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This chapter provides background on trichotillomania (TTM), a disorder of secrecy and shame. Many with the problem do not know it has a name, and many who know what they have cannot find knowledgeable providers. Research on the etiology, maintenance, and treatment of TTM has grown dramatically since the program was first published. This chapter introduces Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) as a treatment for adolescents and adults. The treatment blends the traditional behavior therapy elements of habit reversal training and trigger reduction strategies with the more contemporary behavioral elements of ACT. AEBT-T teaches clients to effectively manage their pulling and to actively increase their functioning.

Obsessive compulsive disorder (OCD) and related disorders share many functional components and are often comorbid with one another. Acceptance and commitment therapy (ACT) for OCD and related disorders is described and is situated as a version of cognitive-behavioral therapy. Also described are the key psychological inflexibility measures for each of these disorders and the outcomes work with OCD and related disorders. Research supports ACT and ACT plus exposure therapy for OCD, and ACT plus habit reversal as a treatment for trichotillomania. The work in skin picking, hoarding disorder, and BDD is limited but is growing. Finally, guidance on the integration of ACT with exposure exercises and habit reversal, as well as future directions for work in this area, are presented.

The insulo-opercular network functions critically not only in encoding taste, but also in guiding behavior based on anticipated food availability. However, there remains no direct measurement of insulo-opercular activity when humans anticipate taste. Here, we collect direct, intracranial recordings during a food task that elicits anticipatory and consummatory taste responses, and during ad libitum consumption of meals. While cue-specific high-frequency broadband (70–170 Hz) activity predominant in the left posterior insula is selective for taste-neutral cues, sparse cue-specific regions in the anterior insula are selective for palatable cues. Latency analysis reveals this insular activity is preceded by non-discriminatory activity in the frontal operculum. During ad libitum meal consumption, time-locked high-frequency broadband activity at the time of food intake discriminates food types and is associated with cue-specific activity during the task. These findings reveal spatiotemporally-specific activity in the human insulo-opercular cortex that underlies anticipatory evaluation of food across both controlled and naturalistic settings., Animal studies have shown that insulo-opercular network function is critical in gustation and in behaviour based on anticipated food availability. The authors describe activities within the human insulo-opercular cortex which underlie anticipatory food evaluation in both controlled and naturalistic settings.

Objective Perfectionism is generally associated with worse mental health outcomes, though evidence suggests elements of it may be helpful. In light of these findings, we examined whether psychological skills like psychological flexibility and self-compassion moderated the relationship between perfectionism and wellbeing (i.e., quality of life, symptom impairment, and psychological distress). Methods Undergraduate students (N = 677) completed self-report measures. Results A latent profile analysis identified three perfectionism groups (low, average, and high) based on four perfectionism subscales: concern over mistakes, need for approval, rumination, and striving for excellence. Generally, we found that psychological flexibility and/or self-compassion buffered the impact of average and high perfectionism on quality of life and symptom impairment. Conclusion Our results support the utility of practicing psychological flexibility and/or self-compassion for people with average and high levels of perfectionism. Limitations include using a cross-sectional design and nonclinical sample.

Deep learning algorithms as tools for automated image classification have recently experienced rapid growth in imaging-dependent medical specialties, including ophthalmology. However, only a few algorithms tailored to specific health conditions have been able to achieve regulatory approval for autonomous diagnosis. There is now an international effort to establish optimized thresholds for algorithm performance benchmarking in a rapidly evolving artificial intelligence field. This review examines the largest deep learning studies in glaucoma, with special focus on identifying recurrent challenges and limitations within these studies which preclude widespread clinical deployment. We focus on the 3 most common input modalities when diagnosing glaucoma, namely, fundus photographs, spectral domain optical coherence tomography scans, and standard automated perimetry data. We then analyze 3 major challenges present in all studies: defining the algorithm output of glaucoma, determining reliable ground truth datasets, and compiling representative training datasets.

