Abbreviated Dialectical Behavior Therapy Virtual Skills Group for Caregivers of Adolescents: An Exploratory Study of Service User and Clinical Outcomes.

Prior work emphasizes involving caregivers in youth mental health services. To support youth with emotion dysregulation, dialectical behavior therapy for adolescents (DBT-A) includes a multi-family skills group, wherein adolescents and caregivers learn skills together. However, limited work has examined the impact of caregiver involvement within DBT-A. The current study examines outcomes of two caregiver-only DBT-A skills groups adapted for abbreviated telehealth delivery. We report on caregivers' (N = 11, 100% mothers, 55% Hispanic) service user outcomes (e.g. self-efficacy at skill usage, group cohesion, therapeutic alliance) and clinical outcomes (i.e. their own emotion functioning, criticism, responses to their adolescent's negative emotions). Results indicate caregiver-only groups were feasible and acceptable, and suggest preliminary efficacy, including improvements in caregiver emotion functioning, distress during interactions with their adolescents, and adolescent-reported criticism. Caregivers also reported reductions in unsupportive responses with their adolescents. Overall, while we caution interpretation due to a small sample size, findings support the preliminary feasibility and efficacy of modifying caregiver participation in DBT-A to be less time-consuming and administered via telehealth.

Learning from Adolescents and Caregivers to Enhance Acceptability and Engagement Within Virtual Dialectical Behavior Therapy for Adolescents Skills Groups: A Qualitative Study.

Despite the significant increase in adolescent mental health challenges in recent years, structural barriers continue to limit access to and engagement in mental health services. As such, opportunities to learn directly from adolescents and their families on how to best structure and deliver services are paramount. The current study assumes a multi-informant approach and reports on adolescents' and caregivers' (N = 33) experiences in an adapted telehealth/hybrid Dialectical Behavior Therapy for Adolescents (DBT-A) program. Focus groups were conducted across two cohorts of families who participated in DBT-A skills groups, to collect family-centered data on the acceptability of program modifications, engagement in the adapted telehealth/hybrid DBT-A, and recommendations for improvement. Participants were predominately Latine White and were from a broad range of socioeconomic backgrounds. Additionally, 45.5% of the adolescents identified as LGBTQ + . Focus group findings emphasized how the telehealth platform was both convenient and disengaging, and how in-person sessions offered improved group connection and content engagement. Participants underscored the importance of balancing multi-family group sessions with adolescent- and caregiver-only group sessions in the program, and adolescents emphasized a need for the DBT-A program to better center adolescents' unique experiences and voices throughout sessions. Both adolescents and caregivers suggested modifications to synthesize the content and improve generalizability of the DBT-A skills to their real lives. Overall, these findings add to a new and evolving branch of DBT-A qualitative inquiry, as well as the growing body of work that recommends incorporating the voices of people with lived experiences into the development and modification of psychological services.

Measuring clinician stuck points about trauma-focused cognitive behavior therapy: The TF-CBT Stuck Points Questionnaire.

Although evidence-based treatments (EBTs) for youth trauma have been developed, trauma-informed EBTs are rarely used in community settings. Clinician concerns about evidence-based trauma treatment may be a barrier to adoption and delivery. However, few instruments to assess clinician beliefs about specific EBTs, such as trauma-focused cognitive behavior therapy (TF-CBT) are available. This study evaluated an instrument of clinician concerns about TF-CBT, the TF-CBT Therapist Stuck Points questionnaire, in a sample of community mental health clinicians training in a year-long TF-CBT community-based learning collaborative. The 26 items in the instruments, which aim to assess clinician views on child trauma treatment and TF-CBT, indicate preliminary psychometric support (i.e., item-total correlations, internal consistency, negative correlations with measures of attitudes towards evidence-based practice). Scores on the TF-CBT Therapist Stuck Points questionnaire revealed that, on average, clinicians expressed concerns about having children talk about their trauma in session, the effectiveness of certain TF-CBT components, and whether to involve caregivers in treatment. Clinician doubts could be targeted during a TF-CBT implementation effort and clinical supervision to facilitate treatment delivery. Implications for assessing TF-CBT specific beliefs during implementation are discussed.

