Acceptance-enhanced behavior therapy for trichotillomania in adults: A randomized clinical trial.

Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.

Maximizing remission from cognitive-behavioral therapy in medicated adults with obsessive-compulsive disorder.

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall.

Predictors of Assertive and Nonassertive Styles of Self-Defense Behavior During a Lab-Based Sexual Assault Scenario.

The current study examined how psychological factors influence hypothetical behavioral responses to threat (BRTT). College women (n = 113) with a history of sexual victimization completed a standardized lab-based self-defense scenario. Interpersonal skills, coping style, and assertive and nonassertive BRTT during a prior assault predicted assertive BRTT during the task. The use of nonassertive BRTT during past assaults no longer predicted assertive BRTT during the task when accounting for rape acknowledgment. Findings regarding rape acknowledgment demonstrate the complexity of recovery from sexual assault. Our results highlight interpersonal skills as an intervention target for innovative sexual assault risk reduction interventions.

Extending the ACEs Framework: Examining the Relations Between Childhood Abuse and Later Victimization and Perpetration With College Men.

Research has revealed that forms of violence are interconnected, but less work focuses on the interconnection of victimization and perpetration, particularly with men. Subsequently, our understanding of the complexities of violence exposure in men's lives and related policies and treatments remains limited. The present study utilizes a sample of at-risk for violence involvement, college men, to examine the relationships between childhood victimization, adulthood victimization, and adulthood perpetration. Participants are 423 college men receiving course credit who completed a battery of standardized questionnaires via an anonymous web survey. Logistic regression is used. Results indicate that 27% of the men report polyperpetration (two or more types of perpetration), 43.5% report polyvictimization (two or more types of victimization), and 60% report experiencing both forms of victimization and perpetration in the past year. Childhood physical abuse has predictive power for perpetration (psychological aggression and polyperpetration) and victimization (sexual violence, psychological aggression, and polyvictimization) for the men in the past year. Childhood sexual abuse has strong predictive power for perpetration (physical violence, sexual violence, and polyperpetration) and victimization (physical violence and sexual violence) with the men in the past year. Finally, emotional abuse has predictive power for victimization (physical violence and psychological aggression), but not perpetration, for the men in the past year. Developmental psychopathology and the adverse childhood experiences frameworks are used to posit potential pathways explaining the relation between childhood abuse and the overlap between victimization and perpetration in adulthood for men. Implications of this study include the use of trauma-informed models of care with men and expanding the scope of study to examine experiences of both victimization and perpetration, and various types of violence, among men.

Acceptance-enhanced behavior therapy for trichotillomania: Randomized controlled trial rationale, method, and strategies for recruiting minority participants.

Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.

Facilitated Extinction Training to Improve Pharmacotherapy for Smoking Cessation: A Pilot Feasibility Trial.

Introduction: Varenicline reduces smoking satisfaction during the pre-cessation run-in period, which may contribute to extinction of cravings and smoking behavior. Research indicates that efficacy is enhanced when the run-in period is increased from 1 to 4 weeks, providing a longer extinction opportunity. We hypothesized that efficacy could be further enhanced by harnessing basic and applied research on extinction. We developed a pre-cessation extinction-facilitating intervention and tested its feasibility in a pilot trial. Methods: The facilitated extinction (FE) intervention comprised brief counseling and workbook-recommending strategies to maximize extinction processes during the run-in, including instructions to smoke at a normal rate across contexts and cues, and use of an extinction cue to enhance generalization. Participants were randomly assigned to one of three varenicline interventions: standard (1-week run-in), extended (4-week run-in), and extended + FE. Interventions were delivered prior to the target quit date (TQD). Assessments were conducted in weeks 1 and 4 pre-TQD and 1 and 3 months post-TQD, with focus on feasibility indices. Results: Recruitment and retention goals were met (N = 58). Treatment satisfaction was high across groups. The majority of FE participants adhered to instructions and maintained their usual smoking rate during the run-in period. Greater decreases in craving and smoking satisfaction were observed among participants in both extended groups versus the standard group (p < .005). Conclusions: Feasibility was demonstrated. Participants adhered to the FE intervention, thereby optimizing the number and variety of extinction trials. Findings support testing the novel FE smoking cessation intervention in a fully powered trial. Implications: This study expands the research on the clinical benefits of extending the pre-cessation run-in period of varenicline. It introduces the hypothesis that further benefit might be achieved by translating basic behavioral research, as well as cue-exposure research and therapy for other disorders, to improve the extinction and generalization processes thought to underlie much of varenicline's effect. A FE intervention was developed and found acceptable to smokers and feasible to implement in a research setting. The study sets the stage for a subsequent randomized controlled trial.