Family accommodation is a common, treatment-relevant construct related to obsessive-compulsive disorder (OCD) severity and treatment outcome. This initial study examined the nature, incidence, and clinical correlates of family accommodation in Chinese adults with OCD and their relative or person in a close relationship. One hundred four outpatients diagnosed with OCD completed self-report measures of obsessive-compulsive, anxiety, and depression symptoms. Additionally, the individuals with OCD and a relative completed a measure of family accommodation and impairment. Patient-reports of family accommodation were significantly correlated with OCD symptomology and severity. A multiple linear regression indicated that OCD symptomology was a significant predictor of family accommodation, but anxiety, stress, and depression were not. In addition, the current Chinese sample demonstrated greater levels of family accommodation than previous English-speaking samples. Potential explanations and implications of the high levels of reported family accommodation are discussed. Family accommodation could play a significant role in OCD development and/or maintenance in China. Future research considerations are discussed.

Clinical perfectionism is associated with various cognitive processes including performance monitoring and emotion regulation. This exploratory study analyzed neurological data from a randomized controlled trial for clinical perfectionism that compared acceptance and commitment therapy (ACT) to a waitlist control. The objective was to assess the effect of ACT on neural activation. Twenty-nine participants underwent a functional near-infrared spectroscopy assessment during which they completed behavioral tasks designed to elicit error detection and error generation at pre- and posttreatment. The hemodynamic response function (HRF) in the dorsolateral prefrontal cortex, dorsomedial prefrontal cortex, and right inferior parietal lobe was analyzed using mixed effects models. In all areas, we found reductions or smaller increases in the total HRF for experimental tasks from pre-to posttreatment in the ACT condition compared to the waitlist condition. Decreases in total oxygenated hemoglobin are consistent with diminished recruitment of neurons in response to previously emotionally salient stimuli, possibly representing greater cognitive processing efficiency. Our preliminary findings tentatively support the processes of change posited by the theory underlying ACT and highlight the need for more precise methodology in neurological assessment to adequately evaluate how treatment affects neurological function. Limitations include lack of an active comparison condition and behavioral data.

The aim of this study is to replicate the findings from previous research about the psychometric properties of the Mandarin Chinese version of the Obsessive-Compulsive Inventory–Revised (OCI-R), which assesses the presence of symptoms obsessive-compulsive disorder and the distress associated with those symptoms. The final clinical sample included 80 participants from multiple psychiatric outpatient clinics in China. Participants completed the following questionnaires: the OCI-R, the Depression, Anxiety, and Stress Scale (DASS-21), the Yale-Brown Obsessive-Compulsive Scale–II (Y-BOCS-II), and the Clinical Global Impressions Scale, Severity (CGI-S). The Mandarin Chinese version of the OCI-R demonstrated good internal consistency for the total scale and each subscale. Good convergent and divergent validity was established. The Mandarin Chinese version of the OCI-R demonstrated good psychometric properties. Further research is needed to examine the factor structure of the Chinese version of the OCI-R and the extent to which it aligns with the original version.

High quality relationships are essential to psychological health and well-being, and relational intimacy is a core feature of these relationships. Decades of research in relationship science have converged on a central model of intimacy wherein individuals develop close, trusting relationships with one another. Functional Analytic Psychotherapy (FAP) is a contextual behavioral intervention approach that is well-equipped to target interpersonal processes through the provision of in-session, therapist mediated reinforcement of skillful intimate relating. Single-subject level analyses of FAP's efficacy and mechanism of action are supportive; however, there is a need for group-level research to evaluate its efficacy and generalizability. This paper presents the development of the Awareness, Courage, and Responsiveness Scale (ACRS), a self-report measure of behaviors essential to intimate relating informed by contextual behavioral science principles and Reis and Shaver's (1988) Intimacy Process Model. In this five-part study, functioning of the ACRS is examined in undergraduate student samples (Studies 1–3), an adult community sample (Study 3), non-clinical dyadic relationships (Study 4), and a transdiagnostic clinical sample (Study 5). Strengths and limitations of the final measure are discussed.

