Minimum Stocking Requirements for Retailers in the Special Supplemental Nutrition Program for Women, Infants, and Children: Disparities Across US States.

OBJECTIVES: To examine state variation in minimum stocking requirements for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-authorized small food retailers. METHODS: We obtained minimum stocking requirements for 50 states and the District of Columbia in 2017 from WIC Web pages or e-mail from the state WIC agency. We developed a coding protocol to compare minimum quantities and varieties required for 12 food and beverage categories. We calculated the median, range, and interquartile range for each measure. RESULTS: Nearly all states set minimum varieties and quantities of fruits and vegetables, 100% juice, whole grain-rich foods, breakfast cereal, milk, cheese, eggs, legumes, and peanut butter. Fewer states set requirements for canned fish, yogurt, and tofu. Most measures had a large range in minimum requirements (e.g., $8-$100 of fruits and vegetables, 60-144 oz of breakfast cereal). CONCLUSIONS: WIC-participating retailers must adhere to very different minimum stocking requirements across states, which may result in disparities in food and beverage products available to WIC recipients. Public Health Implications. The results provide benchmarks that can inform new local, state, and federal program and policy efforts to increase healthy food availability in retail settings.

Successful customer intercept interview recruitment outside small and midsize urban food retailers.

BACKGROUND: Customer intercept interviews are increasingly used to characterize food purchases at retail food outlets and restaurants; however, methodological procedures, logistical issues and response rates using intercept methods are not well described in the food environment literature. The aims of this manuscript were to 1) describe the development and implementation of a customer intercept interview protocol in a large, NIH-funded study assessing food purchases in small and midsize food retailers in Minneapolis and St. Paul, Minnesota, 2) describe intercept interview response rates by store type and environmental factors (e.g., neighborhood socioeconomic status, day/time, weather), and 3) compare demographic characteristics (e.g., gender, race/ethnicity) of participants versus non-participants. METHODS: After a pilot phase involving 28 stores, a total of 616 interviews were collected from customers exiting 128 stores in fall 2014. The number of eligible customers encountered per hour (a measure of store traffic), participants successfully recruited per hour, and response rates were calculated overall and by store type, neighborhood socio-economic status, day and time of data collection, and weather. Response rates by store type, neighborhood socio-economic status, time and day of data collection, and weather, and characteristics of participants and non-participants were compared using chi-square tests. RESULTS: The overall response rate was 35 %, with significantly higher response rates at corner/small grocery stores (47 %) and dollar stores (46 %) compared to food-gas marts (32 %) and pharmacies (26 %), and for data collection between 4:00-6:00 pm on weekdays (40 %) compared to weekends (32 %). The distribution of race/ethnicity, but not gender, differed between participants and non-participants (p < 0.01), with greater participation rates among those identified as Black versus White. CONCLUSIONS: Customer intercept interviews can be successfully used to recruit diverse samples of customers at small and midsize food retailers. Future community-based studies using customer intercept interviews should collect data sufficient to report response rates and consider potential differences between the racial/ethnic composition of the recruited sample and the target population.

The effect of self-regulated caffeine use on cognition in young adults.

OBJECTIVE: Based on previous observational studies that have suggested self-regulated caffeine use by older adults may enhance reaction time performance and vigilance on cognitive tasks, the current study sought to examine whether this effect held true for young adults as well. METHODS: One hundred and four young adults from two major metropolitan areas, ages 18-29 years, not meeting the criteria for a current psychiatric disorder, completed several cognitive tasks related to decision-making (Cambridge Gamble Task), response inhibition and reaction time (stop-signal task), and vigilance and reaction time (Rapid Visual Information Processing). Caffeine usage was self-reported using a reliable quantity and frequency questionnaire. RESULTS: Self-reported caffeine usage was not significantly associated with any of the cognitive measures used in this study after controlling for age, gender, cigarette smoking, alcohol use, cannabis use, and gambling frequency. CONCLUSIONS: These data suggest that self-regulated caffeine usage may not have a significant impact on reaction time, vigilance, response inhibition, or decision-making in young adults, or that these effects are contingent upon other variables not accounted for in the current study.

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.

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.

Mental health and clinical correlates in lesbian, gay, bisexual, and queer young adults.

