A placebo-controlled randomized trial of D-cycloserine augmentation of cue exposure therapy for smoking cessation.

Recent studies underscore the importance of studying d-cycloserine (DCS) augmentation under conditions of adequate cue exposure treatment (CET) and protection from reconditioning experiences. In this randomized trial, we evaluated the efficacy of DCS for augmenting CET for smoking cessation under these conditions. Sixty-two smokers attained at least 18 hours abstinence following 4 weeks of smoking cessation treatment and were randomly assigned to receive a single dose of DCS (n=30) or placebo (n=32) prior to each of two sessions of CET. Mechanistic outcomes were self-reported cravings and physiologic reactivity to smoking cues. The primary clinical outcome was 6-week, biochemically-verified, continuous tobacco abstinence. DCS, relative to placebo, augmentation of CET resulted in lower self-reported craving to smoking pictorial and in vivo cues (d = 0.8 to 1.21) in a relevant subsample of participants who were reactive to cues and free from smoking-related reconditioning experiences. Select craving outcomes were correlated with smoking abstinence, and DCS augmentation was associated with a trend toward a higher continuous abstinence rate (33% vs. 13% for placebo augmentation). DCS augmentation of CET can significantly reduce cue-induced craving, supporting the therapeutic potential of DCS augmentation when applied under appropriate conditions for adequate extinction learning.

Attending to Timely Contingencies: Promoting Physical Activity Uptake Among Adults with Serious Mental Illness with an Exercise-For-Mood vs. an Exercise-For-Fitness Prescription.

Despite evidence for both physical and mental health benefits achieved through regular exercise, most Americans fail to meet minimum recommendations. Altering the behavioral contingency from a focus on long-term health benefits to immediate mood benefits represents a novel method for exercise promotion. The current study examined a single-session exercise-for-mood intervention against two time-matched comparison conditions in 152 patients with serious mental illness attending a partial hospital program, a population marked by significant health disparities. This intervention was compared to a standard exercise-for-fitness intervention and a time-matched no-exercise control. Among patients with high levels of exercise prior to the partial hospital program, the exercise-for-mood intervention yielded significant increases in exercise. Implications for exercise promotion interventions among psychiatrically ill patients are discussed.

Relations Between Past-Week Physical Activity and Recent Nonsuicidal Self-Injury in Treatment-Seeking Psychiatric Adults.

OBJECTIVE: This research study examines the relationship between past-week physical activity and recent (i.e., within the past 30 days) nonsuicidal self-injury (NSSI) in a sample of treatment-seeking adults.  METHOD: Participants included 353 (49.29% female; mean age = 35.16 years) adults attending a partial hospitalization program for acute psychiatric issues. Data were extracted from the program's admission battery of computer-based self-report measures completed by each participant on the first treatment day. RESULTS: Participants with a recent history of NSSI (i.e., within the past 30 days) engaged in significantly less past-week physical activity than those without a history of NSSI. Group differences remained significant while controlling for anxiety, but not depression. CONCLUSION: Results suggest that, on average, individuals who have never engaged in NSSI exercise more in the week prior to entering the partial hospital program than those who have a recent history of NSSI. Regular physical activity may be an interesting area of study to explore as a promising adjunctive intervention for NSSI (e.g., vigorous exercise as a way to tolerate distress and manage urges to self-injure).

Prevalence and Characteristics of Body Dysmorphic Disorder Among Patients in a Partial Hospital Program.

Body dysmorphic disorder (BDD) is a common disorder that is usually associated with impaired functioning and high levels of suicidality. The current study is the first to assess prevalence of BDD among patients in a partial hospital program and compare patients with and without BDD on demographic and clinical variables. Participants were 207 patients with a variety of Axis I diagnoses. Prevalence of current BDD was 7.2%, and a diagnosis of BDD did not predict worse treatment outcome in the program. Patients with current BDD were more likely to be female and younger and have more comorbid diagnoses than patients without current BDD. No other significant differences were found at baseline between patients with and without current BDD. Results indicate that BDD is relatively common among patients in partial hospital programs and that such programs may be as beneficial to patients with BDD as to other patients.

When Partial Hospitalization Fails: Risk Factors for Inpatient Hospitalization.

