Psychophysiological assessment of stress reactivity and recovery in anxiety disorders.

The present study aimed to examine changes in psychophysiological arousal from baseline to a stressor phase (reactivity) and from the stressor phase to a second resting phase (recovery) in patients with anxiety disorders. Fifty adult patients with DSM-5 anxiety disorders (panic disorder, generalized anxiety disorder, or social anxiety disorder) and 28 healthy control (HC) participants underwent psychophysiological monitoring including electrocardiogram, respiration rate, electrodermal activity, gastrocnemius electromyograph, and end-tidal CO2 for a 3-min resting phase, a 6-min mild stressor phase, and a 3-min recovery phase. Anxious patients then went on to receive naturalistic cognitive-behavioral therapy (CBT) in a specialty outpatient clinic. Results for the reactivity phase indicated that compared to HCs, patients with social anxiety disorder exhibited heightened psychophysiological reactivity while patients with panic disorder and generalized anxiety disorder exhibited attenuated reactivity. Results for physiological recovery (return to baseline after the stressor was withdrawn) were mixed, but provided some support for slower autonomic recovery in patients with generalized anxiety disorder and panic disorder compared to HCs. Participants with all anxiety disorders exhibited diminished change in high frequency heart rate variability compared to HCs. Generally, psychophysiological reactivity and recovery were not associated with CBT outcome, though exploratory analyses indicated that greater respiration rate reactivity and stronger respiration rate recovery were associated with better CBT outcomes in patients with panic disorder.

Step one within stepped care trauma-focused cognitive behavioral therapy for young children: a pilot study.

This pilot study explored the preliminary efficacy, parent acceptability and economic cost of delivering Step One within Stepped Care Trauma-Focused Cognitive Behavioral Therapy (SC-TF-CBT). Nine young children ages 3-6 years and their parents participated in SC-TF-CBT. Eighty-three percent (5/6) of the children who completed Step One treatment and 55.6 % (5/9) of the intent-to-treat sample responded to Step One. One case relapsed at post-assessment. Treatment gains were maintained at 3-month follow-up. Generally, parents found Step One to be acceptable and were satisfied with treatment. At 3-month follow-up, the cost per unit improvement for posttraumatic stress symptoms and severity ranged from $27.65 to $131.33 for the responders and from $36.12 to $208.11 for the intent-to-treat sample. Further research on stepped care for young children is warranted to examine if this approach is more efficient, accessible and cost-effective than traditional therapy.

The Cost of Illness Associated with Stepped Care for Obsessive-Compulsive Disorder.

Stepped care for obsessive-compulsive disorders (OCD) is a promising approach for improving the accessibility and cost-effectiveness of exposure and response prevention (ERP). Previous research has shown that stepped care is less costly compared with standard, therapist-directed ERP, owing largely to the roughly one-third of patients who respond to lower intensity guided self-help (GSH). The aim of this study was to recalculate the costs of treatment in stepped versus standard care when also including the cost of illness; defined as costs related to functional disability in work, school, and home functioning attributed to OCD symptoms. It was found that the cost savings of stepped care was reduced to a moderate effect (d = 0.66) when the cost of illness was included. Data also indicated substantial potential cost savings if patient-to-treatment matching variables are identified. Exploratory analyses suggested that problems with attention may be an important variable to investigate as a potential treatment moderator in future GSH treatment outcome research. These data highlight the importance of including the cost of illness in cost-effectiveness analyses, and of identifying predictors that will facilitate matched care and prevent unnecessary treatment delay for the roughly two-thirds of patients who will not respond to GSH for OCD.

Diagnosis and assessment of hoarding disorder.

The acquisition and saving of a large number of possessions that interfere with the use of living areas in the home are remarkably common behaviors that can pose serious threats to the health and safety of the affected person and those living nearby. Recent research on hoarding has led the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Post-traumatic, and Dissociative Disorders Work Group to propose the addition of hoarding disorder to the list of disorders in the upcoming revision of the diagnostic manual. This review examines the research related to the diagnosis and assessment of hoarding and hoarding disorder. The proposed criteria appear to accurately define the disorder, and preliminary studies suggest they are reliable. Recent assessment strategies for hoarding have improved our understanding of the nature of this behavior. Areas in need of further research have been highlighted.

