Abstract task sequence initiation deficit dissociates anxiety disorders from obsessive-compulsive disorder and healthy controls.

In everyday life, humans perform sequences of tasks. These tasks may be disrupted in people with obsessive-compulsive disorder (OCD). Symptoms, such as compulsions, can be considered sequential and often cause repetitions of tasks that disrupt daily living (e.g., checking the stove while cooking). Motor sequences have been used to study behavioral deficits in OCD. However, not all sequences are motor sequences. Some are more "abstract" in that they are composed of a series of tasks (e.g., chopping and stirring) rather than being dependent on individual actions or stimuli. These abstract task sequences require cognitive control mechanisms for their execution. Although theory has proposed deficits in these sequences in OCD as well, they have not been directly investigated. We tested the hypotheses that OCD participants exhibit deficits in the control mechanisms specific to abstract task sequences and more general flexible behavior (measured with task switching within the sequences), relative to health controls (HCs) and clinical controls (participants with anxiety disorders [ANX]). A total of 112 participants completed abstract task sequences consisting of simple categorization tasks. Surprisingly, participants with OCD did not perform worse than HCs or ANX. However, ANX participants showed impairments specific to sequential control that did not extend to more general flexible control. Thus, we showed a novel behavioral dissociation between OCD and ANX specific to abstract task sequential control. These results also implicate deficits in specific frontal sequential control neural circuitry in ANX and not in OCD, where implicit sequential deficits may more closely align with striatal circuits.

The overlap of sleep disturbance and depression in primary care patients treated with buprenorphine.

BACKGROUND: Sleep disturbance is common among patients receiving long-term opioid therapies, such as methadone maintenance. However, little is known about sleep disturbances in patients receiving medication treatment with buprenorphine. We sought to determine the frequency of subjective sleep disturbance in a sample of patients receiving medication treatment and to examine clinical factors related to sleep disturbance. METHODS: Participants were 328 persons receiving buprenorphine at 3 primary care sites. Sleep difficulty was assessed 2 questions adapted from the Patient Health Questionnaire-9 (PHQ-9) item assessing sleep. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD)-10 and PHQ-2. In addition, information was gathered on participant demographics and treatment characteristics. Demographics, buprenorphine treatment history, and depressive symptoms were compared for those with and without self-reported sleep difficulty. Logistic regression was used to estimate the adjusted association of sleep disturbance with these correlates. RESULTS: Seventy-one percent of persons receiving medication treatment with buprenorphine in the present study reported sleep difficulty. Persons reporting sleep disturbance reported shorter time in buprenorphine treatment and more depressed mood compared with those without sleep difficulty (p < .01). Men were significantly less likely to report disturbed sleep than women (odds ratio [OR] = 0.57, 95% confidence interval [CI]: 0.33, 0.98). Sleep disturbance was not associated significantly with age, ethnicity, educational attainment, or buprenorphine dose. CONCLUSIONS: Sleep disturbance is common in patients receiving medication treatment with buprenorphine and is associated with more depressive symptoms as well as a shorter duration of medication treatment. Future research, using subjective and objective sleep measures, is warranted to understand whether sleep disturbance is mitigated by longer buprenorphine treatment and whether difficulty sleeping predicts buprenorphine discontinuation among patients seeking treatment for opioid dependence.

Pilot Randomized Trial of Collaborative Behavioral Treatment for Chronic Pain and Depression in Persons Living with HIV/AIDS.

In this pilot study, we assessed feasibility and acceptability of a behavior therapy intervention for pain and depressive symptoms in persons living with HIV/AIDS (PLWH). We randomly assigned 23 participants to HIV-PASS (HIV-Pain and Sadness Study) or a health education control arm for 3 months. On average, participants attended more than 5 sessions (of 7 possible) in both arms. Qualitative data suggest HIV-PASS participants understood key messages and made concrete behavioral changes. HIV-PASS was associated with effects in the expected direction for three of four outcomes, including the primary outcome (pain-related interference with functioning). Findings suggest that HIV-PASS is promising.

Transcranial Direct Current Stimulation (tDCS) Targeting Left Dorsolateral Prefrontal Cortex Modulates Task-Induced Acute Pain in Healthy Volunteers.