Primary Outcomes for Adults Receiving the Unified Protocol after Hurricane Harvey in an Integrated Healthcare Setting.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated efficacy for treating anxiety and depression. However, there are limited effectiveness data when conducted in real-world settings with diverse populations, including those with trauma. We evaluated treatment outcomes in a naturalistic, community setting among 279 adults who received UP following Hurricane Harvey. We examined change in overall clinical severity, depression and anxiety symptoms, functional impairment, and baseline outcome predictors (i.e., demographic characteristics, impact from Hurricane Harvey, co-occurrence of depression and anxiety symptoms). Global clinical severity, depression and anxiety symptoms, and functional impairment decreased by end-of-treatment. Participants experienced global symptom improvement to a lesser degree than demonstrated in efficacy trials. Participants who experienced greater storm impact reported larger reductions in anxiety symptoms than those less impacted by Harvey. Further studies evaluating the effectiveness of the UP post-disaster and with diverse samples are needed.

Relationship of affect intolerance with anxiety, depressive, and obsessive-compulsive symptoms in youth.

BACKGROUND: Structural research on the construct of affect intolerance (an overarching latent construct indicated by distress tolerance and anxiety sensitivity) has only been conducted in adults. Given that a self-report measure of distress tolerance was recently validated for youth and affect intolerance may be a core mechanism of transdiagnostic interventions for internalizing disorders, we examined how affect intolerance relates to internalizing symptoms in youth. We predicted that a latent affect intolerance factor (indicated by distress tolerance and anxiety sensitivity) would be associated with self and parent-reports of youth anxiety, depressive, and obsessive-compulsive symptoms, controlling for age and gender. METHODS: At a pre-treatment evaluation, youth with a primary depressive, anxiety, or obsessive-compulsive spectrum disorder (N=277) aged 8-17, and their parent, completed questionnaires. RESULTS: Greater levels of the affect intolerance factor predicted greater youth- and parent-reported youth anxiety, depression, and obsessive-compulsive symptoms, controlling for age. LIMITATIONS: Future research should replicate findings in a sample with a greater proportion of depressed youth and utilize experimental or longitudinal methods. CONCLUSIONS: Importantly, distress tolerance and anxiety sensitivity are core transdiagnostic processes that can be targeted in cognitive-behavioral interventions. Future research should examine how transdiagnostic interventions for youth with internalizing disorders can target these cross-cutting emotional vulnerabilities.

Neuroticism as an underlying construct in youth emotional disorders.

Structural research on neuroticism, as indicated by Big Five personality traits and/or internalizing symptoms, has been conducted with youth. However, no structural research has investigated neuroticism as characterized by transdiagnostic risk factors such as distress tolerance (DT), negative affect (NA), and avoidance. No study has investigated whether DT, NA, and avoidance, as a group, are associated with anxiety, depressive, obsessive-compulsive (OC) symptoms, and independent evaluator (lE)-rated symptom severity in a clinical sample of youth. The purpose of the current investigation was to understand the proportion of variance in anxiety, depressive, OC symptoms, and independent evaluator-rated global symptom severity by a latent construct of neuroticism, as indicated by these modifiable features in youth with emotional disorders among a sample of 121 adolescents (ages 13-18, 51.2% female). A latent neuroticism factor was significantly associated with greater youth- and parent-reported anxiety, depressive, and OC symptoms, and greater IE-rated global severity.

Preaching to the Choir? Predictors of Engagement in a Community-Based Learning Collaborative.

This study examined predictors of engagement among 283 professionals from 34 agencies participating in three community-based learning collaboratives (CBLCs) on trauma-focused cognitive-behavioral therapy (TF-CBT). Only 50.2% of participants completed the CBLC, primarily due to not attending consultation calls or completing training cases. While higher engagement was associated with being trauma-informed and using more of the TF-CBT components prior to the CBLC, most predictors were not significant, perhaps due to ceiling effects. Positive attitudes and high organizational support were not sufficient to ensure engagement. Future research using longitudinal measurement of a wider range of predictors is needed.

Anxiety Sensitivity Differentially Predicts Factors of Interpersonal-Psychological Suicide Risk: A Consideration of Specificity.

Recent studies have identified anxiety sensitivity (AS) as a risk factor for suicidality; however, limited work has been performed to understand this risk within the context of the interpersonal-psychological theory of suicide (IPTS; Joiner, 2005). The current study examined the relationship between overall AS, each AS subfactor (cognitive, social, and physical), and the three IPTS domains (perceived burdensomeness, thwarted belongingness, and acquired capability). While each AS subfactor uniquely predicted one IPTS domain, greater overall AS only predicted greater acquired capability, suggesting that assessment of AS at the subfactor level may offer us more information about an individual's interpersonal suicide risk.

Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET): A comparative effectiveness trial of a transdiagnostic treatment and a measurement feedback system.

Emotional disorders, encompassing a range of anxiety and depressive disorders, are the most prevalent and comorbid psychiatric disorders in adolescence. Unfortunately, evidence-based psychosocial therapies typically focus on single disorders, are rarely adopted by community mental health center clinicians, and effect sizes are modest. This article describes the protocol for a comparative effectiveness study of two novel interventions designed to address these challenges. The first intervention is a transdiagnostic treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents, UP-A), a promising new approach that uses a small number of common strategies to treat a broad range of emotional disorders, and their underlying shared emotional vulnerabilities. The second intervention is a standardized measurement feedback system, the Youth Outcomes Questionnaire (YOQ), designed to improve clinical decision making using weekly symptom and relational data. The three study arms are treatment as usual (TAU), TAU plus the YOQ (TAU+), and UP-A (used in combination with the YOQ). The primary aims of the study are to [1] compare the effects of the UP-A and TAU+ to TAU in community mental health clinics, [2] to isolate the effects of measurement and feedback by comparing the UP-A and TAU+ condition, and [3] to examine the mechanisms of action of both interventions. Design considerations and study methods are provided to inform future effectiveness research.

Shame and Defectiveness Beliefs in Treatment Seeking Patients With Body Dysmorphic Disorder.

Shame is a distressing emotion experienced when individuals judge themselves in a broadly negative and critical manner. Clinical descriptions of body dysmorphic disorder (BDD) emphasize the centrality of shame, yet research on shame in BDD remains scarce. This study is the largest investigation of shame in clinically diagnosed individuals with BDD, and it is the first to examine whether shame changes with treatment. Eighty-three adults with BDD were treated with 14 weeks of open-label escitalopram. Shame was measured using the Young Schema Questionnaire-Short Form. Shame was significantly higher in individuals with BDD than in previously reported healthy control and psychiatric outpatient samples. Shame was significantly, moderately correlated with greater suicidal thoughts and hopelessness and marginally significantly correlated with greater BDD severity. Shame decreased significantly with treatment. Reductions in shame with escitalopram were significantly associated with reductions in suicidal thoughts and hopelessness, even when accounting for reductions in BDD and depression severity.

Obsessive-Compulsive and Depressive Symptoms: The Role of Depressive Cognitive Styles.

Obsessive-compulsive disorder (OCD) commonly co-occurs with depression, resulting in heightened severity and poorer treatment response. Research on the associations between specific obsessive-compulsive symptoms (OCS) and depressive symptoms has utilized measures that have not fully considered the relationship across OCS dimensions. Little is known about which factors explain the overlap between OCS and depressive symptoms. OCS and depressive symptoms may be related via depressive cognitive styles, such as rumination or dampening (i.e., down-regulating positive emotions). We evaluated the associations of OCS dimensions with depressive symptoms and cognitive styles. We also examined the indirect effects of rumination and dampening in the relationship between OCS and depressive symptoms. Participants (N = 250) completed questionnaires online. Greater depressive symptoms, rumination, and dampening were associated with greater levels of all OCS dimensions. Path analysis was utilized to examine a model including the direct effect of depressive symptoms on overall OCS and two indirect effects (through rumination and dampening). There was a significant indirect effect of depressive cognitive styles on the relationship between OCS and depressive symptoms, through rumination and dampening. Replication in a clinical sample and experimental manipulations may bear important implications for targeting depressive cognitive styles in treatments for OCD and depression.

Effects of a brief anxiety sensitivity reduction intervention on obsessive compulsive spectrum symptoms in a young adult sample.

