Mindfulness and Modification Therapy for Behavioral Dysregulation: A Comparison Trial Focused on Substance Use and Aggression.

OBJECTIVES: Disorders of behavioral dysregulation often involve more than one dsyregulated behavior (e.g., drug abuse and aggression, alcohol abuse and gambling). The high co-occurrence suggests the need of a transdiagnostic treatment that can be customized to target multiple specific behaviors. METHOD: The current pilot study compared a 20-week, individual transdiagnostic therapy (mindfulness and modification therapy [MMT]) versus treatment as usual (TAU) in targeting alcohol problems, drug use, physical aggression, and verbal aggression in self-referred women. Assessments were administered at baseline, post-intervention, and 2-month follow-up. RESULTS: Wilcoxon signed-ranked tests and multilevel modeling showed that MMT (n = 13) displayed (a) significant and large decreases in alcohol/drug use, physical aggression, and verbal aggression; (b) significantly greater decreases in alcohol/drug use and physical aggression than did TAU (n = 8); and (c) minimal-to-no deterioration of effects at follow-up. Both conditions showed significant decreases in verbal aggression, with no statistically significant difference between conditions. MMT also displayed greater improvements in mindfulness. CONCLUSIONS: Preliminary findings support the feasibility and efficacy of MMT in decreasing multiple dysregulated behaviors.

Personality disorders as maladaptive, extreme variants of normal personality: borderline personality disorder and neuroticism in a substance using sample.

Although the current diagnostic manual conceptualizes personality disorders (PDs) as categorical entities, an alternative perspective is that PDs represent maladaptive extreme versions of the same traits that describe normal personality. Existing evidence indicates that normal personality traits, such as those assessed by the five-factor model (FFM), share a common structure and obtain reasonably predictable correlations with the PDs. However, very little research has investigated whether PDs are more extreme than normal personality traits. Utilizing item-response theory analyses, the authors of the current study extend previous research to demonstrate that the diagnostic criterion for borderline personality disorder and FFM neuroticism could be fit along a single latent dimension. Furthermore, the authors' findings indicate that the borderline criteria assessed the shared latent trait at a level that was more extreme (d = 1.11) than FFM neuroticism. This finding provides further evidence for dimensional understanding of personality pathology and suggests that a trait model in DSM-5 should span normal and abnormal personality functioning, but focus on the extremes of these common traits.

Development of an in-home telehealth program for outpatient veterans with substance use disorders.

A variety of obstacles (e.g., lack of transportation, less availability of treatment in rural districts) contribute to underutilization of treatment among patients with substance use disorders, warranting the need to develop innovative strategies for enhancing access to treatment for these patients. The telehealth in-home-messaging-device is a small message-delivering and monitoring device connected via landline phone to a secure server that provides assessment and disease self-management education to patients in their homes. We describe the development of a Substance Use Disorder telehealth management program (SUD program) for use on this device and a feasibility pilot of the program with six outpatient veterans with substance use disorders referred by their primary medical care providers. These patients indicated that the SUD program was acceptable, easy to use, and helpful toward addressing their substance use problems. Home telehealth technology may be an innovative and feasible approach for providing substance abuse evidence-based treatment either as an adjunct to specialty treatment for substance use disorders or as a stand-alone intervention within primary care for a larger number of patients who may otherwise not access traditional treatment services.

An exploratory randomized controlled trial of a novel high-school-based smoking cessation intervention for adolescent smokers using abstinence-contingent incentives and cognitive behavioral therapy.