OBJECTIVE: Current chronic pain treatments target nociception rather than affective "suffering" and its associated functional and psychiatric comorbidities. The left dorsolateral prefrontal cortex (DLPFC) has been implicated in affective, cognitive, and attentional aspects of pain and is a primary target of neuromodulation for affective disorders. Transcranial direct current stimulation (tDCS) can non-invasively modulate cortical activity. The present study tests whether anodal tDCS targeting the left DLPFC will increase tolerability of acute painful stimuli vs cathodal tDCS. METHODS: Forty tDCS-naive healthy volunteers received anodal and cathodal stimulation targeting the left DLPFC in two randomized and counterbalanced sessions. During stimulation, each participant performed cold pressor (CP) and breath holding (BH) tasks. We measured pain intensity with the Defense and Veterans Pain Rating Scale (DVPRS) before and after each task. RESULTS: Mixed ANOVA revealed no main effect of stimulation polarity for mean CP threshold, tolerance, or endurance, or mean BH time (allP > 0.27). However, DVPRS rise associated with CP was significantly smaller with anodal vs cathodal tDCS (P = 0.024). We further observed a significant tDCS polarity × stimulation order interaction (P = 0.042) on CP threshold, suggesting task sensitization. CONCLUSIONS: Although our results do not suggest that polarity of tDCS targeting the left DLPFC differentially modulates the tolerability of CP- and BH-related pain distress in healthy volunteers, there was a significant effect on DVPRS pain ratings. This contrasts with our previous findings that tDCS targeting the left dorsal anterior cingulate cortex showed a trend toward higher mean CP tolerance with cathodal vs anodal stimulation. The present results may suggest tDCS-related effects on nociception or DLPFC-mediated attention, or preferential modulation of the affective valence of pain as captured by the DVPRS. Sham-controlled clinical studies are needed.

An Experimental Comparison of Techniques: Cognitive Defusion, Cognitive Restructuring, and in-vivo Exposure for Social Anxiety.

BACKGROUND: One of the primary differences between Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for anxiety is the approach to managing negative thoughts. CBT focuses on challenging the accuracy of dysfunctional thoughts through cognitive restructuring exercises, whereas ACT attempts to foster acceptance of such thoughts through cognitive defusion exercises. Previous research suggests that both techniques reduce the distress associated with negative thoughts, though questions remain regarding the benefit of these techniques above and beyond exposure to feared stimuli. AIMS: In the present study, we conducted a brief experimental intervention to examine the utility of cognitive defusion + in-vivo exposure, cognitive restructuring + in-vivo exposure, and in-vivo exposure alone in reducing the impact of negative thoughts in patients with social anxiety disorder. METHOD: All participants completed a brief public speaking exposure and those in the cognitive conditions received training in the assigned cognitive technique. Participants returned a week later to complete a second exposure task and self-report measures. RESULTS: All three conditions resulted in similar decreases in discomfort related to negative thoughts. ANOVA models failed to find an interaction between change in accuracy or importance and assignment to condition in predicting decreased distress of negative thoughts. CONCLUSIONS: These preliminary results suggest that changes in perceived importance and accuracy of negative thoughts may not be the mechanisms by which cognitive defusion and cognitive restructuring affect distress in the short-term.

Effects of Transcranial Direct Current Stimulation (tDCS) on Pain Distress Tolerance: A Preliminary Study.