Partial hospitalization is an understudied bridge between outpatient and inpatient care. One of its primary functions is to prevent the need for inpatient hospitalization. We examined potential demographic and clinical risk factors for inpatient hospitalization for current partial hospital patients. We conducted separate multiple logistic regression analyses for patients referred from inpatient care and the community. For individuals referred from inpatient care, suicidal ideation and greater psychotic symptoms upon admission to the partial program were associated with acute inpatient re-hospitalization. For individuals referred from the community, suicidal ideation and worse relationship functioning upon partial hospital admission were significant risk factors for inpatient hospitalization. Number of previous inpatient hospitalizations and greater substance abuse were not associated with inpatient hospitalization in either sample. Implications at the provider and program level are discussed.

The Development of a Novel Measure to Assess Motives for Compensatory Eating in Response to Exercise: The CEMQ.

Compensatory eating in response to exercise may be an obstacle to achieving weight-loss and fitness goals. In this study we develop and conduct a preliminary examination of the psychometric properties of the Compensatory Eating Motives Questionnaire (CEMQ), a self-report questionnaire of motives for compensatory eating. Development and testing of the CEMQ was conducted in two student samples. Of respondents, 75% reported engaging in compensatory eating. Factor analysis yielded factors representing three domains of motives for compensatory eating: Eating for Reward, Eating for Recovery, and Eating for Relief. Internal consistency of the factors was adequate, and the factor structure was replicated. Correlations between the CEMQ subscales and trait questionnaires supported hypotheses for convergent and divergent validity. These results encourage further investigation of compensatory eating as a potential obstacle to weight loss, and support the continued assessment of the CEMQ as a tool to measure three conceptually distinct motives for compensatory eating.

Properties of the Dialectical Behavior Therapy Ways of Coping Checklist in a Diagnostically Diverse Partial Hospital Sample.

OBJECTIVE: Dialectical behavior therapy (DBT) was developed for treatment of borderline personality disorder (BPD), and adapted forms of DBT are currently used to treat bipolar disorder, eating disorders, anxiety, and depression. This study was designed to validate the Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL) DBT Skills subscale (DSS) for use in a diagnostically heterogeneous sample. METHOD: We used naturalistic data from 228 patients receiving treatment at a partial hospital program to assess psychometric properties of the DBT-WCCL DSS. We assessed interitem correlations, internal consistency, factor structure, construct validity and sensitivity to change. RESULTS: Internal consistency, construct validity, and sensitivity to change were good. The measure displayed good convergent and discriminant validity. Factor analysis results were consistent with previous research indicating a 1-factor solution for this subscale. CONCLUSIONS: Psychometric properties were similar to the original BPD sample, indicating that this measure can be used as an assessment tool for DBT skill use in a diverse psychiatric population.

Predictors of Depression Treatment Response in an Intensive CBT Partial Hospital.

OBJECTIVE: Despite the effectiveness of cognitive behavioral therapy (CBT) for depression, a significant number of patients do not respond. Data examining predictors of treatment response in settings in which CBT is delivered naturalistically are lacking. METHOD: Treatment outcome data collected at a CBT-based partial hospital (n = 956) were used to examine predictors of two types of treatment response: (a) a reliable and clinically significant change in depressive symptoms and (b) a self-rating of "very much" or "much" improved. In multiple logistic regression models, we examined predictors of response in the total sample and separately for patients with a primary diagnosis of major depressive disorder (MDD) versus patients with other primary diagnoses. RESULTS: In the total sample, higher treatment outcome expectations and fewer past hospitalizations predicted clinically significant improvement in depression symptoms, and higher treatment expectations and ethnoracial minority background predicted global improvement. In patients with primary MDD, higher treatment outcome expectations and being referred from the community (vs. inpatient hospitalization) predicted better depression response, and higher treatment outcome expectations predicted global improvement. In patients with other primary diagnoses, higher treatment outcome expectations and fewer borderline personality disorder traits predicted depression reduction, and higher treatment outcome expectations, less relationship difficulty, and female gender predicted global improvement. CONCLUSIONS: Results are generally consistent with data from randomized controlled trials on longer term outpatient CBT. Interventions that increase treatment expectancy and modifications to better target men may enhance treatment outcome. Future research should include objective outcome measures and examine mechanisms underlying treatment response.

The effects of physical activity on sleep: a meta-analytic review.