Primum Non Nocere (First Do No Harm): Symptom Worsening and Improvement in Female Assault Victims After Prolonged Exposure for PTSD.

(Reprinted with permission from Depression and Anxiety 2014; 31:412-419).

Women's Behavioral Responses to the Threat of a Hypothetical Date Rape Stimulus: A Qualitative Analysis.

One in four college women experience sexual assault on campus; yet, campuses rarely provide the in-depth self-defense programs needed to reduce sexual assault risk. Further, little is known about the range of possible behaviors elicited by sexual assault threat stimuli besides assertion. To fill this gap, the aim of the current study was to explore qualitative themes in women's intended behavioral responses to a hypothetical sexual assault threat, date rape, by using a laboratory-controlled threat. College women (N = 139) were randomly assigned to one of four different levels of sexual assault threat presented via an audio-recorded vignette. Participants articulated how they would hypothetically respond to the experimentally assigned threat. Responses were blinded and analyzed using Consensual Qualitative Research methodology. Six major themes emerged: assertion, compliance/acceptance, conditional decision making, avoidance, expressions of discomfort, and allusion to future contact. Although almost all participants described assertion, a number of non-assertive responses were described that are not currently recognized in the literature. These non-assertive responses, including compliance/acceptance, conditional decision making, and avoidance, may represent unique behavioral response styles and likely reflect the complex psychological process of behavioral response to threat. The variety of themes found illustrates the great range of behavioral responses to threat. This broad range is not currently well represented or measured in the literature and better understanding of these responses can inform future interventions, advocacy efforts, and policies focused on sexual assault.

Residential treatment outcomes for adolescents with obsessive-compulsive disorder.

OBJECTIVE: We examined outcomes from a residential treatment program emphasizing exposure and response prevention (ERP) to determine if the typically robust response to this treatment in outpatient settings extends to patients treated in this unique context. METHOD: One hundred and seventy-two adolescents with primary Obsessive-compulsive disorder (OCD) completed measures at admission and discharge. Almost all (92.4%) participants had at least two diagnoses and nearly half (44.2%) had three or more. Treatment consisted of intensive ERP (i.e., approximately 26.5 hr per week), additional cognitive behavioral therapy interventions, and medication management within a residential setting. In contrast to the samples reported on in the vast majority of other pediatric OCD trials, participants in the current study were living apart from their families and were immersed within the treatment setting, with staff members available at all times. RESULTS: Paired sample t-tests revealed significant decreases in OCD and depression severity. CONCLUSIONS: Results suggest that residential treatment for adolescents with OCD using a multimodal approach emphasizing ERP can be effective for complex cases with significant comorbidity. Results were comparable with several randomized controlled trials.

Epidemiological associations between posttraumatic stress disorder and incarceration in the National Survey of American Life.

BACKGROUND: In spite of an elevated prevalence of trauma histories among prisoners, there has been little research examining the relationship between incarceration and posttraumatic stress disorder (PTSD); this is especially true for Black Americans. AIMS: To examine relationships between PTSD and incarceration in a nationally representative sample of Black Americans. METHODS: We conducted analysis of data from the National Survey of American Life sample of 5008 Black American adults in the USA. Multivariate logistic regression analyses controlling for demographic factors including age, gender, home region and education were conducted to examine whether incarceration status was independently associated with PTSD. RESULTS: Incarceration was significantly associated with trauma exposure, PTSD in the 12 months prior to interview and lifetime PTSD, even while controlling for demographic covariates. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Incarceration, trauma exposure and PTSD share a significant number of risk factors and co-vary frequently in some populations, including the one of Black Americans investigated in this study. Interventions that can reduce shared risk factors for incarceration and PTSD and/or facilitate successful treatment of the established condition have the potential to make a large positive impact among incarcerated and formerly incarcerated people.

Six-month outcomes from a randomized trial augmenting serotonin reuptake inhibitors with exposure and response prevention or risperidone in adults with obsessive-compulsive disorder.