OBJECTIVE: Pain remains a critical medical challenge. Current treatments target nociception without addressing affective symptoms. Medically intractable pain is sometimes treated with cingulotomy or deep brain stimulation to increase tolerance of pain-related distress. Transcranial direct current stimulation (tDCS) may noninvasively modulate cortical areas related to sensation and pain representations. The present study aimed to test the hypothesis that cathodal ("inhibitory") stimulation targeting left dorsal anterior cingulate cortex (dACC) would increase tolerance to distress from acute painful stimuli vs anodal stimulation. METHODS: Forty healthy volunteers received both anodal and cathodal stimulation. During stimulation, we measured pain distress tolerance with three tasks: pressure algometer, cold pressor, and breath holding. We measured pain intensity with a visual-analog scale before and after each task. RESULTS: Mixed ANOVA revealed that mean cold pressor tolerance tended to be higher with cathodal vs anodal stimulation (P = 0.055) for participants self-completing the task. Pressure algometer (P = 0.81) and breath holding tolerance (P = 0.19) did not significantly differ. The pressure algometer exhibited a statistically significant order effect irrespective of stimulation polarity (all P < 0.008). Pain intensity ratings increased acutely after cold pressor and pressure algometer tasks (both P < 0.01), but not after breath holding (P = 0.099). Cold pressor pain ratings tended to rise less after cathodal vs anodal tDCS (P = 0.072). CONCLUSIONS: Although our primary results were nonsignificant, there is a preliminary suggestion that cathodal tDCS targeting left dACC may increase pain distress tolerance to cold pressor. Pressure algometer results are consistent with task-related sensitization. Future studies are needed to refine this novel approach for pain neuromodulation.

Who qualifies for deep brain stimulation for OCD? Data from a naturalistic clinical sample.

A few patients with obsessive-compulsive disorder (OCD) remain severely impaired despite exhausting best-practice treatments. For them, neurosurgery (stereotactic ablation or deep brain stimulation) might be considered. The authors investigated the proportion of treatment-seeking OCD patients, in a naturalistic clinical sample, who met contemporary neurosurgery selection criteria. Using comprehensive baseline data on diagnosis, severity, and treatment history for adult patients from the NIMH-supported Brown Longitudinal OCD Study, only 2 of 325 patients met screening criteria for neurosurgery. This finding prompts consideration of new models for clinical trials with limited samples as well as methods of refining entry criteria for such invasive treatments.

Long-term course of pediatric obsessive-compulsive disorder: 3 years of prospective follow-up.

OBJECTIVE: This study assesses the long-term course of treatment-seeking youth with a primary diagnosis of DSM-IV OCD. METHOD: Sixty youth and their parents completed intake interviews and annual follow-up interviews for 3 years using the youth version of the Longitudinal Interval Follow-up Evaluation (Y-LIFE) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Remission was defined as no longer meeting DSM-IV criteria for OCD for 8 weeks or more, and recurrence was defined as meeting full criteria for OCD for 4 consecutive weeks after having achieved symptom remission. Remission rates for youth were compared to rates of adults participating in the same study. RESULTS: The probability of achieving partial remission of OCD was 0.53 and the probability of achieving full remission was 0.27. Among the 24 youth participants who achieved remission, 79% stayed in remission throughout the study (mean of 88 weeks of follow-up) and 21% experienced a recurrence of symptoms. Better functioning at intake and a shorter latency to initial OCD treatment were associated with faster onset of remission (P<.001). CONCLUSIONS: Remission is more likely among youth versus adults with OCD. Treatment early in the course of illness and before substantial impact on functioning predicted a better course.

Allergic Diseases and Mental Health.

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

Food Allergy, Nutrition, Psychology, and Health.

This article explores food allergy and the nascent field of nutritional psychiatry. Individuals with food allergy experience lower levels of "food freedom" than their non-allergic counterparts, which can create cognitive, emotional, social, nutritional, and financial burdens. Patterns of food avoidance may influence neuroinflammatory states as well as the gut microbiome; these changes may be associated with neuropsychiatric symptoms. Food restriction may promote disruption of the microbiome neuroimmune axis, which has been linked to various allergic diseases. Targeted psychological counseling strategies can provide benefit. Food allergy and restricted diets may impact dietary health benefits.

Transcranial direct current stimulation impairs updating of avoidance-based associative learning.