OBJECTIVE: Anxiety sensitivity (AS) has been identified as a transdiagnostic cognitive risk factor for a wide range of affective disorders, including conditions within the obsessive compulsive (OC) spectrum. A growing body of research has demonstrated that directly reducing AS leads to subsequent reductions of other psychiatric symptoms, including anxiety, worry, and mood. To date, no study has examined the efficacy of a brief AS intervention on reducing OC and hoarding symptoms. METHOD: Non-treatment seeking young adults (N = 104; 83.7% female; 81.7% Caucasian) were selected for having elevated levels of AS, and were then randomized into a single-session, computer-assisted AS intervention or a control condition. OC and hoarding symptoms were assessed at post-treatment, as well as at one week and one month follow-ups. RESULTS: Results revealed that the intervention, but not the control condition, reduced OC symptoms across the post-intervention follow-up period. Mediation analysis demonstrated that changes in AS mediated changes in OC symptoms due to the intervention. In contrast, the intervention did not have a specific effect on reducing hoarding symptoms. CONCLUSIONS: These findings have important ramifications for understanding the relationship between AS and OC spectrum symptoms, and raise interesting treatment and prevention implications.

Interpersonal risk for suicide in social anxiety: The roles of shame and depression.

Though research indicates that individuals with social anxiety disorder may experience elevated levels of thwarted belongingness and perceived burdensomeness, two interpersonal risk factors critical for the development of suicidal desire, it remains unclear why. The current investigation considered how shame and depression may help to explain the relationship between social anxiety and interpersonal suicide risk factors. Participants (N=259), recruited using Amazon.com's Mechanical Turk, completed measures of social anxiety, interpersonal suicide risk factors, shame, and depression. Social anxiety was associated with greater thwarted belongingness and perceived burdensomeness. In addition, shame partially explained the association between social anxiety and thwarted belongingness, though the indirect effect was no longer significant after considering depression as a moderator. As predicted, shame was found to fully explain the association between social anxiety and perceived burdensomeness and this indirect effect was most pronounced among individuals with high comorbid depression. The clinical implications of these findings are discussed.

The Relationship between Traumatic Life Events and Hoarding Symptoms: A Multi-Method Approach.

Hoarding Disorder is characterized by difficulties with discarding and frequently excessively acquiring possessions, resulting in substantial clutter. Previous research has implicated trauma in the development of hoarding, but no study to date has examined the relationship between trauma and hoarding using hypothetical hoarding paradigms. This study investigated the association between traumatic events and both self-report and hypothetical indices of hoarding symptoms. We predicted that frequency of trauma would be associated with greater hoarding symptoms (across self-report and hypothetical indices). Undergraduate students (N = 80) completed self-report measures of hoarding symptoms and trauma, and hypothetical measures of acquiring and saving tendencies. As expected, more frequent trauma, and physical/sexual trauma in particular, was associated with greater acquiring tendencies. However, frequency of trauma was not significantly correlated with saving tendencies or self-reported hoarding symptoms. Future research should replicate these findings using longitudinal designs to confirm whether trauma actually serves as a risk factor for hoarding. Replication in a clinical sample is needed to better understand the implications of these results for intervention.

Clinical features of olfactory reference syndrome: An internet-based study.

OBJECTIVE: Preoccupation with perceived bodily odor has been described in neuropsychiatric disorders for more than a century; however, empirical research on olfactory reference syndrome (ORS) is scarce. This study investigated the phenomenology of ORS in a broadly ascertained, diverse sample. METHOD: Data were obtained from 253 subjects in an internet-based survey that operated from January - March 2010. Measures included the Yale-Brown Obsessive Compulsive Scale Modified for ORS (ORS-YBOCS), Work and Social Adjustment Scale (WSAS), Depression Anxiety Stress Scales (DASS), and symptom specific questionnaires developed for this study. RESULTS: Individuals reported, on average, moderately severe ORS symptoms. The average age of onset of ORS symptoms was 21.1 years, with 54% reporting a chronic, unremitting course. Individuals endorsed a lifetime average of two malodorous preoccupations, most commonly stool, garbage, and ammonia. Odors were most often reported to emanate from the armpits, feet, and breasts. Nearly all participants engaged in time-consuming rituals to try to hide or fix their perceived malodor (e.g., checking and camouflaging). Eighteen percent reported poor or delusional insight and 64.0% reported ideas or delusions of reference. More severe ORS symptoms were moderately associated with female gender, poorer insight, and higher levels of impairment (in work, social leisure, ability to maintain close relationships, and consecutive days housebound). CONCLUSION: This is the largest study on ORS to date. Results underscore the clinical significance and psychosocial impact of this understudied disorder, and highlight the need for subsequent research to examine clinical features and inform treatment.