BACKGROUND: There are few effective smoking cessation interventions for adolescent smokers. We developed a novel intervention to motivate tobacco use behavior change by (1) enhancing desire to quit through the use of abstinence-contingent incentives (CM), (2) increasing cessation skills through the use of cognitive behavioral therapy (CBT), and (3) removing cessation barriers through delivery within high schools. METHODS: An exploratory four-week, randomized controlled trial was conducted in Connecticut high schools to dismantle the independent and combined effects of CM and CBT; smokers received CM alone, CBT alone, or CM+CBT. Participants included 82 adolescent smokers seeking smoking cessation treatment. The primary outcome was seven-day end-of-treatment (EOT) point prevalence (PP) abstinence, determined using self-reports confirmed using urine cotinine levels. Secondary outcomes included one-day EOT PP abstinence and cigarette use during treatment and follow up. RESULTS: Among participants who initiated treatment (n=72), group differences in seven-day EOT-PP abstinence were observed (χ(2)=10.48, p<0.01) with higher abstinence in the CM+CBT (36.7%) and CM (36.3%) conditions when compared with CBT (0%). One-day EOT-PP abstinence evidenced similar effects (χ(2)=10.39, p<0.01; CM+CBT: 43%, CM: 43%, CBT: 4.3%). Survival analyses indicated differences in time to first cigarette during treatment (χ(2)=8.73, p=0.003; CBT: Day 3, CM: Day 9, CM+CBT: Day 20). At one- and three-month follow ups, while no differences were observed, the CM alone group had the slowest increase in cigarette use. CONCLUSIONS: High-school, incentive-based smoking cessation interventions produce high rates of short-term abstinence among adolescent smokers; adding cognitive behavioral therapy does not appear to further enhance outcomes.

Functional brain networks associated with cognitive control, cocaine dependence, and treatment outcome.

Individuals with cocaine dependence often evidence poor cognitive control. The purpose of this exploratory study was to investigate networks of functional connectivity underlying cognitive control in cocaine dependence and examine the relationship of the networks to the disorder and its treatment. Independent component analysis (ICA) was applied to fMRI data to investigate if regional activations underlying cognitive control processes operate in functional networks, and whether these networks relate to performance and treatment outcome measures in cocaine dependence. Twenty patients completed a Stroop task during fMRI prior to entering outpatient treatment and were compared to 20 control participants. ICA identified five distinct functional networks related to cognitive control interference events. Cocaine-dependent patients displayed differences in performance-related recruitment of three networks. Reduced involvement of a "top-down" fronto-cingular network contributing to conflict monitoring correlated with better treatment retention. Greater engagement of two "bottom-up" subcortical and ventral prefrontal networks related to cue-elicited motivational processing correlated with abstinence during treatment. The identification of subcortical networks linked to cocaine abstinence and cortical networks to treatment retention suggests that specific circuits may represent important, complementary targets in treatment development for cocaine dependence.

Motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice: a randomized trial for treatment of hazardous substance use in pregnancy and after delivery.

OBJECTIVE: The objective was to compare the efficacy of motivational enhancement therapy coupled with cognitive behavioral therapy (MET-CBT) to brief advice for treatment of substance use in pregnancy. METHOD: This was a randomized, parallel, controlled trial that was yoked to prenatal care and delivered at hospital outpatient clinics. We enrolled 168 substance-using women who had not yet completed an estimated 28 weeks of pregnancy. Obstetrical clinicians provided brief advice, and study nurses administered manualized MET-CBT. The primary outcome was percentage of days in the prior 28 days in which alcohol and/or drugs were used immediately before and 3 months postdelivery. RESULTS: There were no significant differences across groups in terms of self-reported percentage of days in which drugs or alcohol were used prior to and 3 months postdelivery. Biological measures showed similar results. There was a trend (P=.08) for lower risk of preterm birth among those who received MET-CBT. CONCLUSIONS: The tested interventions had similar therapeutic effects. Hence, both treatments may be suitable for pregnant substance users, depending on the population, setting and provider availability. Interventions that are intensified after delivery may decrease postpartum "rebound" effects in substance misuse.

Prenatal hazardous substance use and adverse birth outcomes.

OBJECTIVE: Assess the relative effects of a variety of illicit and licit drugs on risk for adverse birth outcomes. METHODS: We used data from two large prospective investigations, and a novel analytic method, recursive partitioning class analysis to identify risk factors associated with preterm birth and delivering a small for gestational age infant. RESULTS: Compared to cocaine and opiate non-users, cocaine users were 3.53 times as likely (95% CI: 1.65-7.56; p = 0.001) and opiate users 2.86 times as likely (95% CI: 1.11-7.36; p = 0.03) to deliver preterm. The odds of delivering a small for gestational age infant for women who smoked more than two cigarettes daily was 3.74, (95% CI: 2.47-5.65; p<0.0001) compared to women who smoked two or less cigarettes daily and had one previous child. Similarly, less educated, nulliparous women who smoked two or fewer cigarettes daily were 4.12 times as likely (95% CI: 2.04-8.34; p < 0.0001) to have a small for gestational age infant. CONCLUSIONS: Among our covariates, prenatal cocaine and opiate use are the predominant risk factors for preterm birth; while tobacco use was the primary risk factor predicting small for gestational age at delivery. Multi-substance use did not substantially increase risk of adverse birth outcomes over these risk factors.

