Sex Differences in Age at Onset and Presentation of Trichotillomania and Trichobezoar: A 120-Year Systematic Review of Cases.

Trichotillomania (hair-pulling disorder) has high female preponderance. It has been suggested that onset in early childhood represents a distinct developmental subtype that is characterized by higher prevalence of males compared to later onset cases. However, the empirical literature is scarce. We conducted a systematic review of case reports to examine the distribution of age at onset/presentation in males and females with trichotillomania or trichobezoar (a mass of hair in the gastrointestinal tract resulting from ingesting hair). We identified 1065 individuals with trichotillomania and 1248 with trichobezoar. In both samples, males, compared to females, had earlier age at presentation and greater proportion of cases in early childhood. These sex differences remained after potential confounding variables were accounted for. The results showed similar sex differences for age at onset, which was reported in 734 and 337 of the trichotillomania and trichobezoar cases, respectively. The findings may reflect neurodevelopmental underpinnings in early childhood trichotillomania.

Rising to the Occasion of This COVID-19-Impacted Nation: Development, Implementation, and Feasibility of the Brief Assessment-Informed Skills Intervention for COVID-19 (BASIC).

The COVID-19 pandemic has had a profound impact on the global economy, physical health, and mental health. This pandemic, like previous viral outbreaks, has resulted in spikes in anxiety, depression, and stress. Even though millions of individuals face the physical health consequences of infection by COVID-19, even more individuals are confronted with the mental health consequences of this pandemic. This significantly increased demand for mental health services cannot be easily met by existing mental health systems, which often rely on courses of therapy to be delivered over months. Single session interventions (SSIs) may be one important approach to meeting this increased demand, as they are treatments designed to be delivered over the course of a single meeting. SSIs have been found to be effective for a range of mental health challenges, with durable effects lasting months to years later. Here, we describe an SSI designed for the COVID-19 pandemic. This Brief Assessment-informed Skills Intervention for COVID-19 (BASIC) program draws upon therapeutic skills from existing empirically supported treatments to target common presenting complaints due to this pandemic. We discuss the process of developing and implementing this intervention, as well as explore feasibility and initial clinical insights. In short, BASIC is an easy-to-adopt intervention that is designed to be effective in a single session, making it well-suited for handling the increased demand for mental health services due to COVID-19.

Looking beyond depression: a meta-analysis of the effect of behavioral activation on depression, anxiety, and activation.

BACKGROUND: Depression is a prevalent and impairing condition. Behavioral activation (BA) is a parsimonious, cost-effective, and easily disseminated psychological intervention for depression. The current meta-analysis expands on the existing literature supporting the efficacy of BA for depression by examining the effects of BA on additional relevant outcomes for patients with depression, namely the reduction in anxiety symptoms and increase in activation. METHODS: Randomized controlled trials of BA for depression compared to active and inactive control were identified via a systematic review. Effect sizes using Hedges's g were calculated for each outcome compared to both active and inactive control using random effects models. Subgroup analyses were used to examine the inclusion of a discussion of values as a moderator of depression symptom outcome in BA. RESULTS: Twenty-eight studies were included. Meta-analyses of symptom change between groups from baseline-to-post intervention indicated that BA outperformed inactive control conditions for improvements in depression (g = 0.83), anxiety (g = 0.37), and activation (g = 0.64). The difference between BA and active control conditions was not significant for improvements in depression (g = 0.15), anxiety (g = 0.03), and activation (g = 0.04). There was no evidence for a discussion of values augmenting BA efficacy. Study quality was generally low, and there was evidence of publication bias. CONCLUSIONS: In addition to improving depression, BA shows efficacy for reducing symptoms of anxiety and increasing activation. BA may not offer better outcomes relative to other active interventions. There is room for improvement in the quality of research in this area.

Patient experiences with group behavioural activation in a partial hospital program.

BACKGROUND: Behavioural activation (BA) is an evidence-based treatment for depression that has been primarily delivered in individual out-patient treatment. Prior research supports a positive participant experience in individual therapy; however, less is known about the patient experience in group therapy, which is common in acute psychiatric settings. AIMS: The present study examined the patient experience of Brief Behavioral Activation Treatment for Depression (BATD) delivered in group acute psychiatric treatment. METHOD: We used thematic analysis to extract themes from feedback surveys administered as part of quality improvement practice at a partial hospital program. Survey questions explored what patients learned, liked, disliked and thought could be improved in the BATD groups. Three individuals independently coded survey responses and collaboratively developed categories and themes. RESULTS: Themes included several helpful content areas (e.g. value-driven activities, increasing motivation, goal setting, activity scheduling, cognitive behavioural model, self-monitoring) and learning methods (e.g. group format, experiential exercises, worksheets). Patients also identified unhelpful content (e.g. specific focus on depression and listing activities by mood). There was mixed feedback regarding the repetition of material and balance of lecture versus group participation. CONCLUSION: Overall, these findings suggest a mostly positive patient experience of group-delivered BATD and support the acceptability of group-delivered BATD as a component of short-term intensive treatment.