OBJECTIVE: To compare outcomes after 6-month maintenance treatment of adults diagnosed with obsessive-compulsive disorder (OCD) based on DSM-IV criteria who responded to acute treatment with serotonin reuptake inhibitors (SRIs) augmented by exposure and response prevention (EX/RP) or risperidone. METHOD: A randomized trial was conducted at 2 academic sites from January 2007 through December 2012. In the acute phase, 100 patients on therapeutic SRI dose with at least moderate OCD severity were randomized to 8 weeks of EX/RP, risperidone, or pill placebo. Responders entered the 6-month maintenance phase, continuing the augmentation strategy they received acutely (n = 30 EX/RP, n = 8 risperidone). Independent evaluations were conducted every month. The main outcome was the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). RESULTS: Intent-to-treat analyses indicated that, after 6-month maintenance treatment, EX/RP yielded OCD outcomes that were superior to risperidone (Y-BOCS = 10.95 vs 18.70; t40 = 2.76, P = .009); more patients randomized to EX/RP met response criteria (Y-BOCS decrease ≥ 25%: 70% vs 20%; P < .001) and achieved minimal symptoms (Y-BOCS ≤ 12: 50% vs 5%; P < .001). During maintenance, OCD severity decreased slightly in both conditions (Y-BOCS decrease = 2.2 points, P = .020). Lower Y-BOCS at entry to maintenance was associated with more improvement in both conditions (r38 = 0.57, P < .001). CONCLUSIONS: OCD patients taking SRIs who responded to acute EX/RP or risperidone maintained their gains over 6-month maintenance. Because EX/RP patients improved more during acute treatment than risperidone-treated patients, and both maintained their gains during maintenance, EX/RP yielded superior outcomes 6 months later. The findings that 50% of patients randomized to EX/RP had minimal symptoms at 6-month maintenance, a rate double that of prior studies, suggests that EX/RP maintenance helps maximize long-term outcome. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00389493.

Use of the response-latency paradigm for eliciting and evaluating women's responses to the threat of date rape.

This study evaluates the novel use of the response-latency paradigm to elicit women's hypothetical behavioral responses to the threat of acquaintance rape. There were 146 college women recruited and randomly assigned to 4 study conditions. In 3 of the conditions, the threat to which participants responded was experimentally controlled; in the fourth control condition, participants selected the level of threat themselves, following standard procedure of the response-latency paradigm. Results indicated that participant's responses became more intense as threat levels increased; this relationship was not moderated by whether the threat was controlled by the experimenter or the participant. These results indicate the response-latency paradigm is useful for eliciting and evaluating women's hypothetical responses to the threat of acquaintance rape to learn more about this process.

Primum non nocere (first do no harm): symptom worsening and improvement in female assault victims after prolonged exposure for PTSD.

BACKGROUND: Prolonged Exposure (PE) therapy is an efficacious treatment for PTSD; despite this, many clinicians do not utilize it due to concerns it could cause patient decompensation. METHOD: Data were pooled from four published well-controlled studies of female assault survivors with chronic PTSD (n = 361) who were randomly assigned to PE, waitlist (WL), or another psychotherapy, including cognitive processing therapy (CPT), Eye Movement and Desensitization Reprocessing (EMDR), or the combination of PE plus stress inoculation training (SIT) or PE plus cognitive restructuring. PTSD and depression severity scores were converted to categorical outcomes to evaluate the proportion of participants who showed reliable symptom change (both reliable worsening and reliable improvement). RESULTS: The majority of participants completing one of the active treatments showed reliable improvement on both PTSD and depression compared to WL. Among treatment participants in general, as well as those who received PE, reliable PTSD worsening was nonexistent and the rate of reliable worsening of depression was low. There were no differences on any outcome measures among treatments. By comparison, participants in WL had higher rates of reliable symptom worsening for both PTSD and depression. Potential alternative explanations were also evaluated. CONCLUSIONS: PE and a number of other empirically supported therapies are efficacious and safe treatments for PTSD, reducing the frequency of which symptom worsening occurs in the absence of treatment.

Relations Between Resilience, Positive and Negative Emotionality, and Symptoms of Anxiety and Depression.