A randomized trial adapting contingency management targets based on initial abstinence status of cocaine-dependent patients.

OBJECTIVE: Contingency management (CM) reduces drug use, but questions remain regarding optimal targets and magnitudes of reinforcement. We evaluated the efficacy of CM reinforcing attendance in patients who initiated treatment with cocaine-negative samples, and of higher magnitude abstinence-based CM in patients who began treatment positive. METHOD: Initially cocaine-negative patients (n = 333) were randomized to standard care (SC), SC + CM reinforcing submission of negative samples with $250 in prizes ($250Abs), or SC + CM reinforcing attendance ($250Att). Initially cocaine-positive patients (n = 109) were randomized to SC, $250Abs, or higher magnitude CM ($560Abs). RESULTS: For initially cocaine-negative patients, $250Abs and $250Att were equally efficacious to SC in enhancing longest duration of abstinence (LDA); $250Att patients submitted lower proportions of negative samples when missing samples were considered missing, but these patients also attended more study sessions, provided more samples, and submitted a higher proportion of negative samples than SC patients when expected samples were analyzed, ps < .05. In initially cocaine-positive patients, both CM conditions increased proportions of negative samples relative to SC when missing samples were excluded from analyses, but only $560Abs was efficacious in increasing LDA and proportion of negative samples when expected samples were analyzed, ps < .05. Follow-ups revealed no differences among groups, but LDA was consistently associated with abstinence during follow-up, p < .05. CONCLUSIONS: High magnitude abstinence-based reinforcement improved all abstinence outcomes in patients who began treatment while using cocaine. For patients initiating treatment abstinent, both attendance- and abstinence-based CM resulted in improvements on some measures.

College Student Drug Use: Patterns, Concerns, Consequences, and Interest in Intervention.

Although previous surveys have indicated high rates of illicit and prescription drug misuse among college students, few have assessed negative consequences, personal concerns, or interest in interventions for drug use. In a survey of 262 college students who self-reported lifetime use of an illicit drug, 69% reported at least one negative consequence over the course of their lifetime and 63% in the past year. Many also reported being moderately concerned (28%) about their drug or medication misuse and moderately interested in some form of intervention (76%). The frequency of marijuana use and medication misuse in the past month was related to increased negative consequences and personal concerns even when controlling for the frequency of past month alcohol use. There were relatively few differences as a function of gender or year in college.

Baseline trajectories of heavy drinking and their effects on postrandomization drinking in the COMBINE Study: empirically derived predictors of drinking outcomes during treatment.

The Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study sought to answer questions about the benefits of combining behavioral and pharmacological interventions (naltrexone and acamprosate) in alcohol-dependent patients. Our goals were to identify trajectories of heavy drinking before randomization in COMBINE, to characterize patients in these trajectories, and to assess whether prerandomization trajectories predict drinking outcomes. We analyzed daily indicators of heavy drinking 90 days before randomization using a trajectory-based approach. Each patient was assigned to the most likely prerandomization heavy-drinking trajectory, and the baseline characteristics of participants in the baseline trajectories were compared. The main and interactive effects of these trajectories and treatment factors (acamprosate, naltrexone, or combined behavioral intervention) on summary drinking measures during active treatment (16 weeks) were assessed. We identified five trajectories of heavy drinking prerandomization: "T1: frequent heavy drinkers"; "T2: very frequent heavy drinkers"; "T3: nearly daily heavy drinkers"; "T4: daily heavy drinkers"; and "T5: daily heavy drinkers stopping early" before randomization. Trajectory membership was significantly associated with all drinking outcomes. Patients in "T5: daily heavy drinkers stopping early" had comparable drinking outcomes to those in "T1: frequent heavy drinkers," whereas the remaining trajectories were associated with significantly worse outcomes. The baseline trajectory did not interact significantly with the treatment condition. These exploratory analyses confirmed the hypothesis that baseline trajectories predict postrandomization drinking outcomes. Interestingly, "T5: daily heavy drinkers stopping early" had outcomes that were comparable to the least severe baseline trajectory "T1: frequent heavy drinkers," and baseline trajectories of heavy drinking did not moderate the treatment effects.

