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AIMS: Cognitive-behavioral therapy (CBT) is useful for treating substance abusers, and recent data suggest it is also efficacious for pathological gamblers. CBT is purported to exert its beneficial effects by altering coping skills, but data supporting coping changes as the mechanism of action are mixed. This study examined whether coping skills acquisition mediated the effects of CBT on decreasing gambling in pathological gamblers. DESIGN: Participants were assigned randomly to CBT plus referral to Gamblers Anonymous (GA) or to GA referral alone. Setting Out-patient clinic. PARTICIPANTS: A total of 127 pathological gamblers. MEASUREMENTS: Participants completed the Coping Strategies Scale (CSS) before treatment and 2 months later; indices of gambling behavior and problems were administered pretreatment and at months 2 and 12. FINDINGS: Overall, CSS scores increased for participants in both conditions, but those receiving CBT evidenced larger increases than those in the GA condition (P < 0.05), and they also reduced gambling more substantially between pretreatment and month 2. Changes in CSS scores mediated the relationship between treatment assignment and gambling outcomes from pretreatment to month 2, but little evidence of mediation occurred for the long-term follow-ups. CONCLUSIONS: CBT's beneficial effects in decreasing gambling may be related partly to changes in coping responses, and improvements in coping are associated with long-term changes in gambling. However, relationships between coping skills and gambling behavior are fairly strong, regardless of treatment received. [ABSTRACT FROM AUTHOR]

Few studies have evaluated efficacy of psychotherapies for pathological gambling. Pathological gamblers (N = 231) were randomly assigned to (a) referral to Gamblers Anonymous (GA), (b) GA referral plus a cognitive- behavioral (CB) workbook, or (c) GA referral plus 8 sessions of individual CB therapy. Gambling and related problems were assessed at baseline, 1 month later, posttreatment, and at 6- and 12-month follow-ups. CB treatment reduced gambling relative to GA referral alone during the treatment period and resulted in clinically significant improvements, with some effects maintained throughout follow-up ( ps = .05). Individual CB therapy improved some outcomes compared with the CB workbook. Attendance at GA and number of CB therapy sessions or workbook exercises completed were associated with gambling abstinence. These data suggest the efficacy of this CB therapy approach., (Copyright 2006 APA, all rights reserved.)

Aims: Recent findings regarding the prevalence of marijuana dependence and associated consequences indicate the need for empirically validated treatments for this population. The Marijuana Treatment Project (MTP) was a multi-site study of two treatments for adults with marijuana dependence., Design: Participants (N= 450) were randomly assigned to one of three conditions at each of three sites: 1) a 9-session cognitive behavioral treatment (CBT) with motivational enhancement therapy (MET) and case management (CM) components; 2) a 2-session MET intervention; or 3) a delayed treatment control (DTC)., Setting: The study was conducted in outpatient drug treatment clinics in three U.S. cities., Participants: Participants were individuals aged 18 or over who met diagnostic criteria for cannabis dependence and who voluntarily presented for treatment., Measurement: Study variables included DSM-IV dependence criteria, timeline follow-back assessment of drug use, Addiction Severity Index composite scores, and problems related to marijuana use., Findings: Participants were daily users, who smoked marijuana multiple times per day, and had been doing so for more than 15 years. They reported multiple dependence symptoms and negative consequences related to marijuana use. Approximately 32% of the sample was female, and 30% of the sample was either Hispanic (17%), African American (12%), or of mixed racial backgrounds (1%)., Conclusions: The multi-site nature of the MTP allowed for the recruitment of a more ethnically and gender diverse sample than had been studied previously but there were few differences in the clinical characteristics of participants at the geographically and sociodemographically diverse study sites.

Accumulating evidence suggests that psychosocial treatment for cannabis dependence is effective. Earlier investigations were well designed and sought to evaluate efficacy of manual-guided therapies with particular attention to protecting the independent variable. The Marijuana Treatment Project (MTP) represents an effort to build upon previous knowledge about cannabis dependence treatment through an evaluation of an integrative therapy, which was meant to allow for greater therapist latitude in its delivery, and to be more responsive to a potentially more diverse population of clients. The treatment intervention developed for delivery in the Marijuana Treatment Project (MTP) reflects an effort to find a true compromise between the needs of the scientific community to have clearly specified and measurable treatments, and the realities of the treatment community, which demand flexibility, appreciation of the multi-determined nature of most problems, and individualized approaches. This paper will describe the clinical interventions used with the MTP participants, the theoretical rationale guiding their design and practical aspects related to implementation and treatment response.

