and no recommendation can be made that is both safe and accurate enough for general public usage.

Intraocular lens power adjustment nomogram after laser in situ keratomileusis.

PURPOSE: To develop a nomogram for improving the accuracy of intraocular lens (IOL) power calculation at the time of cataract surgery based on the manifest refraction spherical equivalent (MRSE) change produced by laser in situ keratomileusis (LASIK). SETTING: University-based clinical practice, Jules Stein Eye Institute, Los Angeles, California, USA. METHODS: This was a retrospective review of the records of consecutive patients who had cataract surgery after LASIK. Spherical equivalent refractive data before and after LASIK and cataract surgery were recorded. The differences between the targeted postoperative refractive errors after cataract surgery and the achieved refractive errors were plotted against the LASIK-induced MRSE change, yielding postoperative refractive errors to target during IOL power calculation to achieve emmetropia. RESULTS: Thirty-two eyes of 23 patients were identified; 25 eyes had myopic LASIK and 7, hyperopic LASIK. Regression analysis yielded the following polynomial relationship: target postoperative refractive error (D) to achieve emmetropia during IOL power calculation = -0.018(MRSE Change)(2) + 0.192(MRSE Change) - 0.062. The outcomes in 97% of eyes fell within +/-1.00 D of the value predicted by this formula. CONCLUSIONS: A 2nd-order polynomial relationship was found between LASIK-induced MRSE change and the MRSE error after cataract surgery. From this equation, a simple adjustment nomogram was generated and put into a look-up table format. The formula and nomogram should improve IOL power calculation accuracy in post-LASIK eyes when the MRSE change is known.