Cognitive Control Network Homogeneity and Executive Functions in Late-Life Depression.

BACKGROUND: Late-life depression is characterized by network abnormalities, especially within the cognitive control network. We used alternative functional connectivity approaches, regional homogeneity (ReHo) and network homogeneity, to investigate late-life depression functional homogeneity. We examined the association between cognitive control network homogeneity and executive functions. METHODS: Resting-state functional magnetic resonance imaging data were analyzed for 33 older adults with depression and 43 healthy control subjects. ReHo was performed as the correlation between each voxel and the 27 neighbor voxels. Network homogeneity was calculated as global brain connectivity restricted to 7 networks. T-maps were generated for group comparisons. We measured cognitive performance and executive functions with the Dementia Rating Scale, Trail-Making Test (A and B), Stroop Color Word Test, and Digit Span Test. RESULTS: Older adults with depression showed increased ReHo in the bilateral dorsal anterior cingulate cortex (dACC) and the right middle temporal gyrus, with no significant findings for network homogeneity. Hierarchical linear regression models showed that higher ReHo in the dACC predicted better performance on Trail-Making Test B (p < .001; R2 = .49), Digit Span Backward (p < .05; R2 = .23), and Digit Span Total (p < .05; R2 = .23). Used as a seed, the dACC cluster of higher ReHo showed lower functional connectivity with bilateral precuneus. CONCLUSIONS: Higher ReHo within the dACC and right middle temporal gyrus distinguish older adults with depression from control subjects. The correlations with executive function performance support increased ReHo in the dACC as a meaningful measure of the organization of the cognitive control network and a potential compensatory mechanism. Lower functional connectivity between the dACC and the precuneus in late-life depression suggests that clusters of increased ReHo may be functionally segregated.

Examining experiential avoidance as a mediator of the relation between anxiety sensitivity and depressive symptoms.

Initial evidence suggests that experiential avoidance (EA) mediates the relation between anxiety sensitivity (AS) and depression. We examined the AS-EA-depression pathway, examining both concurrent, and prospective (cross-lag), mediation models. Utilizing data from a study that examined the effects of exercise on AS (N = 60), we modeled depressive symptoms, EA, and AS over four time points. Time-varying predictors were disaggregated into between-subjects (each person's mean level of the predictor) and within-subjects change (each person's deviations, at each time point, from their mean level on the predictor) components. Tests of the concurrent relations were partially consistent with predictions, with mean EA levels, but not within-subjects changes in EA, partially mediating the relation between AS and depression symptom severity. However, the prospective, cross-lag mediation model, in which AS predicted future EA controlling for previous EA, and EA predicted future depression, controlling for previous depression, yielded no significant effects. These results suggest that observed between-subjects mediation findings, found here and in previous studies, may not replicate using more stringent, quasi-causal, cross-lag mediation analyses. These results highlight the importance of estimating causal pathways in mediation analyses. Clinical implications and directions for future research are discussed.

Network analyses reveal which symptoms improve (or not) following an Internet intervention (Deprexis) for depression.

BACKGROUND: Depression is a heterogeneous collection of symptoms. Prior meta-analyses using symptom sum scores have shown the Internet intervention, Deprexis, to be an efficacious treatment for depression. However, no prior research has investigated how Deprexis (or any other Internet intervention for depression) impacts specific symptoms of depression. The current study utilizes symptom-level analyses to examine which symptoms are directly, indirectly, or minimally influenced by treatment. METHODS: Network analysis and mean-level approaches examined which symptoms, assessed by the Quick Inventory of Depression Symptoms, were affected by an 8-week course of Deprexis compared with a waitlist in a nationally recruited sample from the United States (N = 295). RESULTS: Deprexis directly improved the symptoms of sadness and indecision. Changes in these symptoms, in turn, was associated with a change in early insomnia, middle insomnia, self-dislike, fatigue, anhedonia, suicidality, slowness, and agitation. All of these symptoms (except for agitation and early insomnia) show decreases with Deprexis compared with a waitlist after correcting for multiple comparisons. Six additional symptoms, particularly the somatic symptoms, were not impacted by Deprexis compared with a waitlist. CONCLUSIONS: In this sample, the efficacy of Deprexis was due to its direct impact on sadness and indecision. Examining the treatment-related change in specific symptoms may facilitate a more nuanced understanding of how a treatment works compared with examining symptom sum scores. Symptom-level approaches may also identify symptoms that do not improve and provide important direction for future treatment development.