Introduction: Exposure-based psychotherapies for the treatment of anxiety- and fear-based disorders rely on "corrective" associative learning. Namely the repeated confrontation with feared stimuli in the absence of negative outcomes allows the formation of new, corrected associations of safety, indicating that such stimuli no longer need to be avoided. Unfortunately, exposure-facilitated corrective learning tends to be bound by context and often poorly generalizes. One brain structure, the prefrontal cortex, is implicated in context-guided behavior and may be a relevant target for improving generalization of safety learning. Here, we tested whether inhibition of the left prefrontal cortex causally impaired updating of context-bound associations specifically or, alternatively, impaired updating of learned associations irrespective of contextual changes. Additionally, we tested whether prefrontal inhibition during corrective learning influenced subsequent generalization of associations to a novel context. Methods: In two separate experiments, participants received either 10 min of 2 mA cathodal transcranial direct current stimulation (tDCS) over EEG coordinate F3 (Experiment 1 n = 9, Experiment 2 n = 22) or sham stimulation (Experiment 1 n = 10, Experiment 2 n = 22) while previously learned associations were reversed in the same or a different context from initial learning. Next, to assess generalization of learning, participants were asked to indicate which of the previously seen images they preferred in a novel, never seen before context. Results: Results indicate that tDCS significantly impaired reversal irrespective of context in Experiment 2 only. When taking learning rate across trials into account, both experiments suggest that participants who received sham had the greatest learning rate when reversal occurred in a different context, as expected, whereas participants who received active tDCS in this condition had the lowest learning rate. However, active tDCS was associated with preferring the originally disadvantageous, but then neural stimulus after stimulus after reversal occurred in a different context in Experiment 1 only. Discussion: These results support a causal role for the left prefrontal cortex in the updating of avoidance-based associations and encourage further inquiry investigating the use of non-invasive brain stimulation on flexible updating of learned associations.

A pilot randomized clinical trial of tDCS for increasing exercise engagement in individuals with elevated depressive symptoms: Rationale, design, and baseline characteristics.

Regular exercise protects against overweight/obesity as well as numerous chronic diseases. Yet, less than half of Americans exercise sufficiently. Elevated levels of depressive symptoms have been identified as an important correlate of physical inactivity as well as poor adherence to exercise programs. Individuals with depression are less sensitive to rewards and demonstrate an attentional bias toward negative stimuli. These, and other features of depression, may place them at increased risk for effectively managing the affective experience of exercise. Lower baseline levels of activation of the left (vs right) frontal cortex, an area implicated in affect regulation, have also been found in depression, potentially pointing to this region as a potential target for intervening on affect regulation during exercise. Transcranial direct current stimulation (tDCS) has shown promise in impacting a variety of cognitive and affective processes in a large number of individuals, including people with depression. Some findings have suggested that tDCS targeting the left dorsolateral prefrontal cortex (DLPFC), specifically, may improve emotion regulation. Transcranial direct current stimulation could theoretically be a novel and potentially promising approach to improving the affective experience of exercise, thereby increasing exercise adherence among individuals with depressive symptoms. Here we present the rationale, design, and baseline characteristics of a pilot randomized controlled trial of tDCS versus sham delivered 3x/week for 8 weeks in the context of supervised aerobic exercise (AE) program among 51 low-active individuals with elevated depressive symptoms (86.3% female; mean age = 49.5). Follow-up assessments were conducted at end of treatment, and three and six months after enrollment to examine changes in levels of objectively-measured moderate-to-vigorous physical activity (MVPA). If effective, this approach could have high public health impact on preventing obesity and chronic diseases among these at-risk individuals.

Associations of ethnicity and SES with IQ and achievement in spina bifida meningomyelocele.

OBJECTIVES: We evaluated whether the phenotypic pattern of higher verbal than nonverbal IQ in children with spina bifida meningomyelocele (SBM) is consistent across subgroups differing in ethnicity and SES. We also explored the relation of cognitive and academic performance. METHODS: Non-Hispanic White (n = 153) and Hispanic (n = 80) children with SBM received the Stanford Binet Test of Intelligence-IV and achievement subtests of the Woodcock-Johnson. Parents completed questionnaires assessing the family environment [socioeconomic status (SES), resources, and educational opportunities]. RESULTS: Multivariate analysis revealed that Hispanic children with lower SES had lower verbal than nonverbal scores. Hispanic children with higher SES and non-Hispanic White children demonstrated the reverse pattern. Verbal and nonverbal IQ interacted to predict reading and math performance. CONCLUSIONS: Lower SES is associated with lower verbal IQ in economically disadvantaged Hispanic children with SBM. Academic achievement is largely correlated with verbal IQ, but children with lower verbal IQ may partially compensate with higher nonverbal ability.

