Neuroanatomical Correlates of Impulsive Action in Excoriation (Skin-Picking) Disorder.

Excoriation (skin-picking) disorder (SPD) has similarities to obsessive-compulsive disorder (OCD) and is included within the obsessive-compulsive and related disorders (OCRD) diagnostic class in DSM-5. Separate neuroimaging and neurocognitive studies suggest that people affected by SPD find it difficult to inhibit dominant motor responses due to a failure of "top-down" control mechanisms. No study has examined the neural correlates of SPD in participants with varying degrees of impulsive motor behavior. This study correlated cortical thickness and volumes of selected subcortical structures with stop-signal task performance in participants with SPD (N=15) and in healthy control subjects (N=8). All participants were free from current psychiatric comorbidity, including OCD. In volunteers with SPD, longer stop-signal reaction times were correlated with cortical thinning in the right insula and right-inferior parietal lobe and with increased cortical thickness in the left-lateral occipital lobe, though these findings did not withstand correction for multiple comparisons. There were no significant correlations between cortical thickness in these three structures and stop-signal reaction times in the control group. This study suggests that structural abnormalities in the insular cortex and parietal and occipital regions may play a role in the pathophysiology of SPD. Further neuroimaging research is needed to understand the neurobiology of SPD and its relationship with other putative OCRDs.

Stealing behavior and impulsivity in individuals with kleptomania who have been arrested for shoplifting.

OBJECTIVES: Kleptomania is characterized by strong urges to steal and is one of only a few psychiatric disorders defined by illegal behaviors, but the clinical characteristics of individuals with kleptomania who have faced legal consequences due to their behavior are poorly understood. METHOD: From 2001 to 2012, we recruited 107 adult participants with DSM-IV kleptomania. Participants with a history of shoplifting-related arrest (N=82) were compared with those who had no such history (N=25) on demographics, clinical features, and a self-report measure of impulsivity. RESULTS: Participants whose shoplifting had resulted in arrest had higher self-rated impulsivity on a weak trend level (Eysenck Impulsiveness Questionnaire), with large to very large effect size (Cohen's d=1.12). Group comparisons showed no significant differences in terms of overall functioning (d=0.60), time spent stealing (d=0.73), frequency of stealing behavior (d=0.33), psychiatric comorbidity, or severity of kleptomania symptoms. CONCLUSIONS: Legal problems in kleptomania may be associated with generalized deficits in inhibitory control independent of kleptomania symptom severity. These findings emphasize the need for treatment to improve functional status in individuals with kleptomania and reduce the social and economic costs associated with reoffending.

Gambling disorder, DSM-5 criteria and symptom severity.

INTRODUCTION: Gambling disorder (GD) is a prevalent psychiatric condition whose severity is typically defined by the number of DSM-5 criteria met out of a maximum of nine. The relationships between the levels of gambling severity, thus defined, and other measures of psychopathology and everyday functioning are clinically important. METHODS: Baseline data were collected in patients with GD, conducted from 2001 to 2016. Participants completed clinical interviews and questionnaires. The impact of disease severity (mild, moderate, and severe) on clinical measures was characterized using analysis of variance models. RESULTS: The sample included 574 adults with GD, of whom 73 (12.7%) had mild, 184 (32.1%) moderate, and 317 (55.2%) severe GD. The moderate and severe cases, compared to mild severity group tended be older, had later age of onset, lost more money to gambling in the preceding year, had worse quality of life, had higher state anxiety and depressive scores, consumed more nicotine via smoking per day, and had lower venturesomeness scores. The moderate and severe groups did not differ significantly on these measures, however. The Yale-Brown Obsessive Compulsive Scale modified for Pathological Gambling (PG-YBOCS) discriminated significantly between all three groups. CONCLUSIONS: Several measures of psychopathology and functional impact of gambling symptoms appear similar between moderate and severe GD cases, while mild cases are clearly differentiated from moderate and severe cases. Thus, the current working definition of GD symptom severity boundaries has important limitations in terms of potential clinical utility.

Trichotillomania and its clinical relationship to depression and anxiety.