A significant body of research has investigated the effects of physical activity on sleep, yet this research has not been systematically aggregated in over a decade. As a result, the magnitude and moderators of these effects are unclear. This meta-analytical review examines the effects of acute and regular exercise on sleep, incorporating a range of outcome and moderator variables. PubMed and PsycINFO were used to identify 66 studies for inclusion in the analysis that were published through May 2013. Analyses reveal that acute exercise has small beneficial effects on total sleep time, sleep onset latency, sleep efficiency, stage 1 sleep, and slow wave sleep, a moderate beneficial effect on wake time after sleep onset, and a small effect on rapid eye movement sleep. Regular exercise has small beneficial effects on total sleep time and sleep efficiency, small-to-medium beneficial effects on sleep onset latency, and moderate beneficial effects on sleep quality. Effects were moderated by sex, age, baseline physical activity level of participants, as well as exercise type, time of day, duration, and adherence. Significant moderation was not found for exercise intensity, aerobic/anaerobic classification, or publication date. Results were discussed with regards to future avenues of research and clinical application to the treatment of insomnia.

Improving the efficiency of drug use disorder screening in psychiatric settings: validation of a single-item screen.

BACKGROUND: Co-occurring drug use disorders are under-detected in psychiatrically ill populations highlighting the need for more efficient screening tools. OBJECTIVES: This study compares a single-item screening tool, previously validated in a primary care setting, to the 10-item Drug Abuse Screening Test (DAST-10) for identifying co-occurring drug use disorders among patients with severe psychiatric illness. METHODS: A total of 395 patients attending a psychiatric partial hospital program completed both the single-item screen and DAST-10. A subsample of consecutive patients (n = 67) was also administered the Structure Clinical Interview for DSM-IV (SCID-IV) as a diagnostic reference standard. RESULTS: Concordance between screening measures was moderate (κ = 0.4, p < 0.01). Sensitivity and specificity of the single-item screen and DAST-10 as compared to the SCID-IV were comparable, while area under the receiver operating curve showed better discriminatory power for the identification of drug use disorders with the single-item screen. CONCLUSIONS: In comparison to the DAST-10, the single-item screen appears to be a more efficient tool to identify co-occurring drug use disorders in a psychiatric treatment setting among patients with a range of psychiatric diagnoses.

A randomized, controlled trial of the efficacy of an interoceptive exposure-based CBT for treatment-refractory outpatients with opioid dependence.

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.

Predictors of dropout from psychosocial treatment in opioid-dependent outpatients.

BACKGROUND AND OBJECTIVES: Early dropout is common in substance abuse treatment settings and may lead to poorer outcomes relative to those completing a full course of treatment. Attempts to identify predictors of dropout have yielded mixed results, highlighting the need for additional research in this area to clarify risk and protective factors to guide intervention and retention efforts. This study evaluated predictors of dropout from psychosocial treatment among opioid-dependent patients on methadone maintenance therapy. METHODS: Participants included 78 patients who had failed to respond to at least 4 months of methadone maintenance plus group counseling with clinic substance abuse counselors, and were enrolled in a study of randomized psychosocial treatment in addition to treatment-as-usual. Several factors that have been implicated in previous studies as well as two affective variables (distress intolerance and coping motives for drug use) were examined. RESULTS: Results indicated that when controlling for various risk factors, age was the only significant predictor of dropout, with younger patients more likely to discontinue treatment early. CONCLUSIONS: This study replicates previous findings in opioid-dependent samples that younger patients are at an increased risk of early treatment dropout. CONCLUSIONS AND SIGNIFICANCE: Targeted intervention may be needed to retain young patients in drug abuse treatment.

Psychosocial predictors of sleep dysfunction: the role of anxiety sensitivity, dysfunctional beliefs, and neuroticism.

The present study examined the relationship of anxiety sensitivity, dysfunctional beliefs about sleep and neuroticism on sleep disturbance. Previous research of these three related concepts-each describing a different kind of reactivity to interoceptive or environmental events-have served as predictors of insomnia and insomnia-related distress; however, it is not known how these concepts have distinctive prediction of sleep outcomes. We completed an Internet survey of 149 undergraduate student participants, a population with elevated risk for disturbed sleep. Participants completed a demographics questionnaire, the Anxiety Sensitivity Index (ASI), the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16), the NEO Five-Factor Inventory, and the Pittsburgh Sleep Quality Index (PSQI). Results revealed a significant association between PSQI total score and the three variables of interest, ASI, DBAS, and neuroticism. However, in a stepwise regression, neuroticism was the statistically most important predictor of sleep disturbance. The DBAS was a statistically more important predictor than ASI total score; however, when the ASI was examined by subscale, DBAS was replaced in the model by the ASI Mental Incapacitation Concerns subscale. Our findings highlight the continued value of higher order concepts like neuroticism in the development of disorder-specific measures like the DBAS, as well as indicate that distress in response to cognitive symptoms (AS-mental incapacitation) may play a role in maintaining sleep dysfunction.