OBJECTIVE: This study examined the prevalence of mental health disorders and their clinical correlates in a university sample of lesbian, gay, bisexual, and queer (LGBQ) students. PARTICIPANTS: College students at a large public university. METHODS: An anonymous, voluntary survey was distributed via random e-mail generation to university students during April and May of 2011. LGBQ students were compared with their heterosexual counterparts on psychological and physical status as well as academic performance. RESULTS: LGBQ students reported worse depressive symptoms, higher levels of perceived stress, considered themselves less attractive, and were more likely to be overweight. LGBQ students were significantly more likely to report histories of affective, substance use, and certain anxiety disorders as well as compulsive sexual behavior and compulsive buying. CONCLUSIONS: The higher rates of many psychiatric conditions among LGBQ students underscore the need for universities to provide LGBQ students a nonjudgmental environment to discuss sexual orientation and health issues.

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.

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.

A randomized, placebo-controlled trial of N-acetylcysteine plus imaginal desensitization for nicotine-dependent pathological gamblers.

OBJECTIVE: Pathological gambling is associated with elevated proportions of nicotine dependence, and tobacco smoking in pathological gamblers has been associated with increased problem-gambling severity. This study examined the addition of N-acetylcysteine to imaginal desensitization in adults with co-occurring nicotine dependence and pathological gambling. METHOD: Twenty-eight individuals with co-occurring DSM-IV nicotine dependence and pathological gambling who were receiving behavioral therapy were recruited from December 2009 to February 2012 and randomized to augmentation with N-acetylcysteine or placebo in an 12-week, double-blind trial. Subjects were assessed with measures of nicotine and gambling severity and followed for 3 months after treatment. The primary outcomes were the Fagerström Test for Nicotine Dependence and the pathological gambling adaptation of the Yale-Brown Obsessive-Compulsive Scale. RESULTS: During the first 6 weeks, there was a significant benefit of N-acetylcysteine treatment versus placebo on Fagerström Test for Nicotine Dependence total scores (t = -2.224; P = .031). After the initial 6 weeks, all subjects significantly (P < .001) benefited from imaginal desensitization. During the 3-month follow-up, there was a significant additional benefit for N-acetylcysteine versus placebo on measures of problem-gambling severity (t = 2.069; P = .043). CONCLUSIONS: N-acetylcysteine treatment during therapy facilitates long-term application of behavioral therapy techniques once patients are in the community after therapy has been completed. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00967005.

Prevalence and characteristics of compulsive buying in college students.

Compulsive buying (CB) is a potentially devastating problem involving repetitive urges to shop and uncontrolled spending behaviors. Prevalence of CB in the general population has been estimated at 5.8%. This epidemiological study aims to better understand the prevalence and characteristics of college students who meet criteria for CB. During the spring of 2011, an online survey examining CB (using a clinically validated screening instrument, the Minnesota Impulse Disorders Interview), stress and mood states, psychiatric comorbidity, and psychosocial functioning was emailed to 2108 University students. Overall survey response rate was 35.1% (n=2108). Our data indicated that 3.6% (n=67) of college students surveyed met criteria for CB with significantly more women affected (4.4%, n=48) than men (2.5%, n=19). Relative to students not meeting criteria for CB, college students who met criteria for CB endorsed significantly greater psychiatric comorbidity, lower grade point averages, increased stress, and poorer physical health. Presence of CB is likely associated with a variety of problems in college students. These data may warrant increased screening of CB in college students to establish early interventions.

A proof of concept study of tolcapone for pathological gambling: relationships with COMT genotype and brain activation.

Pathological gambling (PG) is a disabling disorder experienced by 1-3% of adults, and empirically validated treatments are lacking. Perturbations of prefrontal-dependent cognitive functions are implicated in the pathophysiology of PG. The enzyme catechol-O-methyl-transferase (COMT) is responsible for degradation of dopamine in the cortices and thereby is known to regulate such cognitive functions and their neural substrates. The objective of this study was to determine whether tolcapone, a COMT inhibitor, improves symptoms of PG and to explore whether such effects are dependent on COMT val-158-met polymorphism status and relate to concomitant changes in fronto-parietal activation. Twenty-four individuals with PG were enrolled in an 8-week trial of oral tolcapone (100mg/day titrated to 100mg thrice/day) and 12 undertook pre- and post-treatment fMRI to examine brain activation during an executive planning task in a pre-defined fronto-parietal network. At baseline, patients with PG showed fronto-parietal under-activation versus controls during executive planning. Treatment was associated with statistically significant reductions on PG-Yale Brown Obsessive Compulsive Scale (PG-YBOCS), the extent of which correlated significantly with augmentation of planning-related fronto-parietal activation. Symptom improvement was also significantly more pronounced in subjects with the val/val COMT polymorphism. Tolcapone improved PG symptoms, and the extent of symptomatic improvement was significantly related to augmentation of fronto-parietal activation (fMRI probe) and COMT status. Objective genetic and fMRI markers hold promise in the search for targeting treatment and elucidating brain mechanisms associated with optimal clinical outcomes.