Obsessive-compulsive disorder (OCD) with poor insight can contribute to the refusal to receive treatment, leaving the burden of care on parents or other caregivers. The case presented here involved a young adult with OCD with delusional levels of insight paired with extreme family-accommodating behaviors that had resulted in impaired quality of life and functioning for the young adult and his parents. A parent-led behavioral intervention [The Supportive Parenting for Anxious Childhood Emotions (SPACE)] that was developed for children with anxiety was adapted and utilized for a young adult with severe OCD. The case presents a treatment option for parents and caregivers of individuals with OCD who refuse treatment.

Objective: To examine parent's perceptions of deep brain stimulation (DBS) and whether DBS is perceived to be a viable and safe treatment for their adolescent child presenting with a severe, treatment-resistant neurological or psychiatric condition. Method: Two hundred and seventy-nine parents completed an online survey using Amazon Mechanical Turk (MTurk). Participants were presented with five vignette scenarios involving adolescents with severe, treatment-resistant neurological or psychiatric conditions: Rett syndrome, autism spectrum disorder, epilepsy, obsessive-compulsive disorder, and Tourette syndrome. Parents were then asked to evaluate each scenario and rate overall acceptability of using DBS to improve their child's core symptoms. Data were collected over a period of 2 weeks in the month of October 2018. Results: We found that parents reported favorable impressions of DBS regardless of the target condition, especially when greater improvement could be assured and when their child had the capacity to assist in the treatment decision-making. Parents indicated some reluctance to use DBS when possible safety concerns were present. Familiarity with DBS was directly associated with attitudes. Conclusions: The findings highlight an overall parental willingness to consider DBS as a treatment option for key symptoms of neurological and psychiatric conditions in adolescents.

Process-based therapy (PBT) is model of psychotherapy designed to improve people's ability to use a variety of skills from evidence-based treatments to match environmental needs and personal goals in the moment. This randomized trial tested the effect of an online self-help intervention modeled after PBT principles for participants with perfectionism (N = 77). The intervention comprised two four-session trainings teaching skills from different evidence-based treatments (e.g., cognitive-behavioral therapy, acceptance and commitment therapy) and targeting cognitive and motivational processes: (1) cognitive training and (2) motivational training respectively. Participants completed 17 assessments throughout the intervention and at 3- and 6-month follow-up. Results indicated that the full intervention led to improvement in perfectionism, self-compassion, psychological distress, and cognitive skills targeted by the cognitive intervention (e.g., cognitive defusion; absolute βs = 0.02 to 0.66). In addition, the second four-session training (i.e., training after first four-session training) was associated with improvements in perfectionism, self-compassion, quality of life, and psychological distress (absolute βs = 0.09 to 2.90), suggesting it had incremental benefit. Whereas the cognitive training appeared to specifically impact cognitive processes, the motivational training increased both cognitive and motivational processes. These findings provide initial support for the feasibility and efficacy of a process-based approach, because they show that participants can benefit from learning skills from different orientations and applying them with reference to their goals. However, specific aspects of the PBT model, including whether interventions can precisely improve targeted skills, still need to be empirically tested in larger and more diverse clinical samples.