OBJECTIVE: Trichotillomania (TTM) is associated with high rates of co-occurring depression and anxiety disorders. What the co-occurrence of TTM, depression or anxiety disorders means clinically and cognitively, however, has garnered little research attention. METHODS: About 530 adults with TTM were examined on a variety of clinical measures including symptom severity, psychosocial measures of functioning, psychiatric comorbidity and neurocognitive testing assessing motor inhibition and cognitive flexibility. Clinical features and cognitive functioning were compared between TTM patients with current comorbid major depressive disorder (MDD), a current anxiety disorder, both MDD and an anxiety disorder, or neither. RESULTS: Of 530 participants, 58 (10.3%) had MDD only, 97 (18.3%) had an anxiety disorder only, 58 (10.3%) had both MDD and an anxiety disorder, and 317 (59.8%) had neither. For almost all clinical measures, those with MDD only reported worse symptoms than those with an anxiety disorder only, and the combination of MDD and an anxiety disorder reported the worst level of symptom severity. CONCLUSIONS: These results suggest that adults with TTM and co-occurring MDD and anxiety disorders exhibit unique clinical differences. The clinical differences may also have treatment implications.

Abnormal brain activation in excoriation (skin-picking) disorder: evidence from an executive planning fMRI study.

BACKGROUND: Excoriation (skin-picking) disorder (SPD) is a relatively common psychiatric condition whose neurobiological basis is unknown. AIMS: To probe the function of fronto-striatal circuitry in SPD. METHOD: Eighteen participants with SPD and 15 matched healthy controls undertook an executive planning task (Tower of London) during functional magnetic resonance imaging (fMRI). Activation during planning was compared between groups using region of interest and whole-brain permutation cluster approaches. RESULTS: The SPD group exhibited significant functional underactivation in a cluster encompassing bilateral dorsal striatum (maximal in right caudate), bilateral anterior cingulate and right medial frontal regions. These abnormalities were, for the most part, outside the dorsal planning network typically activated by executive planning tasks. CONCLUSIONS: Abnormalities of neural regions involved in habit formation, action monitoring and inhibition appear involved in the pathophysiology of SPD. Implications exist for understanding the basis of excessive grooming and the relationship of SPD with putative obsessive-compulsive spectrum disorders.

White matter tract integrity in treatment-resistant gambling disorder.

BACKGROUND: Gambling disorder is a relatively common psychiatric disorder recently re-classified within the DSM-5 under the category of 'substance-related and addictive disorders'. AIMS: To compare white matter integrity in patients with gambling disorder with healthy controls; to explore relationships between white matter integrity and disease severity in gambling disorder. METHOD: In total, 16 participants with treatment-resistant gambling disorder and 15 healthy controls underwent magnetic resonance imaging (MRI). White matter integrity was analysed using tract-based spatial statistics. RESULTS: Gambling disorder was associated with reduced fractional anisotropy in the corpus callosum and superior longitudinal fasciculus. Fractional anisotropy in distributed white matter tracts elsewhere correlated positively with disease severity. CONCLUSIONS: Reduced corpus callosum fractional anisotropy is suggestive of disorganised/damaged tracts in patients with gambling disorder, and this may represent a trait/vulnerability marker for the disorder. Future research should explore these measures in a larger sample, ideally incorporating a range of imaging markers (for example functional MRI) and enrolling unaffected first-degree relatives of patients.

A comparison of clinical vs subclinical skin pickers in Israel.

BACKGROUND: Skin-picking disorder (SPD) was recognized as its own entity for the first time in DSM-5. The existing SPD literature is limited and, to date, no study has examined the differences between clinical and sub- clinical SPD. Identifying differences between these 2 groups may improve diagnostic accuracy, treatment, and prevention efforts. METHODS: Israeli adults (N = 4,325) from 2 previous studies were examined for the presence of clinical and subclinical SPD. Individuals with clinical SPD (n = 150) vs subclinical SPD (n = 219) were compared on skin-picking characteristics, psychological phenomena, and clinical correlates. RESULTS: There were many similarities between clinical and subclinical skin pickers. Individuals with clinical SPD, however, had more severe skin picking, greater associated functional impairment, greater perceived stress, and greater depressive and obsessive-compulsive symptoms, and were also more likely to have a first-degree relative with SPD. CONCLUSIONS: This study suggests that although there are some similarities between clinical and subclinical SPD, there also are distinct differences in the clinical presentation. Understanding these differences may be an important factor in treatment and prevention planning.