Although research concerning the effects of traumatic and stressful life events on an individual's mental health has been plentiful in the past several decades, research aimed at understanding the nature of resilience and its role in this process has been less plentiful. The present study examined the relationship between a commonly used measure of resilience, the Connor-Davidson Resilience Scale (CD-RISC), facets of personality, and symptoms of psychopathology-specifically, posttraumatic symptomatology-in a sample of college students. We found that the CD-RISC was most strongly linked with the personality facet of positive emotionality rather than the expected facet of negative emotionality. With regard to psychopathology, the CD-RISC displayed the largest relationship to a measure of anhedonic depression rather than a measure of posttraumatic stress. Lastly, the CD-RISC added little in predicting symptoms of posttraumatic stress above and beyond negative emotionality, a personality facet that has previously shown robust relationships with posttraumatic stress. These results suggest that the CD-RISC is most strongly predictive of positive emotionality and thus may be most useful in predicting resilience for disorders characterized by disruptions in positive affect.

Six-month follow-up of a randomized controlled trial augmenting serotonin reuptake inhibitor treatment with exposure and ritual prevention for obsessive-compulsive disorder.

OBJECTIVE: This article describes the long-term effects of augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention or stress management training in patients with DSM-IV obsessive-compulsive disorder (OCD). METHOD: Between November 2000 and November 2006, 111 OCD patients from 2 academic outpatient centers with partial SRI response were randomized to the addition of exposure and ritual prevention or stress management training, delivered twice weekly for 8 weeks (acute phase); 108 began treatment. Responders (38 of 52 in the exposure and ritual prevention condition, 11 of 52 in the stress management training condition) entered a 24-week maintenance phase. The Yale-Brown Obsessive Compulsive Scale (YBOCS) was the primary outcome measure. RESULTS: After 24 weeks, patients randomized to and receiving exposure and ritual prevention versus stress management training had significantly better outcomes (mean YBOCS scores of 14.69 and 21.37, respectively; t = 2.88, P = .005), higher response rates (decrease in YBOCS scores ≥ 25%: 40.7% vs 9.3%, Fisher exact test P < .001), and higher rates of excellent response (YBOCS score ≤ 12: 24.1% vs 5.6%, Fisher exact test P = .01). During the maintenance phase, the slope of change in YBOCS scores was not significant in either condition (all P values ≥ .55), with no difference between exposure and ritual prevention and stress management training (P > .74). Better outcome was associated with baseline variables: lower YBOCS scores, higher quality of life, fewer comorbid Axis I diagnoses, and male sex. CONCLUSIONS: Augmenting SRIs with exposure and ritual prevention versus stress management training leads to better outcome after acute treatment and 24 weeks later. Maintenance outcome, however, was primarily a function of OCD severity at entrance. Greater improvement during the acute phase influences how well patients maintain their gains, regardless of treatment condition.

Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders.

PURPOSE: Eating disorders and obsessive-compulsive disorder (OCD) commonly co-occur, but there is little data for how to treat these complex cases. To address this gap, we examined the naturalistic outcome of 56 patients with both disorders, who received a multimodal treatment program designed to address both problems simultaneously. METHODS: A residential treatment program developed a cognitive-behavioral approach for patients with both OCD and an eating disorder by integrating exposure and response prevention (ERP) treatment for OCD with ERP strategies targeting eating pathology. Patients also received a supervised eating plan, medication management, and social support. At admission and discharge, patients completed validated measures of OCD severity (the Yale-Brown Obsessive-Compulsive Scale--Self Report [Y-BOCS-SR]), eating disorder severity (the Eating Disorders Examination-Questionnaire), and depressive severity (the Beck Depression Inventory II [BDI-II]). Body mass index (BMI) was also measured. Paired-sample t-tests examined change on these measures. MAIN RESULTS: Between 2006 and 2011, 56 individuals completed all study measures at admission and discharge. Mean length of stay was 57 days (SD = 27). Most (89%) were on psychiatric medications. Significant decreases were observed in OCD severity, eating disorder severity, and depression. Those with bulimia nervosa showed more improvement than those with anorexia nervosa. BMI significantly increased, primarily among those underweight at admission. CONCLUSION: Simultaneous treatment of OCD and eating disorders using a multimodal approach that emphasizes ERP techniques for both OCD and eating disorders can be an effective treatment strategy for these complex cases.

Behavior therapy for pediatric trichotillomania: a randomized controlled trial.

