DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial.

Background and aims Limited treatment options are available for trichotillomania (TTM) and most have modest outcomes. Suboptimal treatment results may be due to the failure of existing approaches to address all TTM styles. Methods Thirty-eight DSM-IV TTM participants were randomly assigned across two study sites to Dialectical Behavior Therapy (DBT) -enhanced cognitive-behavioral treatment (consisting of an 11-week acute treatment and 3-month maintenance treatment) or a minimal attention control (MAC) condition. MAC participants had active treatment after the 11-week control condition. Follow-up study assessments were conducted three and six months after the maintenance period. Results Open trial treatment resulted in significant improvement in TTM severity, emotion regulation (ER) capacity, experiential avoidance, anxiety and depression with changes generally maintained over time. In the randomized controlled trial, those with active treatment had greater improvement than those in the MAC condition for both TTM severity and ER capacity. Correlations between changes in TTM severity and ER capacity were not reported at post-treatment but did occur in maintenance and follow-up indicating reduced TTM severity with improved ER capacity. Conclusions DBT-enhanced cognitive-behavioral treatment is a promising treatment for TTM. Future studies should compare this approach to other credible treatment interventions and investigate the efficacy of this approach in more naturalistic samples with greater comorbidity.

DBT-enhanced habit reversal treatment for trichotillomania: 3-and 6-month follow-up results.

BACKGROUND: Maintenance of gains with cognitive-behavioral treatment for trichotillomania (TTM) has historically been problematic. METHODS: We conducted follow-up assessments 3 and 6 months after completion of a 3-month maintenance phase on 10 individuals with DSM-IV-TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)-enhanced habit reversal treatment (HRT). RESULTS: Significant improvement from baseline was reported at 3-and 6-month follow-up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6-month follow-up, five and four participants were full and partial responders, respectively. Significant correlations were reported at both follow-up time points between changes in hair pulling severity and emotion regulation capacity. CONCLUSIONS: DBT-enhanced HRT offers promise for improved long-term treatment results in TTM. Changes in TTM severity from baseline to 3-and 6-month follow-up is correlated with changes in emotion regulation capacity.

Hoarding among patients seeking treatment for anxiety disorders.

The aim of the present study was to examine the prevalence of hoarding symptoms among individuals presenting for treatment of anxiety symptoms. Participants included 130 adults who were seeking treatment at an outpatient anxiety disorders clinic between January 2004 and February 2006. During their initial assessment, participants (31 with panic disorder, 15 specific phobia, 27 social phobia, 36 obsessive-compulsive disorder, 21 generalized anxiety disorder, mean age 37 years, 57% female, 88% White) completed the Saving Inventory-Revised, a self-report measure of hoarding symptoms, and several measures of anxiety symptoms, depressive symptoms, and functional impairment. Approximately 12-25% of anxious patients reported significant hoarding symptoms. Patients diagnosed with generalized anxiety disorder and obsessive-compulsive disorder were more likely to report significant hoarding symptoms than were those with panic disorder or specific phobia. Hoarding symptoms were positively correlated with trait anxiety, depressive symptoms, and functional impairment. These findings suggest that hoarding symptoms may be associated with anxiety disorders other than obsessive-compulsive disorder. The findings further suggest that hoarding symptoms may be underreported by anxious populations since typical intake assessments do not include specific questions about hoarding and individuals with hoarding symptoms may be unlikely to spontaneously report them.

Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania.

BACKGROUND: Not all hair pullers improve acutely with cognitive-behavioral treatment (CBT) and few maintain their gains over time. METHODS: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM-IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)-enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self-report measures of hair pulling severity and emotion regulation. RESULTS: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. CONCLUSIONS: This study offers preliminary evidence for the efficacy of DBT-enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment.

Course of compulsive hoarding and its relationship to life events.

BACKGROUND: Compulsive hoarding is a common and debilitating, yet poorly understood, condition characterized by excessive acquisition of and failure to discard a large number of objects, resulting in cluttered and often hazardous living conditions. The aim of this study was to examine the onset and course of compulsive hoarding, and the relationships between stressful or traumatic life events and course of illness. METHODS: Seven hundred fifty-one adults with self-reported hoarding symptoms completed an online survey regarding the severity of hoarding behavior over the lifespan and the incidence of stressful or traumatic life events. RESULTS: Median age of onset was between 11 and 15 years, with most respondents reporting symptom onset before age 20. Late-onset (e.g., after age 40) hoarding was rare. Most respondents described a chronic course of illness, with a significant minority describing an increasing or relapsing/remitting course. Stressful and traumatic events were common in this sample; changes in relationships and interpersonal violence were disproportionately associated temporally with periods of symptom onset or exacerbation. CONCLUSIONS: These results highlight the chronic nature of compulsive hoarding, its associated public health burden, and the potential impact of life stressors on symptom development. Directions for further research are discussed.