Does comorbidity matter in body-focused repetitive behavior disorders?

BACKGROUND: Trichotillomania (TTM) and skin-picking disorder (SPD) have been characterized as body-focused repetitive behavior disorders (BFRBs). Because BFRBs frequently co-occur, we sought to discover the similarities and differences for individuals having both TTM and SPD as opposed to 1 of these disorders. METHODS: Participants with primary TTM (N = 421) were evaluated regarding the comorbidity of SPD, and participants with primary SPD (N = 124) were evaluated regarding the comorbidity of TTM. The effects of comorbidity overlap on demographic and clinical measures were evaluated. RESULTS: Of the 421 participants with primary TTM, 61 (14.5%) had co-occurring SPD. Of 124 participants with primary SPD, 21 (16.9%) had comorbid TTM. Participants with primary TTM and comorbid SPD had significantly more severe trichotillomania symptoms and were more likely to have major depressive disorder than those with TTM alone. Participants with primary SPD and comorbid TTM reported significantly more severe skin-picking symptoms than those who had only SPD. CONCLUSIONS: Individuals with co-occurring TTM and SPD may have more problematic symptoms with the primary repetitive behavior. Hair pullers with comorbid SPD were more likely to have comorbid depression. Evaluating patients for multiple BFRBs may be important to assess the severity of symptoms and may have treatment implications.

The Young and the Stressed: Stress, Impulse Control, and Health in College Students.

High levels of stress are common among young adults, particularly those enrolled in college. These degrees of stress have shown numerous deleterious effects across both academic and health variables. Findings regarding the role of stress in the presentation of impulse control disorders, particular among college students, are limited. This study examined potential associations between perceived stress, academic achievement, physical/mental health, and impulse control disorders in young adults. A total of 1805 students completed an online survey and were included in the analysis. Responders were grouped by their overall score on the Perceived Stress Scale into mild, moderate, or severe. Severe perceived stress was associated with worse academic achievement and worse physical health, as well as higher rates of psychiatric and impulsive disorders. These findings may suggest associations between stress and numerous aspects of mental/physical health in young adults, which could be an important consideration for individuals working with college students.

Characteristics and correlates of stealing in college students.

BACKGROUND: Stealing is a fairly common behaviour among young adults. Understanding the potential associations and characteristics of individuals who steal may help educational institutions, health services and young people themselves resolve difficulties before the behaviour impacts on their academic performance and health. AIMS: We aim to test the hypothesis that desires to steal among students would be associated with worse academic achievements and higher rates of mood and impulse control disorders. METHODS: One thousand eight hundred and five students completed the College Student Computer User Survey online and were included in this analysis at a large Midwestern United States University. Responders were grouped according to self-reported stealing urges and behaviours and were compared on measures of psychosocial function, mental health disorders and impulsivity. RESULTS: Urges to steal were associated with worse depressive symptoms, higher levels of perceived stress and a number of psychiatric disorders including bipolar disorder and multiple disorders of impulse control (kleptomania, compulsive sexual behaviour, skin picking, trichotillomania and compulsive buying). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE AND/OR FUTURE RESEARCH: These following data indicate that stealing for many college students may be considered within a spectrum of impulsive behaviours. • Illegal behaviours among students point to mental health difficulties among them. • Our findings may provide clinicians, researchers and health professionals with a clearer picture of a range of impulsive behaviours among college students and promote treatment for this group. • Our findings could also inform preventative approaches to impulsive problems in young adults.

Reduced cortical thickness in gambling disorder: a morphometric MRI study.

