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Cognitive reappraisal is associated with reduced emotional distress; however, little is known about the nature of this relationship in autism. This study tested whether autistic traits moderate reappraisal success (i.e., the negative correlation between reappraisal use and emotional symptom severity). Emotional symptoms were assessed using measures of depression, anxiety, and stress. It was hypothesized that more severe autistic traits would be associated with "weaker" reappraisal success across all scales. Data were collected from 377 adults using an on-line survey. Structural equation models found moderation effects for depression and anxiety, but not stress. Contrary to hypotheses, more severe autistic traits were associated with "stronger" reappraisal success. These preliminary results support including reappraisal in emotion regulation treatments for individuals with autistic traits.

The goal of this study was to compare brain structure between individuals with generalized anxiety disorder (GAD) and healthy controls. Previous studies have generated inconsistent findings, possibly due to small sample sizes, or clinical/analytic heterogeneity. To address these concerns, we combined data from 28 research sites worldwide through the ENIGMA-Anxiety Working Group, using a single, pre-registered mega-analysis. Structural magnetic resonance imaging data from children and adults (5-90 years) were processed using FreeSurfer. The main analysis included the regional and vertex-wise cortical thickness, cortical surface area, and subcortical volume as dependent variables, and GAD, age, age-squared, sex, and their interactions as independent variables. Nuisance variables included IQ, years of education, medication use, comorbidities, and global brain measures. The main analysis (1020 individuals with GAD and 2999 healthy controls) included random slopes per site and random intercepts per scanner. A secondary analysis (1112 individuals with GAD and 3282 healthy controls) included fixed slopes and random intercepts per scanner with the same variables. The main analysis showed no effect of GAD on brain structure, nor interactions involving GAD, age, or sex. The secondary analysis showed increased volume in the right ventral diencephalon in male individuals with GAD compared to male healthy controls, whereas female individuals with GAD did not differ from female healthy controls. This mega-analysis combining worldwide data showed that differences in brain structure related to GAD are small, possibly reflecting heterogeneity or those structural alterations are not a major component of its pathophysiology.

Introduction: Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts. Methods: Study 1 included 213 adult inpatients (n = 127 with substance use disorder [SUD]), who completed assessments of suicide attempt history as well as demographic and clinical suicide risk factors. Study 2 was a narrative analysis of suicide attempt stories described by 20 inpatients diagnosed with SUD. Results: In Study 1, patients with co‐occurring alcohol and drug use disorders reported more actual lifetime suicide attempts than did those without SUD. In addition, alcohol and drug use disorders were independently associated with lifetime suicide attempts after controlling for demographic and clinical confounders. In Study 2, substance use played a role in all suicide attempts through at least one pathway before, during, or after a triggering stressor, or as suicide attempt method. Conclusions: Substances play a role in suicide attempt baseline risk, acute risk and as means. It is important to target chronic and acute substance use in suicide prevention treatment plans. [ABSTRACT FROM AUTHOR]

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.

Trichotillomania (TTM) is a chronic impulse control disorder characterized by repetitive hair-pulling resulting in alopecia. Although this condition is frequently observed in children and adolescents, research on pediatric TTM has been hampered by the absence of validated measures. The aim of the present study was to develop and test a new self-report measure of pediatric TTM, the "Trichotillomania Scale for Children" (TSC), a measure that can be completed by children and/or their parents. One hundred thirteen children meeting self-report criteria for TTM, and 132 parents, provided data over the internet. An additional 41 child-parent dyads from an outpatient clinic also provided data. Replicated principal components analysis, with elimination of poorly-loading items, yielded two components, which we labeled "Severity" (five items) and "Distress/Impairment" (seven items). The TSC total score and subscales showed adequate internal consistency and test-retest reliability. Parent-child agreement was good in the internet sample, but more modest in the clinic sample. Children's TSC scores correlated significantly with other measures of TTM severity, although some exceptions were noted. Parents' TSC scores correlated significantly with other measures of parent-rated TTM severity in the internet sample, but showed more attenuated relationships with child- and interviewer-rated TTM severity in the clinic sample. The present results suggest that the TSC may be a useful measure of TTM for child and adolescent samples, although additional clarification of convergent validity is needed.

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.