Internalizing and externalizing dimensions and alcohol use in first time DWI offenders: indirect effects through coping self-efficacy.

Using cross-sectional data and structural equation modeling, we evaluated whether coping self-efficacy to abstain from drinking in various situations accounted for the relationship between internalizing (depression, anxiety) and externalizing (aggression, low socialization) dimensions with problematic alcohol use in 292 first-time DWI offenders. Results indicated that an internalizing dimension indirectly predicted problematic alcohol use through coping self-efficacy in negative situations only, whereas an externalizing dimension indirectly predicted problematic alcohol use through coping self-efficacy in positive situations only. These findings support two potential pathways to problematic drinking behavior among DWI offenders and suggest that internalizing and externalizing dimensions may differentially predict high risk drinking situations due to one's inability to abstain in specific situations.

White matter integrity and behavioral activation in healthy subjects.

Individual differences in behavioral inhibition and behavioral activation may place certain people at greater risk for neuropsychiatric disorders and engagement in risky behaviors. Therefore, studying the neural correlates of behavioral inhibition and activation may help us understand neural mechanisms underlying risk behaviors in both clinical and non-clinical populations. To investigate, we assessed the relationships between white matter integrity and measures of behavioral inhibition and behavioral activation in 51 healthy participants using diffusion tensor imaging (DTI) and the Behavioral Inhibition System/Behavioral Activation System (BIS/BAS) scale. Scores on the Fun-Seeking subscale of the BAS positively correlated with DTI fractional anisotropy in the left corona radiata and adjacent superior longitudinal fasciculus, and with mean diffusivity in the left inferior longitudinal fasciculus and inferior fronto-occipital fasciculus after controlling for age, gender, and education. These findings suggest that the integrity of white matter connecting extensive brain regions implicated in self-control and the processing of rewards and emotions are associated with individual differences in the motivation for seeking and participating in fun and novel experiences.

Mentorship for Alcohol Problems (MAP): a peer to peer modular intervention for outpatients.

AIMS: This is a Stage I open pilot to develop a new intervention, Mentorship for Alcohol Problems (MAP), for individuals with alcohol-use disorders in community treatment programs. METHODS: Ten mentors participated for 6 months until 30 mentees received MAP for 12 weeks. Behavioral and biological measures were conducted in addition to fidelity measures. Four focus groups were held with participants and clinician feedback surveys were completed. RESULTS: Feasibility and acceptance data in the domains of patient interest, safety and satisfaction were promising. Mentees reduced their alcohol and substance use and the majority of mentors sustained abstinence. Fidelity measures indicated that mentors adhered to the delivery of treatment. CONCLUSION: MAP shows promise to be incorporated into professionally run outpatient alcohol treatment programs to assist in the reduction of alcohol and substance use.

A preliminary study of the neural effects of behavioral therapy for substance use disorders.

BACKGROUND: The mechanisms by which behavioral therapies for substance use disorders (SUDs) exert their effects and the components of treatment that contribute most to substance use outcome remain unclear. Disruptions to aspects of impulse control and attention have been hypothesized to contribute to the development and maintenance of addiction; moreover, alterations in these processes may underlie responses to treatment. METHODS: Individuals participating in a randomized clinical trial evaluating computer-assisted cognitive behavioral therapy (CBT) for substance abuse participated in fMRI Stroop before and after treatment. A non-substance-using comparison group performed the same task under test-retest conditions. RESULTS: The patient group demonstrated decreased Stroop-related BOLD signal in regions including the anterior cingulate, inferior frontal gyrus and midbrain at post-treatment relative to pre-treatment, and displayed a greater decrease in the subthalamic nucleus and surrounding regions compared to healthy controls following test-retest. CONCLUSIONS: Behavioral therapies may be associated with reduction in substance use and effects on neural systems involved in cognitive control, impulsivity, motivation and attention.

Noradrenergic vs serotonergic antidepressant with or without naltrexone for veterans with PTSD and comorbid alcohol dependence.