Gambling disorder has recently been recognized as a prototype 'behavioral addiction' by virtue of its inclusion in the DSM-5 category of 'Substance-Related and Addictive Disorders.' Despite its newly acquired status and prevalence rate of 1-3 % globally, relatively little is known regarding the neurobiology of this disorder. The aim of this study was to explore cortical morphometry in untreated gambling disorder, for the first time. Subjects with gambling disorder (N = 16) free from current psychotropic medication or psychiatric comorbidities, and healthy controls (N = 17), were entered into the study and undertook magnetic resonance imaging (3T MRI). Cortical thickness was quantified using automated segmentation techniques (FreeSurfer), and group differences were identified using permutation cluster analysis, with stringent correction for multiple comparisons. Gambling disorder was associated with significant reductions (average 15.8-19.9 %) in cortical thickness, versus controls, predominantly in right frontal cortical regions. Pronounced right frontal morphometric brain abnormalities occur in gambling disorder, supporting neurobiological overlap with substance disorders and its recent reclassification as a behavioral addiction. Future work should explore the trait versus state nature of the findings and whether similarities exist with other not-yet-reclassified putative behavioral addictions.

Excoriation (skin-picking) disorder in adults: a cross-cultural survey of Israeli Jewish and Arab samples.

OBJECTIVE: We sought to estimate the lifetime prevalence of Excoriation (Skin-Picking) Disorder (SPD) in the Israeli adult population as a whole and compare SPD prevalence in the Jewish and Arab communities. We also explored demographic, medical and psychological correlates of SPD diagnosis. METHODS: Questionnaires and scales screening for SPD, and assessing the severity of perceived stress, depression, obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), alcohol use, illicit drug use, and medical disorders were completed in a sample of 2145 adults attending medical settings. RESULTS: The lifetime prevalence of SPD was 5.4% in the total sample; it did not differ between genders or within Jewish and Arab subsamples. Severity of depression (p<0.001), OCD (p<0.001) and perceived stress (p=<0.001) were greater in the SPD positive sample. Similarly, diagnoses of BDD (p=0.02) and generalized anxiety (p=0.03) were significantly more common in the SPD-positive respondents. Alcohol use and illicit substance use were significantly more common among SPD positive respondents in the total sample (both p's=0.01) and the Jewish subsample (p=0.03 and p=0.02, respectively). Hypothyroidism was more prevalent in the SPD-positive Jewish subsample (p=0.02). In the total sample, diabetes mellitus was more common in women than in men (p=0.04). CONCLUSION: Lifetime SPD appears to be relatively common in Israeli adults and associated with other mental disorders. Differences in the self-reported medical and psychiatric comorbidities between the Jewish and Arab subsamples suggest the possibility of cross-cultural variation in the correlates of this disorder.

The opiate antagonist, naltrexone, in the treatment of trichotillomania: results of a double-blind, placebo-controlled study.

Trichotillomania (TTM) is characterized by repetitive hair pulling resulting in hair loss. Data on the pharmacological treatment of TTM are limited. This study examined the opioid antagonist, naltrexone, in adults with TTM who had urges to pull their hair. Fifty-one individuals with TTM were randomized to naltrexone or placebo in an 8-week, double-blind trial. Subjects were assessed with measures of TTM severity and selected cognitive tasks. Naltrexone failed to demonstrate significantly greater reductions in hair pulling compared to placebo. Cognitive flexibility, however, significantly improved with naltrexone (P = 0.026). Subjects taking naltrexone with a family history of addiction showed a greater numerical reduction in the urges to pull, although it was not statistically significant. Future studies will have to examine whether pharmacological modulation of the opiate system may provide promise in controlling pulling behavior in a subgroup of individuals with TTM.

Pharmacological treatments in pathological gambling.

Pathological gambling (PG) is a relatively common and often disabling psychiatric condition characterized by intrusive urges to engage in deleterious gambling behaviour. Although common and financially devastating to individuals and families, there currently exist no formally approved pharmacotherapeutic interventions for this disorder. This review seeks to examine the history of medication treatments for PG. A systematic review of the 18 double-blind, placebo-controlled pharmacotherapy studies conducted for the treatment of pathological gambling was conducted. Study outcome and the mean dose of medication administered was documented in an effort to determine a preferred medication choice in this population. A variety of medication classes have been examined in the treatment of PG with varying results. Antidepressants, atypical antipsychotics and mood stabilizers have demonstrated mixed results in controlled clinical trials. Although limited information is available, opioid antagonists and glutamatergic agents have demonstrated efficacious outcomes, especially for individuals with PG suffering from intense urges to engage in the behaviour. Given that several studies have demonstrated their efficacy in treating the symptoms associated with PG, opioid antagonists should be considered the first line treatment for PG at this time. Most published studies, however, have employed relatively small sample sizes, are of limited duration and involve possibly non-representative clinical groups (e.g. those without co-occurring psychiatric disorders). Response measures have varied across studies. Heterogeneity of PG treatment samples may also complicate identification of effective treatments. Identification of factors related to treatment response will help inform future studies and advance treatment strategies for PG.