An Experimental Investigation of the Effect of Stress on Saving and Acquiring Behavioral Tendencies: The Role of Distress Tolerance and Negative Urgency.

Stress has been implicated as a risk factor for hoarding, although past research has relied on cross-sectional and self-report designs. Using experimental methods and objective hypothetical behavioral hoarding paradigms, we investigated the direct effect of stress on in-the-moment saving and acquiring behavioral tendencies. We also evaluated whether distress tolerance (DT) and negative urgency interacted with stress to predict saving and acquiring behavioral tendencies. A sample of young adults (N=80) completed questionnaires about DT and negative urgency. Participants were randomized to either a psychosocial stressor or nonstressful control task prior to completing two hypothetical behavioral hoarding paradigms. The discarding task asked participants to choose between saving and disposing of items. For the acquiring task, participants completed a computer-simulated shopping spree that measured items acquired. Unexpectedly, participants in the stress condition saved and acquired fewer items than those in the control condition. As hypothesized, stress interacted with DT to predict saving tendencies. The current study should be replicated in a clinical sample. Longitudinal studies are needed to further examine the long-term effect of stress on hoarding. This is the first examination of the direct effect of stress on saving and acquiring tendencies. Although some study hypotheses were not supported, several results are consistent with our predictions and suggest a complex relationship between stress and hoarding. If findings are replicated in a clinical sample, it may be that hoarding patients could benefit from treatments incorporating DT strategies.

The importance of assessing clinical phenomena in Mechanical Turk research.

Amazon.com's Mechanical Turk (MTurk) website provides a data collection platform with quick and inexpensive access to diverse samples. Numerous reports have lauded MTurk as capturing high-quality data with an epidemiological sample that is more representative of the U.S. population than traditional in-person convenience samples (e.g., undergraduate subject pools). This benefit, in combination with the ease and low-cost of data collection, has led to a remarkable increase in studies using MTurk to investigate phenomena across a wide range of psychological disciplines. Multiple reports have now examined the demographic characteristics of MTurk samples. One key gap remains, however, in that relatively little is known about individual differences in clinical symptoms among MTurk participants. This paper discusses the importance of assessing clinical phenomena in MTurk samples and supports its assertions through an empirical investigation of a large sample (N = 1,098) of MTurk participants. Results revealed that MTurk participants endorse clinical symptoms to a substantially greater degree than traditional nonclinical samples. This distinction was most striking for depression and social anxiety symptoms, which were endorsed at levels comparable with individuals with clinically diagnosed mood and anxiety symptoms. Participants' symptoms of physiological anxiety, hoarding, and eating pathology fell within the subclinical range. Overall, the number of individuals exceeding validated clinical cutoffs was between 3 and 19 times the estimated 12-month prevalence rates. Based on the current findings, it is argued that MTurk participants differ from the general population in meaningful ways, and researchers should consider this when referring to this sample as truly representative. (PsycINFO Database Record

A multifaceted assessment of emotional tolerance and intensity in hoarding.

Hoarding is characterized by emotionally reinforced saving behaviors, which often combine with excessive acquisition to give rise to clutter, distress, and impairment. Despite the central role emotional processes are thought to play in hoarding, very little research has directly examined this topic. There is suggestive evidence linking hoarding with several facets of emotional intolerance and avoidance, though one key limitation of this past research has been the exclusive reliance on self-report questionnaires. The aim of the current study was to conduct a multimethod investigation of the relationship between hoarding and perceptions of, and cognitions about, negative emotional states. A large unselected sample of nonclinical young adults (N=213) completed questionnaires, behavioral tasks, and a series of negative mood inductions to assess distress tolerance (DT), appraisals of negative emotions, and emotional intensity and tolerance. Hoarding symptoms were associated with lowered tolerance of negative emotions, as well as perceiving negative emotions as more threatening. Individuals high in hoarding symptoms also experienced more intense emotions during the mood inductions than individuals low in hoarding symptoms, though there was no association with poorer performance on a behavioral index of DT. Across measures, hoarding was consistently associated with experiencing negative emotions more intensely and reporting lower tolerance of them. This relationship was particularly pronounced for the difficulty discarding and acquiring facets of hoarding. Our results offer initial support for the important role of emotional processes in the cognitive-behavioral model of hoarding. A better understanding of emotional dysfunction may play a crucial role in developing more effective treatments for hoarding.