The wars in Iraq and Afghanistan are associated with high rates of post-traumatic stress disorder (PTSD) and comorbid alcohol use disorders. The pharmacotherapy of these comorbid conditions has received relatively little study. The current study compared the serotonin uptake inhibitor, paroxetine, to the norepinephrine uptake inhibitor, desipramine. It also evaluated the adjunctive efficacy of the Food and Drug Administration (FDA)-approved alcoholism pharmacotherapy, naltrexone, relative to placebo. Four groups of predominately male veterans (n=88) meeting current diagnostic criteria for both alcohol dependence (AD) and PTSD were randomly assigned under double-blind conditions to one of four groups: paroxetine+naltrexone; paroxetine+placebo; desipramine+naltrexone; desipramine+placebo. Main outcome measures included standardized scales that assessed symptoms of PTSD and alcohol consumption. Paroxetine did not show statistical superiority to desipramine for the treatment of PTSD symptoms. However, desipramine was superior to paroxetine with respect to study retention and alcohol use outcomes. Naltrexone reduced alcohol craving relative to placebo, but it conferred no advantage on drinking use outcomes. Although the serotonin uptake inhibitors are the only FDA-approved medications for the treatment of PTSD, the current study suggests that norepinephrine uptake inhibitors may present clinical advantages when treating male veterans with PTSD and AD. However, naltrexone did not show evidence of efficacy in this population. This study was registered with ClinicalTrials.gov, registration number NCT00338962 and URL: http://clinicaltrials.gov/ct2/show/NCT00338962?term=desipramine+AND+alcohol+dependence+AND+depression&recr=Closed&rank=1.

Utilizing peer mentorship to engage high recidivism substance-abusing patients in treatment.

BACKGROUND: Often high recidivism substance-using patients have difficulty connecting to outpatient treatment contributing to greater functioning disturbances. Approaches to address this problem frequently are staff extensive. OBJECTIVE: This study evaluates the impact of peer mentorship and/or enhanced dual recovery treatment (DRT) on individuals who are inpatients, substance abusing, and have a history of high recidivism. The primary outcome is post-discharge treatment attendance. METHODS: In an inpatient Veterans Administration hospital setting, 96 patients with a history of high recidivism and current and/or past diagnosis of substance use disorders were randomized to either (i) Treatment As Usual (TAU), (ii) TAU + DRT + Mentorship for Addictions Problems to Enhance Engagement to Treatment (MAP-Engage), or (iii) TAU + MAP-Engage. RESULTS: Overall MAP-Engage was found to be comparable to the DRT + MAP-Engage and both of these conditions were significantly better than TAU alone at increasing adherence to post-discharge substance abuse, medical, and mental health outpatient appointments. CONCLUSION/SCIENTIFIC SIGNIFICANCE: MAP-Engage offers an alternative approach to address lack of attendance to outpatient treatment appointments post discharge that is relatively low in staff reliance.

Group-based strategies for stress reduction in methadone maintenance treatment: what do patients want?

OBJECTIVES: To assess methadone maintenance treatment (MMT) patients' willingness to use, and perceived efficacy of, conventional and unconventional group stress reduction treatments. METHODS: A survey, developed by the authors, was administered to 150 MMT patients. RESULTS: Levels of treatment willingness and perceived efficacy for both conventional and unconventional treatments were relatively high; however, ratings for conventional interventions were, on average, significantly higher than those for unconventional ones. The highest rated conventional and unconventional treatments in terms of willingness and perceived efficacy were nutrition and spiritual counseling, respectively, whereas the lowest rated conventional and unconventional group treatments were anger management and visualization training, respectively. White race was a significant predictor of lower willingness to try conventional and unconventional group therapies and lower perceived efficacy of unconventional group treatment, whereas female sex and older age were significant predictors of higher levels of willingness to try unconventional group treatment. Higher levels of substance use problems were associated with increased willingness to try conventional group treatment. Higher levels of anxiety emerged as a significant independent predictor of treatment willingness and perceived efficacy for both conventional and unconventional group treatments. CONCLUSIONS: The relatively high levels of treatment willingness and perceived efficacy of conventional and unconventional group stress reduction treatments point to the feasibility of offering these interventions in MMT and suggest that, in particular, high levels of anxiety are associated with greater treatment willingness and perceived treatment efficacy.