Neurocognitive functioning in compulsive buying disorder.

BACKGROUND: Compulsive buying (CB) is a fairly common behavioral problem estimated to affect 5.8% of the population. Although previous research has examined the clinical characteristics of CB, little research has examined whether people with CB manifest cognitive deficits. METHODS: Twenty-three non-treatment-seeking compulsive buyers (mean age, 22.3±3.5; 60.9% female) and 23 age- and sex-matched healthy controls (mean age, 21.1±3.4, 60.9% female) underwent neurocognitive assessment. We predicted that the following cognitive domains would be impaired in CB: spatial working memory (Spatial Working Memory test), response inhibition (Stop-Signal Task), cognitive flexibility (Intra-Extra Dimensional Set Shift task), and decision making (Cambridge Gambling Task). RESULTS: Compared with controls, individuals with CB exhibited significant impairments in response inhibition (P=.043), risk adjustment during decision making (P=.010), and spatial working memory (P=.041 total errors; P=.044 strategy scores). Deficits were of large effect size (Cohen's d, 0.6 to 1.05). CONCLUSIONS: These pilot data suggest that individuals with CB experience problems in several distinct cognitive domains, supporting a likely neurobiological overlap between CB and other putative behavioral and substance addictions. These findings may have implications for shared treatment approaches as well as how we currently classify and understand CB.

A single-blind study of 'as-needed' ecopipam for gambling disorder.

BACKGROUND: Gambling disorder is a disabling illness experienced by 1% to 3% of adults. Pharmacologic management of gambling disorder has produced mixed results, with some but not all studies showing medication to be more effective than placebo. Ecopipam may offer promise for treating gambling disorder because of its antagonism of dopamine-1 receptors. METHODS: Twenty-eight individuals with gambling disorder were enrolled and received ≥1 dose of oral ecopipam in an 8-week trial (1 week placebo lead-in, 6 weeks of medication (50 to 100 mg/d as needed), and 1 week follow-up. Participants were enrolled between September 2010 and June 2011 at 3 sites in the United States. Change from baseline to study endpoint on the Yale-Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS) was the primary outcome measure. RESULTS: Treatment was associated with statistically significant reductions in the PG-YBOCS total score (baseline score of 25.6 reduced to 14.0 at study endpoint; P>.001) and PG-YBOCS subscales (Thought-Urge and Behavior, P>.001). CONCLUSIONS: These findings suggest that pharmacologic targeting of the dopamine-1 receptor may be beneficial in gambling behavior. Placebo-controlled, double-blind studies are warranted to confirm these preliminary findings.

Excluding the typical patient: thirty years of pharmacotherapy efficacy trials for obsessive-compulsive disorder.

BACKGROUND: Over the past 30 years, clinical trials have resulted in several successful pharmacotherapies for obsessive-compulsive disorder (OCD), yet patients in clinical settings often report inadequate response. This study compares clinical characteristics of treatment-seeking OCD patients to the inclusion/exclusion criteria used in pharmacotherapy trials. METHODS: The sample consisted of 325 community members with a DSM-IV diagnosis of OCD who underwent systematic interviews with clinicians knowledgeable in the diagnosis and treatment of OCD. We compiled pharmacotherapy studies for OCD published between 1980 and 2010 using Medline, PubMed, and library resources, and estimated the proportion of patients in each decade satisfying the most common inclusion/exclusion criteria. RESULTS: We included 39 clinical trials and found 72% of the 325 patients would have been excluded from trials conducted between 1980 and 2010. Exclusion was projected as dramatically lower for trials conducted between 1980 and 1989 (19.7%) compared with 74.8% for trials conducted between 1990 and 1999 and 76.9% for trials between 2000 and 2010. CONCLUSIONS: The majority of treatment-seeking individuals with OCD would not qualify for OCD treatment studies due to comorbid psychiatric disorders, and failure to meet OCD severity threshold criteria. This illustrates the need to include a more community-representative sample of OCD patients in clinical trials examining pharmacotherapy efficacy.