An exploration of economic reasoning in hoarding disorder patients.

Current models of hoarding disorder (HD) emphasize problems of decision-making. Evidence for neuropsychological impairment in HD, however, has been mixed. The present study examined whether HD patients show problems of economic reasoning that could be associated with decision-making problems. Forty-two HD patients, 29 obsessive-compulsive disorder (OCD) patients, and 36 healthy control participants completed the Iowa gambling task (IGT), a computerized card playing game that assesses participants' ability to learn and utilize a rule of sacrificing short-term gain for long-term gain, and a cognitive dissonance reduction task that measured changes in preference for items (art prints) after selecting or rejecting them. Results showed no deficits on the IGT for HD participants, and no difference in dissonance reduction results after selecting or rejecting items on the dissonance reduction task. Furthermore, performance on these two tasks was unrelated to hoarding symptom severity or self-reported indecisiveness. It is suggested that the problems of cognitive processing in HD patients may be largely related to as-yet understudied processes, including idiosyncratic categorization problems for personally-owned items as well as other aspects of economic reasoning.

Challenges and advances in treating hoarding.

This article introduces an issue of the Journal of Clinical Psychology: In Session devoted to understanding, assessing, and treating hoarding disorder (HD). After a case example is presented, the proposed the Diagnostic and Statistical Manual, 5th Edition criteria for HD are discussed, and the problems associated with hoarding are discussed from a psychotherapeutic and public health perspective. The articles in this issue are then outlined and summarized.

Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs.

BACKGROUND: Exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention. METHODS: Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in. RESULTS: The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes. CONCLUSIONS: These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.

Stepped care for obsessive-compulsive disorder: An open trial.

This study evaluated the effectiveness and treatment costs associated with a stepped care protocol of exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). In the current open trial, patients (N=14) began with self-directed EX/RP and minimal therapist guidance over the course of six weeks (Step 1). During this phase of treatment, no therapist-directed exposures were conducted. Those who did not respond optimally to Step 1 went on to Step 2, which consisted of 15 sessions of twice-weekly therapist-directed exposures. Results of this study show promise for stepped care utilizing EX/RP for some patients with OCD, with a response rate of 88% and a 60% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score among treatment completers. Significant improvements were found in Y-BOCS from pre to post-treatment for both Step 1 and Step 2 completers. Forty-five percent of participants (n=5) responded following completion of Step 1, resulting in reduced cost of treatment among these participants. All participants who responded to Step 1 maintained acute gains during the brief follow-up period. Limitations include a small sample size and high attrition rate.

Assessment of anxiety in older home care recipients.

PURPOSE: This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services. DESIGN AND METHODS: Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD). RESULTS: Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified). IMPLICATIONS: These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.

The economic and social burden of compulsive hoarding.

The aim of the present study was to determine the economic and social burden of compulsive hoarding in a large sample of individuals with self-identified hoarding, as well as a separate sample of family members of individuals who hoard. Self-identified hoarding participants (N=864, 94% female, 65% met research criteria for clinically relevant compulsive hoarding) and family informants (N=655, 58% described a relative who appeared to meet research criteria for compulsive hoarding), completed an internet survey. Questions were derived in part from those used in the National Comorbidity Survey (NCS), and when possible, hoarding participants were compared to NCS participants. Compulsive hoarding was associated with an average 7.0 work impairment days in the past month, equivalent to that reported by individuals with psychotic disorders and significantly greater than that reported by female NCS participants with all other anxiety, mood, and substance use disorders. Severity of hoarding predicted the degree of work impairment after controlling for age, sex, and non-psychiatric medical conditions. Hoarding participants were nearly three times as likely to be overweight or obese as were family members. Compared to female NCS participants, hoarding participants were significantly more likely to report a broad range of chronic and severe medical concerns and had a five-fold higher rate of mental health service utilization. Eight to 12% had been evicted or threatened with eviction due to hoarding, and 0.1-3.0% had a child or elder removed from the home. These results suggest that compulsive hoarding represents a profound public health burden in terms of occupational impairment, poor physical health, and social service involvement.