OBJECTIVE: To examine the efficacy and durability of a behavioral therapy (BT) protocol for pediatric TTM compared with a minimal attention control (MAC) condition. It was hypothesized that the BT condition would be superior to MAC at the end of acute treatment, and would also demonstrate durability of gains through the maintenance treatment phase. METHOD: A randomized controlled trial in which 24 youths were assigned to either a pilot-tested BT protocol, consisting of eight weekly sessions, or to MAC, consisting of three sessions and five telephone calls over 8 weeks. Independent evaluators assessed outcome at pretreatment (week 0) and post-treatment (week 8) for BT and MAC, and again at week 16 for BT patients only. The primary outcome measure was the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). RESULTS: For the BT condition, the week 8 mean NIMH-TSS score was significantly lower than that of the MAC condition. The BT condition's mean week 8 score was also significantly lower than their own mean week 0 score, whereas no such reductions were observed for the MAC condition. Upon completion of acute treatment at week 8, the BT group's gains were maintained through an 8-week maintenance treatment phase. CONCLUSIONS: BT produced a superior outcome compared with a condition that controlled for participation in a pediatric TTM research study, nonspecific therapist contact effects, repeated assessments, and the passage of time. Maintenance of gains after acute BT provides preliminary support for the durability of treatment gains. CLINICAL TRIAL REGISTRATION INFORMATION: Cognitive Behavioral Treatment of Pediatric Trichotillomania; http://www.clinicaltrials.gov; R21 MH 61457.

The impact of experiential avoidance and obsessive beliefs on obsessive-compulsive symptoms in a severe clinical sample.

The present study sought to replicate and extend a study by Abramowitz et al. (2009), who examined how well experiential avoidance (EA) and obsessive beliefs predicted obsessive-compulsive (OC) symptoms in a non-clinical sample. The current study utilized a severe, clinical, treatment-seeking sample (N=108), and examined how well EA and obsessive beliefs predicted changes in OC symptoms from pre- to post-treatment. Findings were generally consistent with Abramowitz et al. EA was generally not related to OC severity and did not add significantly to the prediction of OC symptom domains above and beyond depression or general anxiety, whereas obsessive beliefs did. Pre- to post-treatment change in one type of obsessive belief (perfectionism/certainty), but not change in EA, predicted global change in OC severity. Results suggest that EA as it is measured currently may not play a significant role in OC severity or changes in OC severity across treatment.

Evidence for poorer outcome in patients with severe negative trauma-related cognitions receiving prolonged exposure plus cognitive restructuring: implications for treatment matching in posttraumatic stress disorder.

In the current article, we address the existing assumption in the literature on cognitive behavioral treatment of PTSD that patients with severe negative trauma-related cognitions would benefit more from a treatment package that includes exposure and cognitive techniques compared with a treatment that includes exposure only. To test this assumption, 54 PTSD patients were randomized to prolonged exposure therapy or prolonged exposure therapy plus cognitive restructuring. Contrary to expectations, findings revealed that patients characterized by more severe pretreatment trauma-related cognitions (and more severe pretreatment PTSD symptoms) fared slightly worse in treatment combining exposure and cognitive restructuring. However, there was no relationship between pre- and post-treatment measures of negative cognitions and PTSD symptoms in the exposure alone group. The implications of these findings for examining Person X Treatment interactions and the efficacy of combining treatments for PTSD are discussed.

Noradrenergic modulation of extinction learning and exposure therapy.

Memory consolidation is enhanced by emotional arousal, an effect mediated by noradrenergic beta-receptor signaling. Norepinephrine strengthens consolidation of both appetitive and aversive learning, and is implicated in extinction of conditioned responses. In this review, we summarize work on the noradrenergic mechanisms of extinction learning and implications for extinction-based exposure therapy. The evidence suggests that norepinephrine release evoked by conditioned stimuli during extinction strengthens extinction memory via beta-receptor signaling. The modulatory effect of norepinephrine during extinction depends on predictable presentation of conditioned stimuli and optimal levels of norepinephrine release. Mechanistically, norepinephrine acts to increase cellular excitability and enhance synaptic plasticity within extinction-related neural circuitry. Currently, drugs that modulate norepinephrine are being used to treat symptoms of anxiety disorders, and are now being tested as pharmacotherapeutic prophalactics in the prevention of chronic posttraumatic stress reactions and as adjuncts to extinction-based exposure therapy. Studies of these new applications of noradrenergic drugs show a converging pattern of results with basic science suggesting ways in which basic laboratory findings can be translated into procedures to enhance clinical outcomes.