Efficacy of d-cycloserine for enhancing response to cognitive-behavior therapy for panic disorder.

BACKGROUND: Traditional combination strategies of cognitive-behavior therapy plus pharmacotherapy have met with disappointing results for anxiety disorders. Enhancement of cognitive-behavior therapy with d-cycloserine (DCS) pharmacotherapy represents a novel strategy for improving therapeutic learning from cognitive-behavior therapy that remains untested in panic disorder. METHOD: This is a randomized, double-blind, placebo-controlled augmentation trial examining the addition of isolated doses of 50 mg d-cycloserine or pill placebo to brief exposure-based cognitive-behavior therapy. Randomized participants were 31 outpatients meeting DSM-IV criteria for panic disorder with or without agoraphobia, who were offered five sessions of manualized cognitive-behavior therapy emphasizing exposure to feared internal sensations (interoceptive exposure) but also including informational, cognitive, and situational exposure interventions. Doses of study drug were administered 1 hour before cognitive-behavior therapy sessions 3 to 5. The primary outcome measures were the Panic Disorder Severity Scale (PDSS) and Clinicians' Global Impressions of Severity. RESULTS: Results indicated large effect sizes for the additive benefit of d-cycloserine augmentation of cognitive-behavior therapy for panic disorder. At posttreatment and 1 month follow-up, participants who received d-cycloserine versus placebo had better outcomes on the PDSS and global severity of disorder and were significantly more likely to have achieved clinically significant change status (77% vs. 33%). There were no significant adverse effects associated with DCS administration. CONCLUSIONS: This pilot study extends support for the role of d-cycloserine in enhancing therapeutic learning from exposure-based cognitive-behavior therapy and is the first to do so in a protocol emphasizing exposure to feared internal sensations of anxiety in panic disorder.

Assessment of anxiety in older home care recipients.

PURPOSE: This study determined the psychometric properties of a variety of anxiety measures administered to older adults receiving home care services. DESIGN AND METHODS: Data were collected from 66 adults aged 65 years and older who were receiving home care services. Participants completed self-report and clinician-rated measures of anxiety and diagnostic interviews for generalized anxiety disorder (GAD). RESULTS: Most measures demonstrated acceptable psychometric properties. All of the measures showed excellent interrater reliability to support verbal administration, which is the typical mode of assessment in home care. The ease of use for each measure (e.g., time of administration) was also evaluated. The Geriatric Anxiety Inventory (GAI) demonstrated the strongest and the Beck Anxiety Inventory the weakest psychometric properties. The GAI and the GAD screening questions from The Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) demonstrated the greatest utility in screening for anxiety disorders (either GAD or anxiety disorder not otherwise specified). IMPLICATIONS: These data support the use of anxiety measures within a geriatric home care setting. The strengths and weaknesses of each measure are discussed to facilitate selection of the optimal measure depending upon assessment goals and available resources.

Affective and sensory correlates of hair pulling in pediatric trichotillomania.

Hair pulling in pediatric populations has not received adequate empirical study. Investigations of the affective and sensory states contributing to the etiology and maintenance of hair pulling may help to elucidate the classification of trichotillomania (TTM) as an impulse control disorder or obsessive-compulsive spectrum disorder. The current study aimed to examine children's self-reported affective and sensory states associated with hair pulling. Fifteen participants completed a questionnaire assessing children's experiences during first and recent hair pulling episodes. Results revealed that pulling hair for the first time was associated with pleasure and pain whereas recent hair pulling was associated with pleasure only, suggesting that the punishing quality of hair pulling may diminish over time. The findings also support the notion that hair pulling may be maintained primarily through positive reinforcement, which is consistent with its classification as an impulse control disorder.

Extending cognitive-behavioral therapy for late-life anxiety to home care: program development and case examples.

Data suggesting that cognitive-behavioral therapy (CBT) is efficacious for late-life anxiety are accumulating; however, effectiveness has not been well established. Incorporating CBT for anxiety into home care is needed to facilitate access to evidenced-based treatment for a growing population of community-dwelling, functionally impaired elderly people. In this article, the authors describe the development of a home-based CBT program for late-life anxiety, outlining their experience partnering with a community care management organization. They also describe the CBT protocol and present data form two participants who completed the treatment. The two case examples illustrate multiple barriers to achieving successful treatment outcomes with this population. Future research needs to determine the extent to which adaptations are necessary to optimize the success of CBT for anxiety in a home care setting.