Anxiety sensitivity and illicit sedative use among opiate-dependent women and men.

OBJECTIVES: Research has suggested that individuals with elevated anxiety sensitivity (AS) (the fear of benign bodily sensations associated with anxiety) are more likely to use substances to cope with distress, particularly substances with arousal-dampening effects such as benzodiazepines and other sedatives. Such coping motives may also vary as a function of gender, with women more likely to use substances for coping (self-medicating) purposes. Given these findings, we hypothesized that AS would be associated with illicit sedative use in an opioid-dependent sample and that gender would moderate this relationship, with a greater association among women. METHOD: Participants were 68 opioid-dependent patients recruited from a methadone maintenance clinic. A logistic regression was used to determine whether AS was associated with presence or absence of a history of illicit sedative use. RESULTS: AS was significantly associated with sedative use and this relationship was moderated by gender; elevated AS was associated with greater sedative use only in women. CONCLUSION: The presence of elevated AS is related to greater illicit use of sedatives in women but not in men. Women may be more susceptible to seek sedatives as a means of coping with unpleasant, anxious sensations.

The effects of prior cognitive control task exposure on responses to emotional tasks in healthy participants.

BACKGROUND: Recent advances have been made in the application of cognitive training strategies as interventions for mental disorders. One novel approach, cognitive control training (CCT), uses computer-based exercises to chronically increase prefrontal cortex recruitment. Activation of prefrontal control mechanisms have specifically been identified with attenuation of emotional responses. However, it is unclear whether recruitment of prefrontal resources alone is operative in this regard, or whether prefrontal control is important only in the role of explicit emotion regulation. This study examined whether exposure to cognitive tasks before an emotional challenge attenuated the effects of the emotional challenge. AIMS: We investigated whether a single training session could alter participants' reactivity to subsequent emotional stimuli on two computer-based tasks as well as affect ratings made during the study. We hypothesized that individuals performing the Cognitive Control (CC) task as compared to those performing the Peripheral Vision (PV) comparison task would (1) report reduced negative affect following the mood induction and the emotion task, and (2) exhibit reduced reactivity (defined by lower affective ratings) to negative stimuli during both the reactivity and recovery phases of the emotion task and (3) show a reduced bias towards threatening information. METHOD: Fifty-nine healthy participants were randomized to complete CC tasks or PV, underwent a negative mood induction, and then made valence and arousal ratings for IAPS images, and completed an assessment of attentional bias. RESULTS: RESULTS indicated that a single-session of CC did not consistently alter participants' responses to either task. However, performance on the CC tasks was correlated on subsequent ratings of emotional images. CONCLUSIONS: While overall these results do not support the idea that affective responding is altered by making healthy volunteers use their prefrontal cortex before the affective task, they are discussed in the context of study design issues and future research directions.

Not the exercise type? Personality traits and anxiety sensitivity as predictors of objectively measured physical activity and sedentary time.

Personality traits have been investigated as predictors of sedentary behavior, while both personality traits and anxiety sensitivity have been investigated as predictors of physical activity; however, few studies employed objective measurement of these behaviors. The current study recruited 64 young adults who completed the Anxiety Sensitivity Index-3 and NEO-Personality Inventory-3, then wore accelerometers for 1 week. Results revealed that agreeableness and anxiety sensitivity were inversely associated with moderate intensity or greater physical activity; however, none of the investigated constructs predicted sedentary time. These results highlight the importance of objective measurement when studying these behaviors and clinical implications for the identification of individuals at risk for physical activity avoidance.

Does anxiety sensitivity predict addiction severity in opioid use disorder?