Cognitive-behavioral therapy incorporating exposure and ritual prevention (EX/RP) is the first-line psychosocial treatment of choice for obsessive-compulsive disorder (OCD). However, several barriers to care prevent many OCD patients from receiving this treatment. Previous research has indicated that some OCD patients may benefit from less intensive treatment options, such as bibliotherapy; however, it is not clear how to assign patients to their appropriate level of treatment. We suggest that an optimal approach may be to use a stepped care protocol, in which patients begin with a low-intensity treatment and then progress to more costly (but perhaps more efficacious) treatments as needed. In this pilot study, 11 adults with OCD initially received bibliotherapy EX/RP treatment; 20% of patients completing this treatment met stringent responder criteria. The remaining patients were then assigned to a therapist who provided brief education and EX/RP advice but did not actually assist patients with exposure exercises. Twenty-nine percent of patients who completed this treatment were classified as responders. The remaining patients then received the more traditional therapist-administered EX/RP; 67% of patients completing this treatment were responders. Across the entire protocol, 86% of treatment completers and 80% of the intent-to-treat sample were rated as "much improved" or "very much improved." Cost-effectiveness analyses, in which the total cost of treatment was divided by the degree of symptom reduction, showed that stepped care compared favorably to other forms of EX/RP delivery. We provide a detailed case discussion that illustrates the clinical decision-making process and one patient's response to different levels of treatment.

At least four academic clinical trials have demonstrated the utility of cognitive behavior therapy (CBT) for older adults with generalized anxiety disorder (GAD). These data may not generalize, however, to more heterogeneous and functionally impaired patients and the medical settings in which they typically receive care. A recent pilot project suggested the potential benefits of a new version of CBT for GAD among older patients in primary care. The manual developed and tested in this pilot project is presented here. Treatment components include motivation and education, relaxation skills, cognitive therapy, problem-solving-skills training, exposure exercises, and sleep-management-skills training. Procedures are designed to be administered flexibly to maximize attention to individual patient needs. Examples of session summaries, patient handouts, and homework forms are provided.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.brat.2010.07.010 Byline: Christina M. Gilliam (a), Gretchen J. Diefenbach (a), Sara E. Whiting (a), David F. Tolin (a)(b) Abstract: This study evaluated the effectiveness and treatment costs associated with a stepped care protocol of exposure and response prevention (EX/RP) for obsessive-compulsive disorder (OCD). In the current open trial, patients (N =14) began with self-directed EX/RP and minimal therapist guidance over the course of six weeks (Step 1). During this phase of treatment, no therapist-directed exposures were conducted. Those who did not respond optimally to Step 1 went on to Step 2, which consisted of 15 sessions of twice-weekly therapist-directed exposures. Results of this study show promise for stepped care utilizing EX/RP for some patients with OCD, with a response rate of 88% and a 60% reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score among treatment completers. Significant improvements were found in Y-BOCS from pre to post-treatment for both Step 1 and Step 2 completers. Forty-five percent of participants (n =5) responded following completion of Step 1, resulting in reduced cost of treatment among these participants. All participants who responded to Step 1 maintained acute gains during the brief follow-up period. Limitations include a small sample size and high attrition rate. Author Affiliation: (a) Anxiety Disorders Center, The Institute of Living, Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA (b) Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA Article History: Received 10 February 2010; Revised 11 July 2010; Accepted 22 July 2010

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.brat.2007.04.014 Byline: Gretchen J. Diefenbach (a), Jonathan S. Abramowitz (b)(c), Melissa M. Norberg (a), David F. Tolin (a) Keywords: Obsessive-compulsive disorder; Quality of life; Cognitive-behavioral therapy Abstract: Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention is a first line treatment for obsessive-compulsive disorder (OCD). Although, the efficacy of CBT in reducing OCD symptoms is well documented, less is known about its effects on quality of life (QOL). In the current study, functional impairment aspects of QOL (as measured by the Sheehan Disability Scale) were assessed among 70 adult outpatients with OCD before and after CBT. Statistically significant improvements in QOL and large pre- to post-treatment effect sizes were observed for work, social, and family functioning. Improvements in social and family functioning were predicted by improvements in OCD symptom severity even after controlling for improvements in depressive symptoms. In addition, clinically significant change in OCD symptoms and QOL were highly related, although there was a subset of participants whose symptoms improved without corresponding improvements in QOL. These results suggest that the effects of CBT may extend beyond OCD symptom reduction to QOL. Author Affiliation: (a) Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT 06106, USA (b) University of North Carolina at Chapel Hill, Campus Box 3270, Davie Hall, Chapel Hill, NC 27599, USA (c) Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Article History: Received 28 December 2006; Revised 25 April 2007; Accepted 30 April 2007

Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.beth.2006.01.006 Byline: Gretchen J. Diefenbach, David F. Tolin, Scott Hannan, Nicholas Maltby, Johanna Crocetto Abstract: In this randomized controlled trial, group behavior therapy (BT; n =12) was compared to group supportive therapy (ST; n =12) in the treatment of trichotillomania (TTM). Both treatments were also compared to a naturally occurring waiting period, the time period that participants waited for groups to form. Participants completing group BT experienced significantly greater decreases in self-reported hair-pulling symptoms and clinician-rated hair loss severity than did those in group ST. Decreases were significantly greater after treatment than after the naturalistic waiting period. In addition, a significantly higher percentage of those in the BT than ST condition were rated as much improved or very much improved on the Clinical Global Impression scale at posttreatment. However, despite substantial symptom improvement, TTM severity remained problematic at posttreatment. Specifically, few participants in either treatment met criteria for clinically significant change at posttreatment. In addition, relapse of symptoms occurred over the 6-month follow-up period. Results provided partial support for the short-term efficacy of group BT. However, the group format may not maximize the efficacy of BT for TTM. Thus, it is recommended that future BT research test either individual therapy or a combination of group and individual formats for TTM. Author Affiliation: The Institute of Living/Hartford Hospital Article History: Received 12 March 2005; Accepted 27 January 2006 Article Note: (footnote) [star] This research was funded by a grant from Hartford Hospital (Grant #126073) to the first author.

This study explored the impact of hair pulling on psychosocial functioning for patients diagnosed with trichotillomania (TTM; n = 28). TTM patients were compared to age and gender-matched groups of psychiatric patients without TTM (n = 28) and nonpsychiatric control volunteers (NC, n = 28) on measures of psychological distress, functioning/quality of life, and self-esteem. Results indicated that TTM patients reported more severe psychosocial impairments than did NC volunteers; however, these differences were mediated by differences in level of depression. Regression analyses indicated significant relationships between some measures of psychosocial functioning and severity of hair pulling, independent of level of depression. Finally, an interview of the impact of hair pulling on 6 domains of daily functioning (negative affect/negative self-evaluations, grooming, recreational activities, social interaction, work/housework productivity, and physical health) indicated common and wide-ranging impairments for both lifetime and current (i.e., past week) ratings. These results highlight the importance of promoting and improving resources for the clinical care of TTM patients, and provide some directions for clinicians to enhance assessment of interference caused by TTM. Keywords: Trichotillomania; Hair pulling; Quality of life

The authors pooled data from three independently conducted treatment outcome studies to examine predictors of outcome from group-administered cognitive-behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD). Data were collected from 65 patients with a mean age of 67.7 years (SD = 6.6). Average reliable change indices (RCI) based on 3 outcome measures were calculated at posttreatment and at 6-month follow-up. Approximately half of patients achieved a significant RCI at posttreatment and two-thirds achieved a significant RCI at follow-up. Factors associated with better outcomes included better homework adherence, higher baseline GAD severity, and presence of a comorbid psychiatric diagnosis. Results suggest that at-home practice is associated with better and longer-lasting outcomes from CBT in older adults with GAD.

Subsyndromal emotional symptoms are common in older adults and are associated with increased disability, health care utilization, and risk for developing psychiatric disorders. The purpose of this study was to examine subsyndromal generalized anxiety disorder (GAD) in older adults. Participants included 30 older adults with diagnosable GAD, 19 with subsyndromal anxiety symptoms [minor GAD; (MGAD)], and 21 normal control volunteers (NC). Participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV and completed self-report measures of anxiety, worry, depression, and life satisfaction. Excessive worry on more days than not, difficulty controlling worry, and clinically significant distress or impairment were the diagnostic criteria endorsed by MGAD participants least often. Therefore, these criteria may be useful in distinguishing between GAD and subsyndromal GAD. Self-reported anxiety and worry also systematically differed across groups in the expected directions, with a discriminant analysis yielding good classification of the GAD and NC groups based on these measures. Categorization of MGAD participants generally was poor, with most misclassified as GAD patients. Clinical implications of these findings are discussed. Keywords: Geriatric, Generalized anxiety disorder; Subsyndromal anxiety

This study addressed the efficacy of cognitive-behavioral therapy (CBT), relative to minimal contact control (MCC), in a sample of 85 older adults (age 60 years and over) with generalized anxiety disorder (GAD). All participants completed measures of primary outcome (worry and anxiety), coexistent symptoms (depressive symptoms and specific fears), and quality of life. Results of both completer and intent-to-treat analyses revealed significant improvement in worry, anxiety, depression, and quality of life following CBT relative to MCC. Forty-five percent of patients in CBT were classified as responders, relative to 8% in MCC. Most gains for patients in CBT were maintained or enhanced over 1-year follow-up. However, posttreatment scores for patients in CBT failed to indicate return to normative functioning.