Augmentation of behavior therapy with D-cycloserine for obsessive-compulsive disorder.

OBJECTIVE: This study examined whether d-cycloserine, a partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor, enhances the efficacy of behavior therapy for obsessive-compulsive disorder (OCD). METHOD: A randomized, double-blind, placebo-controlled trial investigating D-cycloserine versus placebo augmentation of behavior therapy was conducted in 23 OCD patients. Patients first underwent a diagnostic interview and pretreatment evaluation, followed by a psychoeducational/treatment planning session. Then they received 10 behavior therapy sessions. Treatment sessions were conducted twice per week. One hour before each of the behavior therapy sessions, the participants received either D-cycloserine, 100 mg, or a placebo. RESULTS: Relative to the placebo group, the D-cycloserine group's OCD symptoms were significantly more improved at mid-treatment, and the D-cycloserine group's depressive symptoms were significantly more improved at posttreatment. CONCLUSIONS: These data provide support for the use of D-cycloserine as an augmentation of behavior therapy for OCD and extend findings in animals and other human disorders suggesting that behavior therapy acts by way of long-term potentiation of glutamatergic pathways and that the effects of behavior therapy are potentiated by an NMDA agonist.

Emotion regulation and trichotillomania: a comparison of clinical and nonclinical hair pulling.

This study investigated the emotion regulation hypothesis of trichotillomania (TTM) using a retrospective self-report measure and an experimental hair-pulling task. Participants diagnosed with TTM (n=34) and nonclinical control (NC) volunteers (n=32) were compared on ratings of emotional experiences associated with hair pulling. Data from the retrospective self-report measure supported the emotion regulation hypothesis of TTM. The TTM group reported larger decreases than the NC participants in boredom, sadness, anger, and tension, and larger increases in relief and calm from before to during pulling. The TTM group also reported significantly higher ratings of pleasure while pulling. When exploring changes in emotions from during to after pulling, the TTM group reported larger increases than the NC participants in guilt, sadness, and anger; and larger decreases in boredom; while the NC group reported larger increases than the TTM group in happiness, calm, and relief. On the experimental hair-pulling task, the TTM group reported larger decreases in anxiety from before to after pulling, but this effect was only found for a nontypical hair-pulling site. Methodological limitations may account for the lack of group differences on the experimental hair-pulling task.

Structural differentiation of disgust from trait anxiety in the prediction of specific anxiety disorder symptoms.

Research has begun to implicate the role of disgust in the etiology of specific phobias and obsessive-compulsive disorder (OCD). However, it remains unclear if the association between disgust and specific anxiety disorder symptoms is an artifact of trait anxiety or a potential mechanism through which trait anxiety effects specific anxiety disorder symptoms. The present study employed structural equation modeling to differentiate disgust from trait anxiety in the prediction of four types of specific anxiety disorder symptoms in a non-clinical sample (N=352). Results indicate that disgust and trait anxiety latent factors were independently related to spider fears, blood-injection-injury (BII) fears, general OCD symptoms, and OCD washing concerns. However, when both variables were simultaneously modeled as predictors, latent disgust remained significantly associated with the anxiety disorder symptoms, whereas the association between latent trait anxiety and the anxiety disorder symptoms became non-significant or was substantially reduced. Statistical tests of intervening variable effects converged in support of disgust as a significant intervening variable between trait anxiety and spider fears, BII fears, and OCD symptoms (particularly washing concerns). The relevance of these findings for future research investigating the role of disgust in specific anxiety disorders is discussed.

Pediatric trichotillomania: descriptive psychopathology and an open trial of cognitive behavioral therapy.

In study 1, 46 children and adolescents with trichotillomania who sought treatment at 2 specialty outpatient clinics were assessed. Most children reported pulling hair from multiple sites on the body, presented with readily visible alopecia, reported spending 30-60 minutes per day pulling or thinking about pulling, and reported experiencing significant distress about their symptoms. Most were described by their parents as having significant problems in school functioning. Few children met criteria for obsessive-compulsive disorder or tic disorder. Child and family rates of other forms of psychopathology were high. In study 2, 22 of these children were enrolled in an open trial of individual cognitive behavioral therapy with particular attention to relapse prevention. Trichotillomania severity decreased significantly and 77% of children were classified as treatment responders at post-treatment and 64% at 6-month follow-up.