Context: Cognitive impairments are associated with long-term cannabis use, but the parameters of use that contribute to impairments and the nature and endurance of cognitive dysfunction remain uncertain., Objective: To examine the effects of duration of cannabis use on specific areas of cognitive functioning among users seeking treatment for cannabis dependence., Design, Setting, and Participants: Multisite retrospective cross-sectional neuropsychological study conducted in the United States (Seattle, Wash; Farmington, Conn; and Miami, Fla) between 1997 and 2000 among 102 near-daily cannabis users (51 long-term users: mean, 23.9 years of use; 51 shorter-term users: mean, 10.2 years of use) compared with 33 nonuser controls., Main Outcome Measures: Measures from 9 standard neuropsychological tests that assessed attention, memory, and executive functioning, and were administered prior to entry to a treatment program and following a median 17-hour abstinence., Results: Long-term cannabis users performed significantly less well than shorter-term users and controls on tests of memory and attention. On the Rey Auditory Verbal Learning Test, long-term users recalled significantly fewer words than either shorter-term users (P =.001) or controls (P =.005); there was no difference between shorter-term users and controls. Long-term users showed impaired learning (P =.007), retention (P =.003), and retrieval (P =.002) compared with controls. Both user groups performed poorly on a time estimation task (P<.001 vs controls). Performance measures often correlated significantly with the duration of cannabis use, being worse with increasing years of use, but were unrelated to withdrawal symptoms and persisted after controlling for recent cannabis use and other drug use., Conclusions: These results confirm that long-term heavy cannabis users show impairments in memory and attention that endure beyond the period of intoxication and worsen with increasing years of regular cannabis use.

Treatment and follow-up session attendance data from Project MATCH, a multisite clinical trial investigating patient-treatment matching, were analyzed to study compliance. High rates of compliance to both therapy and research protocols were achieved, enhancing treatment integrity and data quality. Strong baseline predictors of compliance did not emerge, and the small relationships found were consistent with reports from previous studies. Attendance at therapy sessions was moderately correlated with research follow-up participation. Treatment compliance predicted drinking outcome, underscoring the importance of retaining patients in treatment. Future studies should examine the associations between compliance and structural features of the treatment environment, treatment delivery, and context-features that are often under the control of the clinician/investigator.

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.

The Relapse Replication and Extension Project (RREP) has failed to provide empirical support for Marlatt's relapse taxonomy. Neither the reliability of the original Marlatt coding system nor its predictive or construct validity was supported by this group of studies. The present commentary explores a number of possible reasons for the generally negative outcomes. These findings should certainly lead to a re-evaluation of Marlatt's relapse taxonomy and its operationalization. Nevertheless, despite the negative results, there are a number of reasons why the general Relapse Prevention concept is likely to survive in some form: it has been widely adopted and imitated clinically, key elements of the taxonomy are often focal points of treatment, and clinical research studies have repeatedly supported some elements of the taxonomy (e.g. negative emotional states, social pressure, interpersonal conflict, positive emotional states and temptations/urges). The RREP also evaluated some modifications of the original taxonomy as well as the use of more structured assessment instruments, and some of these provided more promising results. Further developments will need to take into account both research needs for greater precision, most likely through the use of more structured assessment instruments, and clinical needs for richness of detail and sensitivity to a wide variety of life circumstances.

Structured or semi-structured interviews, including the Structured Clinical Interview for DSM-III-R (SCID), are used widely to maximize the reliability and validity of psychiatric diagnoses. Although the reliability of such interviews appears adequate, there has been little effort to evaluate their validity. In a sample of 100 substance abuse patients, we evaluated the concurrent, discriminant and predictive validity of SCID substance use diagnoses, as well as co-morbid disorders that occur commonly among these patients. The validity of current and life-time substance use diagnoses obtained by a research technician using the SCID was good; it was moderate for antisocial personality disorder and major depression and poor for anxiety disorders. Although accurate diagnosis of substance use disorders in substance abuse patients can be accomplished by a research technician, the diagnosis of co-morbid psychiatric disorders requires either additional expertise or the use of a diagnostic instrument specially designed for that purpose.