Mindfulness training for smoking cessation: results from a randomized controlled trial.

BACKGROUND: Cigarette smoking is the leading cause of preventable death in the world, and long-term abstinence rates remain modest. Mindfulness training (MT) has begun to show benefits in a number of psychiatric disorders, including depression, anxiety and more recently, in addictions. However, MT has not been evaluated for smoking cessation through randomized clinical trials. METHODS: 88 treatment-seeking, nicotine-dependent adults who were smoking an average of 20cigarettes/day were randomly assigned to receive MT or the American Lung Association's freedom from smoking (FFS) treatment. Both treatments were delivered twice weekly over 4 weeks (eight sessions total) in a group format. The primary outcomes were expired-air carbon monoxide-confirmed 7-day point prevalence abstinence and number of cigarettes/day at the end of the 4-week treatment and at a follow-up interview at week 17. RESULTS: 88% of individuals received MT and 84% of individuals received FFS completed treatment. Compared to those randomized to the FFS intervention, individuals who received MT showed a greater rate of reduction in cigarette use during treatment and maintained these gains during follow-up (F=11.11, p=.001). They also exhibited a trend toward greater point prevalence abstinence rate at the end of treatment (36% vs. 15%, p=.063), which was significant at the 17-week follow-up (31% vs. 6%, p=.012). CONCLUSIONS: This initial trial of mindfulness training may confer benefits greater than those associated with current standard treatments for smoking cessation.

Adapting Dialectical Behaviour Therapy for Children: Towards a New Research Agenda for Paediatric Suicidal and Non-Suicidal Self-Injurious Behaviours.

BACKGROUND: Dialectical Behaviour Therapy (DBT) has been used to treat adults and adolescents with suicidal and non-suicidal self-injury. This article describes initial progress in modifying DBT for affected pre-adolescent children. METHOD: Eleven children from regular education classes participated in a 6-week pilot DBT skills training program for children. Self-report measures of children's emotional and behavioural difficulties, social skills and coping strategies were administered at pre- and post-intervention, and indicated that the children had mild to moderate symptoms of depression, anxiety and suicidal ideation at baseline. RESULTS: Subjects were able to understand and utilise DBT skills for children and believed that the skills were important and engaging. Parents also regarded skills as important, child friendly, comprehensible and beneficial. At post-treatment, children reported a significant increase in adaptive coping skills and significant decreases in depressive symptoms, suicidal ideation and problematic internalising behaviours. CONCLUSIONS: These promising preliminary results suggest that continued development of DBT for children with more severe clinical impairment is warranted. Progress on adapting child individual DBT and developing a caregiver training component in behavioural modification and validation techniques is discussed.

Deficits in default mode network activity preceding error in cocaine dependent individuals.

BACKGROUND: Cocaine dependence is associated with cognitive deficits and altered task-related cerebral activation in cognitive performance (see Li and Sinha, 2008, for a review). Relatively little is known whether these individuals are also impaired in regional brain activation of the default mode network (DMN). We demonstrated previously that greater activation of the default brain regions precedes errors in a stop signal task performed by healthy controls (SST, Li et al., 2007). We seek to determine whether individuals with cocaine dependence are impaired in DMN activity, specifically activity preceding error, as compared to the healthy people. We also examine the relation to years of cocaine use. METHODS: Individuals with cocaine dependence (CD, n=23) and demographics-matched healthy controls (HC, n=27) performed a SST that employed a tracking procedure to adjust the difficulty of stop trials and elicit errors approximately half of the time. Blood oxygenation level dependent (BOLD) signals of go trials preceding stop error as compared to those preceding stop success trials were extracted with generalized linear models using statistical parametric mapping. RESULTS: HC showed activation of bilateral precuneus and posterior cingulate cortices and ventromedial prefrontal cortex (vmPFC) preceding errors during the SST. In contrast, despite indistinguishable stop signal performance, CD did not show these error predicting activations. Furthermore, the effect size of error-preceding vmPFC activation was inversely correlated with years of cocaine use. CONCLUSIONS: These findings indicate DMN deficits and could potentially add to our understanding of the effects of chronic cocaine use on cerebral functions in cocaine dependence. Work to further clarify potential changes in functional connectivity and gray matter volume is warranted to understand the relevance of DMN to the pathology of cocaine misuse.