The Anxiety Sensitivity Profile revisited: factor structure and psychometric properties in two nonclinical samples.

Anxiety sensitivity (AS) refers to the fear of anxiety-related symptoms based upon the belief that the sensations have harmful consequences. Although the most popular existing measure is the Anxiety Sensitivity Index (ASI), the Anxiety Sensitivity Profile (ASP) was developed as an alternative and theoretically improved assessment of the multifaceted nature of the AS construct. Nevertheless, there has been a paucity of research on this measure. We evaluated the psychometric properties and factor structure of the ASP in two large, geographically diverse undergraduate samples who completed the ASP and measures of anxiety and depression. Exploratory factor analysis revealed four lower order ASP factors in both samples: (1) fear of arousal-related symptoms, (2) fear of cognitive dyscontrol and dissociation, (3) fear of gastrointestinal symptoms, and (4) fear of cardiac symptoms. The fear of cardiac symptoms factor was relatively unstable in both studies. Correlations between the ASP factors and related variables were consistent with AS theory. The strengths and limitations of the ASP are offered as well as the implications of our findings for the nature and assessment of AS.

Hypnotic enhancement of cognitive-behavioral interventions for pain: an analogue treatment study.

Recent meta-analyses have shown that adding hypnosis enhances the effectiveness of cognitive-behavioral psychotherapy. This hypnotic enhancement effect was evaluated in the analogue treatment of pain. Individuals scoring in the high (n = 135) and low (n = 150) ranges of hypnotic suggestibility were randomly assigned to 1 of 6 conditions: Stress Inoculation Training, the same treatment provided hypnotically, nonhypnotic analgesia suggestions, hypnotic analgesia suggestions, a hypnotic induction treatment, or a control condition. The 5 analogue treatments reduced experimental pain more than the control condition, but were not different from one another. Under circumstances optimized to detect an enhancement effect, neither Stress Inoculation Training nor analgesia suggestions produced more relief when delivered in a hypnotic context than identical treatments provided nonhypnotically.

Fear, disgust, and information processing in specific phobia: the application of signal detection theory.

A growing body of research suggests that individuals with small animal and blood-injection-injury (BII) phobias respond to phobia-relevant stimuli with a combination of fear and disgust. Despite the recognition that disgust may serve a functional role in phobic avoidance behavior, little is known about biased information processing for disgust-related material. Two studies examined recognition memory, using signal detection analyses, for phobia-relevant and general disgust pictures. Study I failed to find differences between spider phobics, BII phobics, and nonphobics in discrimination ability (d') and response bias (c) for spider, surgical, and two categories of general disgust pictures. Results indicated that all participants responded in a liberal manner toward surgical and disgust pictures, whereas they responded more conservatively when judging spider pictures. Study 2 also failed to find differences between BII phobics and nonphobics in discrimination ability and response bias for surgical and disgust pictures presented at 500 and 50 ms exposure durations. All participants again adopted a liberal response bias toward surgical and disgust pictures, although only under the 500 ms stimulus presentation condition. These results do not suggest the presence of preferential information processing of phobia-relevant or general disgust elicitors among phobic participants. The functional value of disgust-mediated information processing biases is questioned given the available literature. Implications and suggestions for continued information processing research for fearful and disgusting stimuli in specific phobia are outlined.

Emotional responding to fearful and disgusting stimuli in specific phobics.

Individuals with small animal and blood-injection-injury (BII) phobias respond to phobia-relevant stimuli with both fear and disgust. However, recent studies suggest that fear is the dominant emotional response in animal phobics whereas disgust is the primary emotional response in BII phobics. The present study examined emotional responding toward pictures of spiders, surgical procedures, and two categories of general disgust elicitors (rotting food and body products) among analogue spider phobics, BII phobics, and nonphobics. Dominant emotional responses to phobia-relevant stimuli clearly differentiated the groups. as spider phobics were more likely to be classified as primarily fearful when rating pictures of spiders (74%), whereas BII phobics were more likely to be classified as primarily disgusted when rating pictures of surgical procedures (78%). Discriminant function analyses revealed that disgust ratings, but not fear ratings, of the phobic pictures were significant predictors of phobic group membership. Both phobic groups were characterized by elevated disgust sensitivity toward video and pictorial general disgust elicitors. Implications and suggestions for continued research examining fearful and disgusting stimuli in specific phobia are outlined.