Although structured diagnostic interviews are increasingly being used in substance abuse treatment settings, there has been limited systematic evaluation of their ability to enhance reliability and validity of psychiatric diagnoses. The present report provides data on the concurrent, discriminant, and predictive validity of current substance use disorders and common comorbid diagnoses in a sample of 100 substance abuse patients. Diagnoses formulated primarily by master's-level clinicians in the usual course of their duties were compared with diagnoses formulated by research technicians using a semistructured interview. Results indicated that the validity of clinician diagnoses was good for substance use disorders, moderate for personality disorders, and poor for anxiety disorders and major depression. Greater validity was observed for substance abuse diagnoses formulated by research technicians using the semistructured interview. Based on these findings, we conclude that psychiatric diagnosis in substance abuse patients may be improved by adding elements of structured interviews to the clinician's usual assessment.

This report presents results of a field trial of Substance Use Disorders as defined by DSM-III-R, DSM-IV (proposed) and ICD-10. Diagnoses based on the three systems were derived from interviews using the Composite International Diagnostic Interview (CIDI) in a heterogeneous sample of 521 adults drawn from clinical and community settings. Two issues are addressed: (1) cross system agreement; and (2) syndrome coherence of proposed criterion sets for Substance Dependence in each of the three systems. Findings were as follows: (1) Cross system agreement for Dependence was generally high, especially between DSM-III-R and DSM-IV. (2) Cross system agreement was lower for DSM-III-R and DSM-IV Abuse and very low for DSM-IV Abuse and ICD-10 Harmful Use. (3) Agreement varied across drug categories with lowest DSM-III-R/DSM-IV agreement for alcohol abuse and DSM-IV/ICD-10 agreement for marijuana use disorders. (4) Overall prevalence differed for the three systems with DSM-IV yielding highest rates followed by DSM-III-R and ICD-10 in that order. (5) Factor analysis of Dependence criteria showed high loadings of all items on a single factor across the three diagnostic systems and for all categories of drugs. Implications for validity of the dependence syndrome construct and for revisions in DSM-IV are discussed.

Data from 79 male alcoholics who were randomly assigned to either coping skills training or interactional group psychotherapy were used to replicate a multidimensional, empirically derived typology and to evaluate the typology's usefulness in matching patients to treatment. Consistent with previous cluster analysis research, indicators of risk for alcoholism, alcohol dependence, drinking history, and psychopathological impairment distinguished alcoholics along two broad dimensions of vulnerability and severity, with one subtype (type B alcoholics) manifesting an earlier onset of problem drinking, more familial alcoholism, greater dependence on alcohol, and more symptoms of antisocial personality than the other subtype (type A alcoholics). Analyses of outcome indicated that type A alcoholics fared better in interactional treatment and more poorly with coping skills training. Conversely, type B alcoholics had better outcomes with the coping skills treatment and worse outcomes with interactional therapy. Differences in treatment response were maintained for 2 years from the beginning of aftercare treatment.

An instrument designed to measure components of two distinct alcoholism aftercare treatments was developed and evaluated for reliability and validity. Trained judges reliably rated audiotaped samples of coping skills and interactional group therapy sessions. Coping skills groups engaged in significantly more education and skill training, problem solving, and role playing. Interactional groups showed more interpersonal learning, expression/exploration of feelings, and here-and-now focus. Groups that employed more education and skill training, less expression and exploration of feelings, and less here-and-now focus were associated with fewer members reporting subsequent drinking-related problems. None of the ratings of group activities was related to abstinence.

This article describes a multidisciplinary team approach to the treatment of alcohol and drug dependence and comorbid disorders. The principal aim of this approach is the identification and treatment of patients' chemical dependence, as well as the medical and psychiatric disorders that contribute to and/or stem from the chronic use of alcohol and drugs. The focus of treatment is on the identification of high risk and other problem situations, training coping skills to handle these situations, developing insight, and enhancing patients' motivation for sobriety and ongoing treatment. In this article we describe the features of our program that address these various goals.

Ninety-six subjects were recruited from an inpatient alcoholism treatment program and randomly assigned to aftercare group treatment with either coping skills training or interactional therapy. Survival analyses using 2-year outcome data provided evidence for the durability of matching interaction effects. The data supported a priori hypotheses that individuals scoring high on measures of sociopathy or global psychopathology have better outcomes in coping skills treatment, whereas patients low on these dimensions have better outcomes in interactional treatment. Contrary to the original hypothesis, patients with cognitive impairment had better outcomes in interactional treatment, and patients without cognitive impairment did better in coping skills treatment.