The COVID-19 pandemic has had a profound effect on the delivery of healthcare in the United States and globally. The aim of this study was to evaluate the impact of COVID-19 on common ophthalmic procedure utilization and normalization to pre-pandemic daily rates. Leveraging a national database, Clinformatics™ DataMart (OptumInsight, Eden Prairie, MN), procedure frequencies and daily averages, defined by Current Procedural Terminology codes, of common elective and non-elective procedures within multiple ophthalmology sub-specialties were calculated. Interrupted time-series analysis with a Poisson regression model and smooth spline functions was used to model trends in pre-COVID-19 (January 1, 2018–February 29, 2020) and COVID-19 (March 1, 2020–June 30, 2020) periods. Of 3,583,231 procedures in the study period, 339,607 occurred during the early COVID-19 time period. Anti-vascular endothelial growth factor injections (44,412 to 39,774, RR 1.01, CI 0.99–1.02; p = .212), retinal detachment repairs (1,290 to 1,086, RR 1.07, CI 0.99–1.15; p = .103), and glaucoma drainage implants/trabeculectomies (706 to 487, RR 0.93, CI 0.83–1.04; p = .200) remained stable. Cataract surgery (61,421 to 33,054, RR 0.77; CI 0.76–0.78; p < .001), laser peripheral iridotomy (1,875 to 890, RR 0.82, CI 0.76–0.88; p < .001), laser trabeculoplasty (2,680 to 1,753, RR 0.79, CI 0.74–0.84; p < .001), and blepharoplasty (1,522 to 797, RR 0.71, CI 0.66–0.77; p < .001) all declined significantly. All procedures except laser iridotomy returned to pre-COVID19 rates by June 2020. Most ophthalmic procedures that significantly declined during the COVID-19 pandemic were elective procedures. Among these, the majority returned to 2019 daily averages by June 2020.

Shame is a transdiagnostic emotion of strong clinical and research interest. Yet, there is a lack of consensus on the definition and varying methods employed across self-report measures, potentially affecting our ability to accurately study shame and examine whether clinical interventions to alter shame are effective. This paper offers a systematic review of self-report measures of generalized shame.PubMed, PsycInfo, and Web of Science were searched. Studies were included when they were available in English and the primary aim was to evaluate measurement properties of scales or subscales designed to measure generalized shame in adults.Thirty-six papers examining 19 scales were identified, with measures of trait shame more common than state shame. Construct validity, internal consistency, and structural validity were relative strengths. Development and content validity studies were lacking and suffered from low methodological quality.All measures evaluated needed additional research to meet criteria for recommended use.

PURPOSE: To measure the association between blood pressure, blood pressure medications, and glaucoma using the All of Us Research Program database. DESIGN: A retrospective, longitudinal cohort study leveraging a national electronic health records database administered by the National Institute of Health. SUBJECTS, PARTICIPANTS AND/OR CONTROLS: Eye patients in the All of Us Research Program database with at least fifteen months of follow up and one blood pressure (BP) measurement. METHODS, INTERVENTION, OR TESTING: Univariable and multivariable Cox regression models predicted the risk of developing incident open angle glaucoma (OAG). Mean arterial pressure (MAP) and the number of BP medication classes were entered as time-varying predictors to account for changes over time. MAIN OUTCOME MEASURES: The risk of developing incident OAG, as defined by billing diagnosis codes. RESULTS: Of 20815 eligible eye patients who qualified for this study, 462 developed OAG. Low blood pressure (MAP < 83.0 mmHg) was associated with increased risk of developing OAG (hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.04 – 1.67). High blood pressure (MAP > 101.3 mmHg) and the number of BP medication classes were not associated with OAG after adjustment for covariates. Other risk factors associated with OAG included being Black (HR 3.31, 95% CI 2.63 – 4.17), Hispanic or Latino (HR 2.53, 95% CI 1.94 – 3.28), Asian (HR 2.22, 95% CI 1.24 – 3.97), older in age (80+ years, HR 20.1, 95% CI 9.10 – 44.5), and diabetic (HR 1.32, 95% CI 1.04 – 1.67). Female gender was associated with decreased hazard of developing OAG (HR 0.66, 95% CI 0.55 – 0.80). No significant interaction was observed between MAP and the number of BP medications on the risk of developing OAG. CONCLUSIONS: We found that low blood pressure is associated with increased risk of developing OAG in a national longitudinal electronic health records database. We did not find evidence supporting a differential effect of medically treated and untreated low BP. This study adds to the body of literature implicating vascular dysregulation as a potential etiology for the development of OAG, particularly emphasizing the lack of influence of blood pressure medications on this relationship.