Examining differential relationships among self-reported attentional control, depression, and anxiety in a transdiagnostic clinical sample.

BACKGROUND: Poor attentional control, defined as difficulty focusing attention on a task or shifting attention flexibly between tasks, is a transdiagnostic construct theorized to confer risk for, and maintain, depression and anxiety. Research to date in non-clinical samples has suggested a dissociable relationship between the two factors of self-reported attentional control and psychopathology, with depression being associated with difficulties shifting and anxiety being associated with focusing. However, to our knowledge no study has tested this differential set of relationships in a clinical sample. METHODS: Adults (N = 493) presenting for psychiatric treatment completed measures of depressive and anxiety symptom severity and self-reported attentional control. Hierarchical linear regression and Zou's (2007) confidence interval method were used to examine the relationship between clinical symptoms and attentional control. RESULTS: Both shifting and focusing were significantly correlated with anxiety and depressive symptoms in this sample. However, focusing was more strongly associated with clinical symptomatology than shifting, which showed a weak correlation. LIMITATIONS: All constructs were measured cross-sectionally by self-report questionnaires. CONCLUSIONS: In contrast to studies conducted in non-clinical samples, attentional focusing appears to be more relevant than attentional shifting in a clinical sample for both depression and anxiety symptoms. These findings lend support to efforts to develop neurocognitive interventions that improve focusing. Replication of these findings, particularly in longitudinal studies, is warranted.

The effects of exercise on transdiagnostic treatment targets: A meta-analytic review.

BACKGROUND: The present study meta-analytically reviewed the effects of exercise on four transdiagnostic treatment targets: anxiety sensitivity (AS), distress tolerance (DT), stress reactivity (SR), and general self-efficacy (GSE). METHODS: We conducted systematic searches of peer-reviewed studies in bibliographical databases (Cochrane Library, psychINFO, PubMed) before April 1, 2018. Only randomized controlled trials (RCT) evaluating the effect of exercise on AS, DT, SR, or GSE using at least one validated outcome instrument in a sample of adolescents (≥13 years old) or adults were selected. We employed a meta-analysis of effects using random-effects pooling modeling for each treatment target. RESULTS: The systematic search yielded 28 RCTs meeting eligibility criteria. Exercise interventions had a large effect on reducing AS (six studies, Hedges's g = 0.72, p = .001), a medium effect on increasing GSE (eight studies, Hedges's g = 0.59, p < .001), and a small effect on reducing SR (ten studies, Hedges's g = 0.32, p < .001). Evidence from four studies suggested that exercise interventions had a small but non-significant effect on increasing DT (Hedges's g = 0.21, p = .26). CONCLUSIONS: This meta-analysis provides preliminary evidence exercise can engage certain transdiagnostic targets. Further research is required to optimize exercise intervention parameters to achieve the strongest effects on these important mechanistic variables.

Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials.

Trials of virtual reality exposure therapy (VRET) for anxiety-related disorders have proliferated in number and diversity since our previous meta-analysis that examined 13 total trials, most of which were for specific phobias (Powers & Emmelkamp, 2008). Since then, new trials have compared VRET to more diverse anxiety and related disorders including social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and panic disorder (PD) with and without agoraphobia. With the availability of this data, it is imperative to re-examine the efficacy of VRET for anxiety. A literature search for randomized controlled trials of VRET versus control or in vivo exposure yielded 30 studies with 1057 participants. Fourteen studies tested VRET for specific phobias, 8 for SAD or performance anxiety, 5 for PTSD, and 3 for PD. A random effects analysis estimated a large effect size for VRET versus waitlist (g = 0.90) and a medium to large effect size for VRET versus psychological placebo conditions (g = 0.78). A comparison of VRET and in vivo conditions did not show significantly different effect sizes (g = -0.07). These findings were relatively consistent across disorders. A meta-regression analysis revealed that larger sample sizes were associated with lower effect sizes in VRET versus control comparisons (ß = -0.007, p < 0.05). These results indicate that VRET is an effective and equal medium for exposure therapy.