Using behavioral psychotherapy techniques to address HIV patients' pain, depression, and well-being.

For persons with HIV (PWH), aims of psychotherapy can extend beyond HIV-related topics. Issues such as HIV stigmatization and disclosure and HIV-related self-care including treatment adherence might be ongoing concerns, but patients often need support to develop skills to manage other problems, whether functional or psychiatric. In the context of an ongoing randomized clinical trial, we delivered an individual, behavioral activation-based intervention to PWH with comorbid chronic pain and depression. Our primary treatment target was to reduce pain-related interference in physical and psychosocial functioning. Throughout the course of the 7-session intervention, clinicians used 4 core strategies to help patients improve a variety of domains related to their health and well-being: (a) teaching value-based goal setting, (b) developing skills to be an activated and informed patient, (c) focusing on changing behavior despite discomfort, and, (d) facilitating access to care (e.g., flexible scheduling and primarily phone sessions). The application of these strategies to HIV-related and non-HIV-related problems are presented to illustrate how and when clinicians can utilize these strategies. These practical lessons will inform a flexible approach to helping PWH address a myriad of health and functional issues related to their overall well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Comparison of the Association Between Goal-Directed Planning and Self-reported Compulsivity vs Obsessive-Compulsive Disorder Diagnosis.

Importance: Dimensional definitions of transdiagnostic mental health problems have been suggested as an alternative to categorical diagnoses, having the advantage of capturing heterogeneity within diagnostic categories and similarity across them and bridging more naturally psychological and neural substrates. Objective: To examine whether a self-reported compulsivity dimension has a stronger association with goal-directed and related higher-order cognitive deficits compared with a diagnosis of obsessive-compulsive disorder (OCD). Design, Setting, and Participants: In this cross-sectional study, patients with OCD and/or generalized anxiety disorder (GAD) from across the United States completed a telephone-based diagnostic interview by a trained rater, internet-based cognitive testing, and self-reported clinical assessments from October 8, 2015, to October 1, 2017. Follow-up data were collected to test for replicability. Main Outcomes and Measures: Performance was measured on a test of goal-directed planning and cognitive flexibility (Wisconsin Card Sorting Test [WCST]) and a test of abstract reasoning. Clinical variables included DSM-5 diagnosis of OCD and GAD and 3 psychiatric symptom dimensions (general distress, compulsivity, and obsessionality) derived from a factor analysis. Results: Of 285 individuals in the analysis (mean [SD] age, 32 [12] years; age range, 18-77 years; 219 [76.8%] female), 111 had OCD; 82, GAD; and 92, OCD and GAD. A diagnosis of OCD was not associated with goal-directed performance compared with GAD at baseline (ß [SE], -0.02 [0.02]; P = .18). In contrast, a compulsivity dimension was negatively associated with goal-directed performance (ß [SE], -0.05 [0.02]; P = .003). Results for abstract reasoning task and WCST mirrored this pattern; the compulsivity dimension was associated with abstract reasoning (ß [SE], 2.99 [0.63]; P < .001) and several indicators of WCST performance (eg, categories completed: ß [SE], -0.57 [0.09]; P < .001), whereas OCD diagnosis was not (abstract reasoning: ß [SE], 0.39 [0.66]; P = .56; categories completed: ß [SE], -0.09 [0.10]; P = .38). Other symptom dimensions relevant to OCD, obsessionality, and general distress had no reliable association with goal-directed performance, WCST, or abstract reasoning. Obsessionality had a positive association with requiring more trials to reach the first category on the WCST at baseline (ß [SE], 2.92 [1.39]; P = .04), and general distress was associated with impaired goal-directed performance at baseline (ß [SE],-0.04 [0.02]; P = .01). However, unlike the key results of this study, neither survived correction for multiple comparisons or was replicated at follow-up testing. Conclusions and Relevance: Deficits in goal-directed planning in OCD may be more strongly associated with a compulsivity dimension than with OCD diagnosis. This result may have implications for research assessing the association between brain mechanisms and clinical manifestations and for understanding the structure of mental illness.