The current study examined psychological inflexibility and self-compassion as theoretically relevant mediators and moderators of outcomes following acceptance and commitment therapy (ACT) for clinical perfectionism. Fifty-three participants with clinical perfectionism were randomized to either a 10-session ACT condition or a 14-week waitlist control condition (only 39 completed the posttreatment assessment). Outcomes tested include concern over mistakes, doubting of actions, personal standards, quality of life, symptom distress and functional impairment, and valued action. Multilevel modeling analyses showed reduced psychological inflexibility mediated the relationship between condition and higher quality of life and increased self-compassion mediated the relationship between condition and decreased concern over mistakes. No other mediation effects were observed. In addition, baseline psychological inflexibility differentially moderated outcomes depending on outcome tested; for example, lower baseline inflexibility predicted more improvement in quality of life whereas higher baseline inflexibility predicted more improvement in symptom distress and functional impairment. Participants with average baseline self-compassion tended to benefit the most from ACT. These findings clarify how psychological inflexibility and self-compassion influence outcomes following ACT for clinical perfectionism. Theoretical and clinical implications of ACT for clinical perfectionism are discussed.

Psychological flexibility refers to a way of interacting with internal experiences and the external environment that advances one toward chosen values whereas psychological inflexibility reflects rigid adherence to ineffective responses such that valued living is compromised. Psychological flexibility is a critical variable of interest in acceptance and commitment therapy, thus, accurate assessment of this construct is pertinent to professionals in the field. Numerous measures of psychological flexibility for specific conditions exist and the psychometric validation of each of these measures varies in breadth and depth. To orient professionals to the scope of available measures as well as their psychometric properties, the current review summarizes the existing literature on context-specific measures of psychological flexibility. Most measures demonstrated satisfactory basic psychometric properties, though their clinical utility (e.g., treatment sensitivity) has largely been underexplored. Generally, context-specific measures performed better than a generic measure of psychological flexibility with respect to incremental validity and treatment sensitivity. Still, further research is needed to validate these measures (e.g., discriminant validity) in order to justify their use across settings and study designs.

Anxiety is a common experience and component of the human condition, but as a construct it is difficult to define and anxiety scales vary in which aspects are emphasized. In the present study, we analyzed and quantified the content overlap of self-report instruments used to measure non- specific or global anxiety. Categorization of the 320 items across fourteen commonly used anxiety scales resulted in 60 disparate categories that spanned a wide variety of symptoms. The Jaccard index was used to determine symptom overlap between the various scales. Mean overlap between all of the selected scales was very low, indicated by a weak Jaccard Index (0.23). On average, only 29.5% of all symptoms were captured by any given measure. Results indicate that the scales are heterogenous in the content that they measure. Therefore, anxiety-related scales should not be assumed to be interchangeable and careful consideration should be taken when selecting measures.

Treatment of adolescent trichotillomania is understudied, and treatment providers are difficult to find. In this pilot study, we compared ACT-enhanced behavior therapy to a waitlist, with treatment delivered over Zoom, to 28 adolescents who met criteria for trichotillomania. This study partially occurred during the COVID-19 pandemic. A detailed description of the treatment protocol is provided for ACT-enhanced behavior therapy adapted to a Zoom format for adolescents. Pretreatment assessments were completed over Zoom by an assessor unaware of study condition; pretreatment and posttreatment questionnaires were completed online. Results indicated that therapy was delivered with fidelity and competence over Zoom, with 100% session completion. Adolescents reported that pulling severity decreased significantly more in the treatment condition than waitlist. No differences were seen in other adolescent or parent-reported pulling severity or distress. However, significant medium to large within-condition effect sizes were observed in the treatment condition. Medium effect size changes were seen in the treatment group on a measure of trichotillomania-related psychological flexibility, and a small effect size was seen for psychological distress. Overall, pilot results provide preliminary support for ACT-enhanced behavior therapy, delivered over Zoom, for adolescent trichotillomania, indicating the need for a fully powered confirmatory efficacy trial.