White matter abnormalities predict residual negative self-referential thinking following treatment of late-life depression with escitalopram: A preliminary study.

BACKGROUND: Negative self-referential thinking is a common symptom of depression associated with poor treatment response. In late-life depression, white matter abnormalities may contribute to negative self-referential thoughts following antidepressant treatment. We investigated the association of fractional anisotropy (FA) in select regions of the negative valence system (NVS) with residual negative self-referential thoughts following treatment with escitalopram for late-life depression. METHODS: The participants were older adults with major depression and psychiatrically normal controls. Depressed participants received 12 weeks of treatment with escitalopram. To assess self-referential thinking, participants completed a Trait Adjective Task at baseline and at week 12. Baseline MRI scans included a diffusion imaging sequence for FA analyses. RESULTS: Participants with late-life depression differed from controls on all performance measures of the Trait Adjective Task at baseline and at 12 weeks. Depressed participants endorsed fewer negative personality traits and more positive personality traits at week 12 compared to baseline. Lower FA in the dorsal anterior cingulate and in the uncinate fasciculus in depressed participants was correlated with residual negative self-referential thinking (e.g., more endorsed negative adjectives, fewer rejected negative adjectives) at treatment end. LIMITATIONS: The sample size is modest so the findings are preliminary. FA analyses were restricted to predetermined regions. CONCLUSIONS: Negative self-referential thinking improved in depressed older adults following 12 weeks of treatment with escitalopram. Baseline FA in select white matter regions of the NVS was associated with residual negative self-referential thinking. These findings may help identify treatment targets for residual negative self-referential thoughts.

A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder.

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges' g = 1.24) and follow-up (mean Hedges' g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.

Posttraumatic stress disorder and cigarette smoking: A systematic review.

BACKGROUND: Previous reviews of the PTSD and cigarette smoking literature showed high PTSD-smoking comorbidity and problematic smoking outcomes (Feldner et al., 2007, Clinical Psychology Review, 27, 14-45; Fu et al., 2007, Nicotine & Tobacco Research, 9, 1071-1084). However, past reviews also noted several prominent gaps in the literature, including a lack of etiological work examining underlying mechanisms and research on specialized PTSD-smoking treatments. The present review summarizes an extensive body of research conducted since the previous reviews targeting these areas of need. METHODS: Literature searches identified 66 empirical studies specific to smoking and PTSD. RESULTS: Smokers were approximately twice more likely to have PTSD than nonsmokers in the general population, and individuals with PTSD were approximately twice as likely to be current smokers. Smokers with PTSD evidenced more negative affect, trauma history, and comorbid psychiatric history, as well as quit attempts and higher relapse rates. PTSD symptoms were associated with expectations that smoking would reduce negative affect, which, in turn, was associated with increased smoking rate and nicotine dependence. Male sex was associated with nicotine dependence and PTSD avoidance, while the relationship between PTSD and smoking relapse due to withdrawal was stronger in females. Specialized, integrated PTSD and smoking cessation treatments showed promise in increasing quit success relative to standard care in randomized trials. CONCLUSIONS: Rates of PTSD-smoking co-occurrence remain high. Notable gains have been made in relevant epidemiological and etiological research, although more work is needed in trauma-specific subpopulations. Several promising specialized treatments for comorbid smoking-PTSD have been developed and empirically tested but require replication.

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

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

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

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

Eating in response to exercise cues: Role of self-control fatigue, exercise habits, and eating restraint.

Identifying moderators of compensatory eating is important for understanding the failure of many people to lose weight in response to increased exercise levels. A previous study demonstrated that individuals shown action words (e.g., "active" or "go") were primed by these words to increase energy intake. Further studies have demonstrated that individual differences (e.g. differences in body mass) affect susceptibility to relevant priming cues. Based on these findings, this study examined individual differences, including exercise habits, tendencies toward compensatory eating, dietary restraint, and body mass that may serve as moderators of compensatory eating in the context of conceptual priming. A 2 × 2 design was utilized to analyze the effects of both priming and a self-control task on energy intake. Participants were presented with several snack foods under the guise of a taste test, with energy intake (kcal) during this taste test as the primary outcome variable. Results of this study indicate that, among those with higher baseline levels of exercise, lower energy intake was found for those exposed to exercise cues relative to those who did not receive these cues. In addition, the influence of the self-control fatigue condition was dependent on body mass index.

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

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