The ability of the Cognitive Status Examination (CSE), a brief neuropsychological screening instrument, to detect cognitive impairment in substance abusing patients was evaluated in 200 consecutive admissions to a drug/alcohol rehabilitation unit. While a significant proportion (25%) of patients screened were classified as impaired using the cutoff derived in the original study, agreement with an independent neurological impairment classification was much lower than that reported in the earlier work. Possible reasons for this discrepancy are discussed, including the relatively subtle nature of cognitive impairment in substance abusing patients. Implementation of regular screening did seem to heighten staff sensitivity to cognitive impairment in this sample. Alternate methods of determining the usefulness of cognitive screening tools (e.g., relationship to treatment relevant skills) are also discussed.

A contingency management system is described for enhancing participation in an inpatient chemical dependency rehabilitation program. The system employs reinforcers that are readily available in a residential milieu and makes receipt of them contingent upon appropriate patient behaviors. The behaviors include arranging aftercare treatment, involving family members in the treatment process, appropriate participation in ongoing treatment activities, and assisting with unit chores. A patient's status within the program is first regulated on a noncontingent basis, after which an accumulation of nine specified accomplishments results in the acquisition of a number of privileges. Accumulation of three demerits, given for inappropriate behaviors, results in a status reduction that can only be restored by completing ten additional behaviors. Improvement in patients' program involvement was documented in a number of areas, with a concomitant reduction in resistance to treatment. The system also resulted in an improvement in staff's charting of patients' behavior.

It has been theorized that respondent conditioning processes in part underlie desire for alcohol and thus contribute to relapse after alcoholism treatment. One implication of this theory is that the relevant conditioned responses could be eliminated by respondent extinction, in which the alcoholic patient is exposed to alcohol-related stimuli while being prevented from consuming alcohol. However, exteroceptive cues such as the sight and smell of alcoholic beverages are not always sufficient to elicit desire for alcohol. In view of this, it has been suggested that interoceptive cues, such as mood states, may also play a role in eliciting desire for alcohol. To test this, eight alcoholic subjects were induced to experience negative or neutral moods on four separate days, and then exposed to the sight and smell of their favorite alcoholic drink, and to a neutral stimulus (seltzer water), in a within-subjects design. Results from this work indicate that: (a) negative moods can be reliably induced in the laboratory as confirmed by subjects' reports; (b) exposure to alcohol cues had no effect on desire for alcohol while subjects were in a relaxed, neutral mood state; (c) the presence of negative mood states alone appeared to be sufficient to elicit desire for alcohol in some subjects, regardless of whether alcohol or water was presented. These data argue that negative mood states may cue desire for alcohol independent of other cues. The data also suggest that reactivity to alcohol cues may be substantially reduced by relaxation.

Heart rate, systolic and diastolic blood pressures were recorded during classical delay conditioning of rhesus macaque monkeys. When portions of the autonomic nervous system were selectively blocked by pharmacological agents, it appeared that the initial increases in heart rate and blood pressures in response to the conditioned stimulus were the result of increased sympathetic activity and a concomitant decrease in parasympathetic activity. Towards the end of the conditioned stimulus, an increase in parasympathetic activity was indicated. Blockade of the autonomic system which produced total elimination of the conditioned cardiac rate response and substantial reduction or elimination of the conditioned blood pressure response, was not necessarily or always accompanied by a corresponding elimination of the respective unconditioned responses. Such a finding suggests a different underlying neural mediation of these conditioned and unconditioned responses.

Classical delay conditioning of heart rate, and of systolic and diastolic blood pressures, was carried out in 16 rhesus monkeys. Blood pressure and inter-systolic interval were measured from an in-dwelling arterial catheter; recordings were taken prior to conditioned stimulus (CS) on each trial, during a 20 sec visual stimulus that filled the conditioned-unconditioned stimulus (CS-UCS) interval, and following UCS (a brief electric tail-shock). The heart rate response both to CS and to UCS was biphasic (acceleration followed by deceleration); the blood pressure response functions were more complex, and were different for the CS and post-UCS periods. Comparison of the patterns of cardiac and blood pressure responses on any trial indicates a possible sequence of baroreceptor reflex activity.