The present study aimed to examine changes in psychophysiological arousal from baseline to a stressor phase (reactivity) and from the stressor phase to a second resting phase (recovery) in patients with anxiety disorders. Fifty adult patients with DSM-5 anxiety disorders (panic disorder, generalized anxiety disorder, or social anxiety disorder) and 28 healthy control (HC) participants underwent psychophysiological monitoring including electrocardiogram, respiration rate, electrodermal activity, gastrocnemius electromyograph, and end-tidal CO2 for a 3-min resting phase, a 6-min mild stressor phase, and a 3-min recovery phase. Anxious patients then went on to receive naturalistic cognitive-behavioral therapy (CBT) in a specialty outpatient clinic. Results for the reactivity phase indicated that compared to HCs, patients with social anxiety disorder exhibited heightened psychophysiological reactivity while patients with panic disorder and generalized anxiety disorder exhibited attenuated reactivity. Results for physiological recovery (return to baseline after the stressor was withdrawn) were mixed, but provided some support for slower autonomic recovery in patients with generalized anxiety disorder and panic disorder compared to HCs. Participants with all anxiety disorders exhibited diminished change in high frequency heart rate variability compared to HCs. Generally, psychophysiological reactivity and recovery were not associated with CBT outcome, though exploratory analyses indicated that greater respiration rate reactivity and stronger respiration rate recovery were associated with better CBT outcomes in patients with panic disorder.

Pediatric obsessive-compulsive disorder is a common childhood psychiatric illness. The primary focus of the chapter is on obsessive-compulsive disorder per se given the more robust evidence base, although additional evidence is briefly reviewed for other obsessive-compulsive related disorders such as body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. The cause of this disorder remains unknown, however, there are multiple biobehavioral etiological theories. The cause is likely multi-determined and includes cognitive-behavioral, biological, and environmental factors. The chapter discusses therapeutic considerations for the psychosocial treatment of pediatric OCD and related disorders. Cognitive-behavioral therapies have been identified as efficacious treatments for this pediatric condition. There is a strong evidence base from meta-analyses for both traditional cognitive behavioral treatments and cognitive-behavioral family treatment modalities. Emerging research has also focused on remote treatment delivery options and novel modalities for nonresponders such as intensive cognitive-behavioral therapies. Other psychosocial modalities have not been demonstrated as efficacious based on available evidence.

Objective The psychometric properties of the Mandarin Chinese version of the Yale-Brown Obsessive Compulsive Scale–Self Report (Y-BOCS-SR) were examined. Method Participants included 80 outpatients with a primary diagnosis of obsessive compulsive disorder. Measures included the Mandarin Chinese version of the Yale-Brown Obsessive-Compulsive Scale–Self Report, the Yale-Brown Obsessive-Compulsive Scale–II (clinician rated), the Clinical Global Impression, and the Depression Anxiety Stress Scales–21. Internal consistency was calculated with the Cronbach's alpha coefficient, Pearson's correlations were examined between the measures, and confirmatory factor analyses and a subsequent exploratory factor analysis were performed. Results Results indicated good internal consistency. Correlations with other measures were as expected and indicated good convergent and divergent validity. The Y-BOCS-SR performed similarly to the Y-BOCS-II with regard to correlations with other measures. Confirmatory factor analysis revealed poor model fit for all tested models. An exploratory factor analysis indicated a single factor solution instead of the more traditional two-factor solution. Conclusions Overall, the findings provide evidence for good psychometric properties of the Mandarin Chinese version of the Y-BOCS-SR. Future research is needed to better explore the factor structure of the measure, examine other types of reliability and validity, and to increase the generalizability of the findings.