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.

Prediction of alcohol and gambling problems in young adults by using a measure of decision making.

OBJECTIVES: Individuals who regularly gamble, regularly consume alcohol, or meet criteria for an alcohol-use disorder or pathological gambling may make riskier decisions on cognitive tasks. What remains unclear in the literature is whether these decision-making deficits precede or result from these addictive behaviors. This study aimed to determine whether risky decision making on a cognitive task is predictive of increasing gambling behaviors and alcohol use. METHODS: Fifty-eight young adults (aged 18-29 years) free from Axis I disorders and reporting no symptoms of at-risk gambling behavior or alcohol consumption, who were participating in a longitudinal study of impulsivity, were grouped as either high-risk decision makers (n = 29) or low-risk decision makers (n = 29) by using the Cambridge Gamble Task. Subjects were assessed at 1-year follow-up to examine gambling frequency, alcohol consumption, at-risk alcohol-use criteria, alcohol-use disorder criteria, at-risk gambling criteria, and pathological gambling criteria. RESULTS: High-risk decision makers were found to be more likely to meet at-risk criteria for alcohol use after 1 year. Decision-making group membership was not significantly correlated with frequency of gambling or development of pathological gambling or alcohol-use disorder over 1 year. CONCLUSIONS: A variable measuring risky decision making on the Cambridge Gambling Task may be able to predict who is more likely to increase alcohol use per session later in life.

Phenomenology and treatment of behavioural addictions.

Behavioural addictions are characterized by an inability to resist an urge or drive resulting in actions that are harmful to oneself or others. Behavioural addictions share characteristics with substance and alcohol abuse, and in areas such as natural history, phenomenology, and adverse consequences. Behavioural addictions include pathological gambling, kleptomania, pyromania, compulsive buying, compulsive sexual behaviour, Internet addiction, and binge eating disorder. Few studies have examined the efficacy of pharmacological and psychological treatment for the various behavioural addictions, and therefore, currently, no treatment recommendations can be made.

Les dépendances comportementales se caractérisent par une incapacité à résister à une motivation ou une pulsion entraînant des actions qui sont nuisibles pour soi ou les autres. Les dépendances comportementales ont des caractéristiques en commun avec l'abus de substances et d'alcool, et avec des domaines comme l'évolution naturelle, la phénoménologie, et les conséquences indésirables. Les dépendances comportementales sont notamment le jeu pathologique, la cleptomanie, la pyromanie, les achats compulsifs, le comportement sexuel compulsif, la dépendance à Internet, et la suralimentation compulsive. Peu d'études ont examiné l'efficacité du traitement pharmacologique et psychologique des diverses dépendances comportementales et par conséquent, aucune recommandation de traitement ne peut être faite à l'heure actuelle.

Clinical and neurocognitive markers of suicidality in young adults.

BACKGROUND: Suicide represents a leading cause of death in young people, yet relatively little is known regarding the neurobiological sequelae of preceding suicidal thoughts and behaviours. Although some studies have reported cognitive deficits associated with suicidality, very few studies have been undertaken in young people, especially from non-clinical contexts. AIMS: To quantify cognitive deficits associated with suicidality using a representative sample of young people, recruited from the general community using media advertisements. METHOD: 304 adults (18-29 years) undertook the Mini-International Neuropsychiatric Inventory (MINI) suicidality module, along with Cambridge Gamble and Stop-Signal tasks. Suicidality was defined as non-zero MINI scores (broad definition) and a past history of suicide attempt(s) (narrow definition). Clinical features and cognitive performance were compared between those with and those without suicidality, using analysis of variance/chi-square; findings were further explored using linear regression. RESULTS: Suicidality was relatively common (broad definition: 14.8%; narrow definition: 5.3%) in young people and was associated with impaired decision-making on the Cambridge Gamble task (p < 0.05, Bonferroni corrected at the analysis level of each suicidality definition). Linear regression demonstrated that decision-making performance was associated with a significant incremental benefit with respect to predicting suicidality, over and above the utility of demographic and clinical variables considered (p < 0.05 uncorrected). CONCLUSIONS: Impaired decision-making exists in young people with suicidality, and may thereby predispose towards a range of suicidal thoughts and behaviours. Further work is needed to clarify the chain of progression from such thoughts/behaviours, which are relatively common, through to actual suicide, which is not.

White matter abnormalities in skin picking disorder: a diffusion tensor imaging study.