Identification of Clinical Features and Biomarkers that may inform a Personalized Approach to rTMS for Depression.

Repetitive transcranial magnetic stimulation (rTMS), an established treatment for treatment-resistant depression, may hold promise as a personalized medicine approach for the treatment of major depressive disorder (MDD). Clinical research has begun to identify patient-specific factors that could be used to guide rTMS treatment decisions or individualized treatment approaches. This literature review describes a range of patient factors which have been evaluated as potential biomarkers of rTMS treatment response, including patient- and illness-related characteristics, genetic factors, and biomarkers derived from neuroimaging and EEG. We highlight the need for validation data for imaging and electrophysiological biomarkers associated with rTMS as well as prospective evaluation of clinical predictors. Finally, we consider implications for future efforts to move toward a personalized medicine approach in the treatment of depression with rTMS.

Pediatric OCD in the era of RDoC.

The NIMH Research Domain Criteria (RDoC) initiative was established with the goal of developing an alternative research classification to further research efforts in mental health. While RDoC acknowledges that constructs should be considered within a developmental framework, developmental considerations have not yet been well integrated within the existing RDoC matrix. In this paper, we consider RDoC in relation to pediatric OCD, a paradigmatic example of a neuropsychiatric disorder that often has onset in childhood but is also present across the lifespan. We discuss three RDoC subdomains with relevance to OCD as exemplars, providing for each construct a brief review of normative developmental changes, the state of construct-relevant research in pediatric OCD, and challenges and limitations related to developmental considerations within each subdomain. Finally, we conclude with a brief discussion of how RDoC may continue to evolve with regard to developmental considerations in order to further research in pediatric OCD.

Introduction to the Special Issue on Cognitive and Behavioral Flexibility in Fear and Anxiety Disorders.

Converging lines of research highlight the significance of cognitive and behavioral flexibility in the etiology, maintenance, and treatment of fear and anxiety disorders. We have developed a Special Issue to highlight recent empirical investigations, contemporary theory, and novel directions for future study. It is hoped that this special issue will (a) underscore the centrality of cognitive and behavioral flexibility to fear- and anxiety-related psychopathology, (b) call attention to cognitive science approaches investigating related neuropsychological correlates, and (c) highlight novel experimental and theoretical research on germane contextual factors.

Updates on Transcranial Magnetic Stimulation Therapy for Major Depressive Disorder.

Transcranial magnetic stimulation has emerged as a treatment option for treatment-resistant depression. While existing data largely support efficacy of transcranial magnetic stimulation for major depressive disorder, ongoing research aims to optimize treatment parameters and identify biomarkers of treatment response. In this article, the authors describe data from controlled trials and ongoing efforts to enhance transcranial magnetic stimulation outcomes for major depressive disorder. Findings from preliminary research aimed at identifying neuroimaging and neurophysiological biomarkers of transcranial magnetic stimulation effects are discussed.

The Brown Incompleteness Scale (BINCS): Measure development and initial evaluation.

BACKGROUND: In recent years, incompleteness has received increased clinical attention as a core motivation underlying obsessive-compulsive spectrum disorders. Yet, assessment of incompleteness has relied almost exclusively on self-report and has assumed a unitary conceptualization of this phenomenon. Therefore, we sought to develop and validate a new multi-faceted clinician-administered measure of incompleteness. The Brown Incompleteness Scale (BINCS) consists of 21 items; each rated on a 5-point scale, with higher scores indicating a greater degree of incompleteness. The current study describes the measure's development and preliminary validation. METHODS: The scale was administered to 100 consecutive participants who were part of a longitudinal follow-up study of OCD. The reliability, validity, and factor analytic structure of the scale were evaluated. RESULTS: Exploratory factor analysis supported a two-factor solution, which can best be described as representing both behavioral and sensory manifestations of incompleteness. CONCLUSIONS: The BINCS demonstrated strong internal consistency as well as convergent and divergent validity. This clinician-administered scale will provide a more comprehensive clinical assessment of patients with incompleteness.