The purpose of this study was to examine acceptance and commitment therapy (ACT) as a standalone treatment for trichotillomania in a randomized controlled trial of adults and adolescents. Participants consisted of a community sample of treatment seeking adults and adolescents with trichotillomania. Of the eligible 39 participants randomized into treatment and waitlist groups, 25 completed treatment and were included in the final analysis. Treatment consisted of a 10-session ACT protocol. Multiple mixed models repeated measures analyses were utilized to evaluate changes in trichotillomania symptom severity, daily number of hairs pulled and urges experienced, and experiential avoidance from pretreatment to posttreatment. Findings indicated significant changes in symptom severity and daily hairs pulled, but not daily urges experienced or psychological flexibility. However, psychological flexibility saw a 24.5% decrease in the treatment group and reduced from clinical to subclinical levels on average. This study suggests that ACT alone is an effective treatment for adults and adolescents with trichotillomania. Outcomes appear to be similar to trials that combined ACT and habit reversal training (HRT).

Despite its prevalence, quality treatment for trichotillomania is often difficult to find. The use of telepsychology has been an effective method for disseminating treatment services for a variety of mental health conditions. However, no research has examined the use of telepsychology to treat trichotillomania. This randomized controlled trial used Acceptance and Commitment Therapy Enhanced Behavior Therapy delivered by way of telepsychology to treat trichotillomania in adults. The study compared an active treatment condition (n = 12) to a delayed treatment waitlist control condition (n = 10). Results showed significant reductions in hair pulling severity from pre- to post-treatment compared to the waitlist condition. The 22 participants all received treatment and were combined to examine overall treatment effects from pre-treatment to a 12-week follow-up. The effect of treatment on hair pulling severity remained significant at follow-up. Measures of psychological flexibility and perceived shame also saw significant improvement. Quality of life, however, did not improve over the course of treatment. The findings demonstrate that telepsychology is a viable option to disseminate treatment for trichotillomania.

Many psychotherapies, including cognitive behavioral therapy and acceptance and commitment therapy (ACT), have been found to be effective interventions for a range of psychological and behavioral health concerns. Another aspect of treatment utility to consider is dropout, as interventions only work if clients are engaged in them. To date, no research has used meta-analytic methods to examine dropout in ACT. Thus, the objectives of the present meta-analysis were to (1) determine the aggregate dropout rate for ACT in randomized controlled trials, (2) compare dropout rates in ACT to those in other psychotherapies, and (3) identify potential moderators of dropout in ACT. Our literature search yielded 68 studies, representing 4,729 participants. The weighted mean dropout rates in ACT exclusive conditions and ACT inclusive conditions (i.e., those that included an ACT intervention) were 15.8% (95% CI: 11.9%, 20.1%) and 16.0% (95% CI: 12.5%, 19.8%), respectively. ACT dropout rates were not significantly different from those of established psychological treatments. In addition, dropout rates did not vary by client characteristics or study methodological quality. However, master's-level clinicians/therapists (weighted mean = 29.9%, CI: 17.6%, 43.8%) were associated with higher dropout than psychologists (weighted mean = 12.4%, 95% CI: 6.7%, 19.4%). More research on manipulable, process variables that influence dropout is needed.

This study examines the effects of different techniques on the management of unwanted sexual thoughts. Participants (N = 150; 67 who found sexual thoughts distressing, 83 participants who did not) were randomly placed into one of three experimental conditions: experiential willingness, distraction, or no strategies for dealing with unwanted sexual thoughts. Participants answered questions assessing attitudes about their sexual thoughts and recorded sexual thought frequency for a 3-minute period pre- and post-intervention. Thought frequencies decreased for all groups post intervention for both the distressed and nondistressed samples. Acceptability of thoughts increased for the experiential willingness group, remained similar for the distraction group, and decreased for the control group. The findings indicate that distraction was more easily implemented, more commonly used, and equally effective to experiential willingness at reducing sexual thoughts in the short term. However, the short experiential willingness intervention increased acceptability of sexual thoughts, which could have an impact on longer-term results.