Increased anxiety sensitivity (AS), or the fear of anxiety-related cognitive, social, and physical symptoms which are misinterpreted as having harmful implications, has shown a relationship with substance use disorders. People with substance use disorders also experience addiction-related problems across domains of life functioning. However, few studies have evaluated the relationship between elevated AS and addiction-related problems across specific life areas. We evaluated, first, whether AS predicted addiction-related problems in a sample of treatment-refractory outpatients with opioid use disorders and, second, whether sex moderated the relationship between AS and addiction-related problems in this sample. Participants with treatment-refractory opioid use disorders (n = 92, 53.3% male) completed baseline assessments of AS (the Anxiety Sensitivity Index) and addiction-related problems (the Addiction Severity Index). Baseline AS total score was a significant independent predictor of both baseline Addiction Severity Index medical status (ß = 0.29, t = 2.84, p = .006) and psychiatric status (ß = 0.30, t = 2.99, p = .004) composite scores but was not associated with social, employment or legal difficulties. These findings were maintained when controlling for drug use severity, though baseline AS total score became a significant predictor of baseline legal difficulties (ß = -0.23, t = -2.25, p = .027). There was no moderating role of sex on the relationship between baseline AS and addiction-related problems. Our findings suggest that, regardless of sex, elevated AS predicts increased addiction-related medical and psychiatric problems, and decreased legal problems when accounting for drug use severity, in outpatients with opioid use disorders.

Attentional bias and craving in smokers: the impact of a single attentional training session.

INTRODUCTION: Investigations in both alcohol and smoking have provided preliminary evidence for the use of attentional training interventions to reduce vigilance toward salient drug cues. The current study evaluated the efficacy of an attentional training intervention for reducing attentional bias toward smoking cues and craving among cigarette smokers. METHODS: Participants were randomized to receive an attentional training intervention or a control training. Sixty-four regular cigarette smokers (individuals smoking at least 10 cigarettes/day for at least 1 year) provided informed consent and were enrolled in the study. The dot probe paradigm was used both to measure attentional bias and for the training intervention. Attentional bias and craving were measured prior to and following training. RESULTS: Results indicated that the randomized groups did not differ significantly in attentional bias as measured by novel stimuli and, correspondingly, in craving response to relevant cues following the training intervention. CONCLUSIONS: These results for a single-session training suggest that this "dose" is insufficient for reducing attentional bias. Given the success of this intervention in other applications, research on the efficacy of multiple-session trainings is an important area for further study.

Anxiety Sensitivity Uniquely Predicts Exercise Behaviors in Young Adults Seeking to Increase Physical Activity.

Individuals with elevated levels of anxiety sensitivity (AS) may be motivated to avoid aversive emotional or physical states, and therefore may have greater difficulty achieving healthy behavioral change. This may be particularly true for exercise, which produces many of the somatic sensations within the domain of AS concerns. Cross-sectional studies show a negative association between AS and exercise. However, little is known about how AS may prospectively affect attempts at behavior change in individuals who are motivated to increase their exercise. We recruited 145 young adults who self-identified as having a desire to increase their exercise behavior. Participants completed a web survey assessing AS and additional variables identified as important for behavior change-impulsivity, grit, perceived behavioral control, and action planning-and set a specific goal for exercising in the next week. One week later, a second survey assessed participants' success in meeting their exercise goals. We hypothesized that individuals with higher AS would choose lower exercise goals and would complete less exercise at the second survey. AS was not significantly associated with exercise goal level, but significantly and negatively predicted exercise at Time 2 and was the only variable to offer significant prediction beyond consideration of baseline exercise levels. These results underscore the importance of considering AS in relation to health behavior intentions. This is particularly apt given the absence of prediction offered by other traditional predictors of behavior change.

Examining the efficacy of d-cycloserine to augment therapeutic learning in depression.

Despite advances in individual and combined treatments for major depression, issues with non-response and partial-response remain relatively common, motivating the search for new treatment strategies. This study aims to develop one such novel treatment. In this proof-of-concept study, we are investigating whether the treatment enhancing effects of d-cycloserine (DCS) administration can be extended outside the extinction-learning paradigms where they have been primarily examined. Using uniform delivery of cognitive behavioral therapy (CBT) content via computer-administered interventions for depression, we are assessing the value of pre-session administrations of DCS for retention of therapeutic learning. Recall of this information is evaluated in conjunction with performance on standardized tests of memory recall with both emotional and non-emotional stimuli. Specifically, in a randomized, double-blind trial we will compare the benefits of two pre-session administrations of DCS augmentation to those achieved by similar administrations of modafinil or placebo. Because modafinil is associated with a number of discriminable effects in addition to cognitive enhancement (e.g., feelings of vigor, alertness, positive mood); whereas these effects would not be expected with DCS, we will assess drug context effects in relation to memory augmentation effects.