Family burden of compulsive hoarding: results of an internet survey.

Compulsive hoarding, the acquisition of and failure to discard large numbers of possessions, is associated with substantial health risk, impairment in functioning, and economic burden. Despite clear indications that hoarding has a detrimental effect on people living with or near someone with a hoarding problem, no empirical research has examined these harmful effects. The aim of the present study was to examine the burden of hoarding on family members. Six hundred sixty-five family informants who reported having a family member or friend with hoarding behaviors completed an internet-based survey. Living with an individual who hoards during childhood was associated with elevated reports of childhood distress and family strain. Family members reported high levels of patient rejection attitudes, suggesting high levels of family frustration and hostility. Rejecting attitudes were predicted by severity of hoarding symptoms, the individual's perceived lack of insight into the behavior, and having lived in a cluttered environment during childhood. These results suggest that compulsive hoarding adversely impacts not only the hoarding individual, but also those living with them.

Multimodal assessment of disgust in contamination-related obsessive-compulsive disorder.

The present study utilizes multiple methods to examine the relationship between disgust and contamination-related obsessive-compulsive disorder (OCD) symptoms in an analogue sample. Questionnaire findings revealed that participants with high OCD contamination concerns showed stronger disgust sensitivity than did participants with low OCD contamination symptoms after controlling for negative affect. High OCD participants (N=30) also reported significantly more disgust than did low OCD participants (N=30) when exposed to a disgust-inducing video, whereas no significant between-group differences were detected on other negative emotional dimensions. Results from a series of disgust-specific behavioral avoidance tasks (BATs) revealed that high OCD participants demonstrated both less compliance and less approach behavior. Subsequent analysis also revealed that disgust sensitivity generally mediated avoidance on the BATs among high OCD subjects. High OCD participants also rated the BATs as more fearful and disgusting than did low OCD participants, with disgust generally emerging as the dominant emotional response. The results are consistent with a disgust-based, disease-avoidance approach in understanding contamination-related OCD themes.

Late-life anxiety disorders among Puerto Rican primary care patients: impact on well-being, functioning, and service utilization.

With the growing population of older Hispanic adults there is a need for additional research on the mental health care of this patient group. This study explored the impact of anxiety disorders on the health status of 291 older (>/=50 years) Puerto Rican primary care patients (n = 65 with anxiety disorders, n = 226 without anxiety disorders). All analyses controlled for potential confounding variables, including depression diagnosis and physical health burden. Logistic regression indicated that anxiety disorders were associated with higher psychological distress, suicidality, and emergency room service utilization, as well as lower instrumental functioning and perceived health quality. Analysis of covariance indicated that both anxiety disorder status and history of ataque de nervios were related to higher percentages of lifetime somatic symptoms. These data highlight the need for improved recognition and treatment of anxiety disorders in older Puerto Rican adults.

Tracking levels of psychiatric distress associated with the terrorist events of September 11, 2001: a review of the literature.

BACKGROUND: Early publicized predictions of an onslaught of psychiatric distress following the terrorist events of September 11, 2001, have not materialized, and it remains unlikely at present that the medical and insurance communities will experience a significant increase in psychiatric utilization rates secondary to September 11. A handful of research studies have begun to characterize the psychiatric impact of the events associated with the September 11 terrorist attacks. Information related to the manifestation of psychiatric distress following disasters is of particular interest to the scientific, clinical and disability insurance communities given the ongoing threat of further terrorist attacks. METHODS: A comprehensive literature search was completed to identify articles that address our current understanding of posttraumatic stress disorder (PTSD) and patterns of psychiatric distress that typically follow manmade disasters. To help in conveying such a conceptual framework, we integrated basic research relating to PTSD with epidemiological data relating to past disasters (e.g., the Oklahoma City bombing) and the events of September 11. RESULTS AND CONCLUSIONS: A critical analysis of the September 11 research literature is offered with suggestions for research that would strengthen our understanding of the manifestation of psychiatric distress associated with manmade disasters.