Skin picking disorder (SPD) is characterized by the repetitive and compulsive picking of skin, resulting in tissue damage. Neurocognitive findings in SPD implicate difficulty with response inhibition (suppression of pre-potent motor responses). This function is dependent on the integrity of the right frontal gyrus and the anterior cingulate cortices, and white-matter tracts connecting such neural nodes. It was hypothesized that SPD would be associated with reduced fractional anisotropy in regions implicated in top-down response suppression, particularly white-matter tracts in proximity of the bilateral anterior cingulate and right frontal (especially orbitofrontal and inferior frontal) cortices. 13-subjects meeting proposed SPD criteria for DSM-5 free from other current psychiatric comorbidities, and 12 healthy comparison subjects underwent MRI with a 3-T system. Between-group comparisons of imaging data underwent voxelwise analysis with permutation modeling and cluster correction. Fractional anisotropy (measured using diffusion tensor imaging) was the primary outcome measure. Subjects with SPD exhibited significantly reduced fractional anisotropy in tracts distributed bilaterally, which included the anterior cingulate cortices. Fractional anisotropy did not correlate significantly with SPD disease severity, or depressive or anxiety scores. These findings implicate disorganization of white-matter tracts involved in motor generation and suppression in the pathophysiology of SPD, findings remarkably similar to those previously reported in trichotillomania. This study adds considerable support to the notion that-in addition to the phenomenological and comorbid overlap between SPD and trichotillomania-these disorders likely share overlapping neurobiology.

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.

Memantine reduces stealing behavior and impulsivity in kleptomania: a pilot study.

Kleptomania is characterized by repetitive stealing behavior and has been associated with deleterious unwanted outcomes including forensic contact and increased rates of suicidal behavior. Very few trials have been conducted to investigate pharmacological treatment options for this neglected condition. Memantine is an NMDA-receptor antagonist that has shown promising results in the treatment of other behavioral addictions and substance addictions. Twelve individuals with kleptomania received memantine (10 mg/day, titrated to 30 mg/day maximum depending on clinical response and tolerability) over the course of 8 weeks, in an open-label trial. The effects of treatment were quantified using well-validated measures and select neurocognitive tests (last observation carried forward analyses). Kleptomania disease severity scores decreased across all measures considered, and 11 (91.7%) of the participants met the responder criteria (35% improvement on the primary effectiveness measure plus CGI improved/very much improved; significant improvements were also observed in terms of mood, anxiety, and disability scores along with a significant improvement in stop-signal response inhibition. Memantine was generally well tolerated. This study shows the effectiveness of memantine in reducing urges to shoplift and shoplifting behavior along with improving impulsivity, mood, anxiety, and psychosocial functioning.

Personality dimensions and disorders in pathological gambling.

PURPOSE OF REVIEW: This review presents the most current research in personality dimensions and disorders with respect to pathological gambling. RECENT FINDINGS: Personality dimensions, such as impulsivity and impulsivity-related variables, are important aspects that may shape our understanding of the pathogenesis and treatment of pathological gambling. Furthermore, a large percentage of pathological gamblers have a co-occurring personality disorder which may impact the clinical presentation of pathological gambling. SUMMARY: Evidence suggests that pathological gamblers exhibit impulsivity or impulsivity-related traits, as well as a range of personality disorders. Subtyping pathological gamblers based on personality domains has been proposed; however, more research is needed to provide support for these models. Overall, recent research represents an advancement in our understanding of how personality impacts pathological gambling, but further research is warranted to better understand how personality impacts the clinical presentation and treatment outcomes of pathological gambling.

Skin picking disorder in university students: health correlates and gender differences.

OBJECTIVE: This study sought to examine the prevalence of skin picking disorder (SPD) in a university sample and assess associated physical and mental health correlates. METHODS: A 54-item anonymous, voluntary survey was distributed via random email generation to a sample of 6000 university students. Current psychological and physical status was assessed, along with academic performance. Positive screens for SPD were determined based upon individuals meeting full proposed DSM-V criteria. RESULTS: A total of 1916 participants (31.9%; mean age 22.7 ± 5.1; 58.1% female) responded and were included in the analysis. The overall prevalence of SPD was 4.2% (females=5.8%; males=2.0%). SPD was associated with significantly higher lifetime rates of affective, anxiety, eating, substance use and impulse control disorders. Men with SPD had significantly higher BMI ratings and perceived themselves as significantly less attractive to others while women had significantly higher depressive symptoms. CONCLUSION: SPD is common in both genders and is associated with significant mental and physical health detriments, including higher levels of stress, more psychiatric comorbidity and poorer perceived health. Academic institutions, clinicians and public health officials should be aware of the multimodal presentation of SPD and screen for it in primary care and dermatologic settings.