This experiment extends Pavlov's method of contrasts for training a stimulus discrimination to the case of the cardiac conditional response in the rhesus monkey. It explores the parameter of temporal placement of an additional stimulus ("CS2") within a 10-sec CS (or "CS1"), with the appearance of the former stimulus on any trial signalling the absence of UCS (electric shock) on that trial. This experimental paradigm is a parallel to that of the "intruded stimulus" studies in operant conditioning. In both cases, several ways of describing the function of the added stimulus are possible, but all seem reducible to the same operational terms. Data were taken in the present study with respect to the form and latency of the cardiac rate changes produced by intrusion of CS2 (light), across a range of placements varying from simultaneity with CS1 (a different light) onset to two sec before UCS would have been delivered. The control of CS2 over the cardiac rate CR was occasionally exhibited with a latency as short as three beats after stimulus onset. The order of CS2 temporal placements to which a subject was exposed was a factor in determining the form of the conditioned cardiac rate response to CS1.

The functional relationship between heart rate, under atrial pacing, and the intensity of pacing pulses, was determined for intensities ranging from well below the complete heart rate capture threshold to suprathreshold intensities. A separate capture-intensity function was determined for each of the pacing frequencies 180, 240, 300 and 360 pulses per min, and then used to evaluate the effects of propranolol hydrochloride and atropine sulfate on atrial pacing. Propranolol resulted in an increase in the amount of current (mA) required to achieve a given degree of cardiac capture, whereas atropine resulted in a decrease. These shifts in the capture-intensity functions along the intensity axis were possibly caused by drug antagonism of beta-adrenergic and cholinergic receptors, respectively, although the effects might also have been due to modifications of the electrical responsivity of the cardiac muscle, independently of the neural blockade.

This study tested the hypothesis that patients could be matched to effective treatments on the basis of certain pretreatment characteristics. Specifically, it was hypothesized that those Ss who showed more sociopathy, more psychopathology, and greater neuropsychological impairment would have better outcomes when treated with coping skills training and, conversely, that those with less impairment in these areas would have better outcomes with interactional treatment. Ninety-six male and female Ss were recruited from an inpatient alcoholism treatment program and randomly assigned to 1 of these 2 types of aftercare group treatment. Linear and logistic regression analyses partially confirmed the hypotheses. Coping skills training was more effective for Ss higher in sociopathy or psychopathology, and interactional therapy was more effective for Ss lower in sociopathy. Generally, both treatments appeared equally effective for Ss lower in psychopathology. Contrary to expectations, those more neuropsychologically impaired appeared to have better outcomes after interactional therapy.

Heart rates of 5 rhesus monkeys (Macaca mulatta) were monitored during classical conditioning trials consisting of a visual conditioned stimulus followed after 10 sec by an electric shock to the tail. Heart rates typically increased at the onset of the visual stimulus, and returned to baseline before shock delivery. Autonomic blocking agents were subsequently administered; their effects on resting heart rates, and on acceleratory and deceleratory phases of the biphasic conditioned heart rate responses were examined, both in the raw data, and with a statistical regression technique. Beta-adrenergic blockade by propranolol lowered resting heart rates and was found, after regression analysis, to reduce the heart rate increase phase, and to weakly enhance the subsequent heart rate decrease phase of the conditioned response. Vagal blockade by atropine sulfate elevated resting heart rate, and markedly reduced both acceleratory and deceleratory heart rate phases of the conditioned responses. Ganglionic blockade by chlorisondamine also elevated resting heart rates (less than atropine), and almost completely eliminated conditioned heart rate changes. Several sources of evidence suggest a predominant vagal tone over resting heart rates, as well as mostly vagal mediation (with some sympathetic contribution) of the biphasic conditioned rate response.

This paper examines definitions of alcoholism from theoretical and historical points of view. It begins with a review of definitions of alcoholism from the 19th century to the present, giving particular attention to medical approaches, psychiatric formulations, behavioral concepts, and definitions proposed by the American Psychiatric Association and the World Health Organization. It is concluded that current definitions differ widely in scope, the meanings attached to words like disease and disorder, the criteria for including signs and symptoms as essential characteristics, and the potential uses of the definitions. Based on these considerations, the practical issues of developing and applying clinically useful diagnostic procedures are discussed. The paper concludes with a discussion of diagnostic issues that should be considered in any effort to improve clinical identification, treatment planning and international communication.