Losing control: assaultive behavior as a predictor of impulse control disorders in young adults.

OBJECTIVE: Assaultive behaviors are common among young people and have been associated with a range of other unhealthy, impulsive behaviors such as substance use and problem gambling. This study sought to determine the predictive ability of single assaultive incidents for impulse control disorders, an association that has yet to be examined, especially in young adults. METHODS: The authors conducted a university-wide email survey in the spring of 2011 on 6000 university students. The survey examined assaultive behavior and associated mental health variables (using a clinically validated screening instrument, the Minnesota Impulsive Disorders Interview), stress and mood states, and psychosocial functioning. RESULTS: The rate of response was 35.1% (n=2108). 109 (5.9%) participants reported that they had assaulted another person or destroyed property at some time in their lives. Compared with respondents without lifetime assaultive behavior, those with a history of assaultive or destructive behavior reported more depressive symptoms, more stress, and higher rates of a range of impulse control disorders (intermittent explosive disorder, compulsive sexual behavior, compulsive buying, and skin picking disorder). CONCLUSIONS: Assaultive behavior appears fairly common among college students and is associated with symptoms of depression and impulse control disorders. Significant distress and diminished behavioral control suggest that assaultive behaviors may often be associated with significant morbidity. Additional research is needed to develop specific prevention and treatment strategies for young adults attending college who report problems with assaultive behaviors.

Compulsive sexual behavior in young adults.

BACKGROUND: Compulsive sexual behavior (CSB) is estimated to affect 3% to 6% of adults, although limited information is available on the true prevalence and impact of CSB in young adults. This epidemiological study aims to estimate the prevalence and health correlates of CSB using a large sample of students. METHODS: The survey examined sexual behaviors and their consequences, stress and mood states, psychiatric comorbidity, and psychosocial functioning. RESULTS: The estimated prevalence of CSB was 2.0%. Compared with respondents without CSB, individuals with CSB reported more depressive and anxiety symptoms, higher levels of stress, poorer self-esteem, and higher rates of social anxiety disorder, attention-deficit/hyperactivity disorder, compulsive buying, pathological gambling, and kleptomania. CONCLUSIONS: CSB is common among young adults and is associated with symptoms of anxiety, depression, and a range of psychosocial impairments. Significant distress and diminished behavioral control suggest that CSB often may have significant associated morbidity.

Problematic Internet use and associated risks in a college sample.

OBJECTIVE: The Internet is commonly used among young adults; however, Internet use may become a problematic behavior. Past research has examined Internet behavior in young adults and its relationship to other behaviors and health issues, yet further research is needed to gain a more comprehensive understanding of this relationship. METHOD: A sample (n=2108) of college students (56.9% female) was examined using a self-report Internet survey concerning demographic characteristics, Internet use, health behaviors, psychosocial functioning, and psychiatric comorbidities. The IAT was used to determine levels of problematic Internet use (limited use (none or almost no use), mild use (typical user), moderate use (occasional problems) and severe use (frequent, serious problems)) and the MINI for testing for psychiatric problems. RESULTS: We found that 237 students (12.9%) met criteria for limited Internet use, 1502 (81.8%) for mild Internet use and 98 (5.3%) for moderate to severe Internet use. Variables significantly associated with greater frequency of Internet use included lower Grade Point Average (p=.006), less frequent exercise (p=.018), higher PHQ-9 scores (p<.0001) (indicative of greater depression symptoms) and higher Perceived Stress Scores (p<.0001). CONCLUSIONS: These data indicate that moderate to severe Internet use is associated with a range of psychosocial problems in young adults. More research is needed to better understand the relationship between Internet use and physical and mental health, as well as academic variables.