The aim of this study was to investigate the effects of adding group acceptance and commitment therapy (ACT) to adults diagnosed with obsessive compulsive disorder (OCD) who were already on an optimal dose of selective serotonin reuptake inhibitors (SSRIs). Forty-six Iranian women, on SSRIs, were randomized to group ACT + SSRI or continued SSRI conditions. SSRI dosages stayed stable during the study. Assessments included the Structured Clinical Interview (SCID-I), Yale-Brown Obsessive-Compulsive Scale Self report (Y-BOCS-SR), Beck Depression Inventory-II (BDI-II), Ruminative Response Scale (RRS), and Acceptance and Action Questionnaire (AAQ-II). The results showed significant reductions on the Y-BOCS-SR and BDI-II in both conditions at posttreatment with significantly greater reductions in the ACT + SSRI condition at follow-up. The RRS and AAQ-II saw significant improvements in the ACT + SSRI condition at posttreatment and follow-up compared to the SSRI condition. Results provide cross-cultural support for group ACT as a treatment for OCD and as a successful adjunct to SSRI treatment.

Objective The purpose of this study was to examine the psychometric properties of the Body Image-Acceptance and Action Questionnaire in a severe eating disorder population, as previous validation has occurred only with nonclinical samples. Method Data on body image psychological flexibility, general psychological flexibility, eating disorder severity, and other related constructs were gathered from 72 adolescent and 60 adult female, residential patients diagnosed with an eating disorder. Psychometrics were examined through the use of exploratory and confirmatory factor analyses, Cronbach's alpha, correlations, and hierarchical multiple regressions to assess model fit, reliability, and validity. Results The BI-AAQ demonstrated excellent convergent, discriminant, and incremental validity as well as excellent internal reliability, however, factor analyses resulted in overall poor model fit. Removal of item 6 from the BI-AAQ resulted in improved psychometric properties in all regards, yet still demonstrated overall poor model fit. Discussion This study suggests that the BI-AAQ is psychometrically sound in many areas and provides some clinical utility; however, it may be somewhat problematic when used in severe eating disorder populations. When using the measure in clinical settings, removal of item 6 is recommend. Recommendations for future measurement and utilization of body image flexibility are discussed.

Objective The purpose of this study was to test whether pre-treatment levels of psychological flexibility would longitudinally predict quality of life and eating disorder risk in patients at a residential treatment facility for eating disorders. Method Data on body image psychological flexibility, quality of life, and eating disorder risk were collected from 63 adolescent and 50 adult, female, residential patients (N = 113) diagnosed with an eating disorder. These same measures were again collected at post-treatment. Sequential multiple regression analyses were performed to test whether pre-treatment levels of psychological flexibility longitudinally predicted quality of life and eating disorder risk after controlling for age and baseline effects. Results Pre-treatment psychological flexibility significantly predicted post-treatment quality of life with approximately 19% of the variation being attributable to age and pre-treatment psychological flexibility. Pre-treatment psychological flexibility also significantly predicted post-treatment eating disorder risk with nearly 30% of the variation attributed to age and pre-treatment psychological flexibility. Discussion This study suggests that levels of psychological flexibility upon entering treatment for an eating disorder longitudinally predict eating disorder outcome and quality of life.

The embarrassing nature of unwanted sexual thoughts in individuals with obsessive-compulsive disorder (OCD) increases shame and generates feelings of disgust. This requires a specialized approach by clinicians to address the challenges associated with the sexual subtype of OCD (S-OCD). This chapter first addresses psychoeducation as it relates to unwanted sexual thoughts, facing fears, and building mental fitness. The authors then provide a session-by-session guide designed to assist clinicians in the provision of exposure and response prevention therapy (Ex/RP) to S-OCD sufferers. The protocol provides strategies aimed at increasing a client’s behavioral flexibility and control in the specialized treatment of S-OCD using Ex/RP and also includes cognitive therapy, acceptance and commitment therapy (ACT), and mindfulness techniques.

This study examined the transdiagnostic effect of acceptance and commitment therapy (ACT) on impulsive decision-making in a community sample. A total of 40 adults were randomized to eight individual sessions of ACT or an inactive control. Participants completed pre-, mid-, and post-assessments for psychological symptoms; overall behavior change; valued living; delay discounting; psychological flexibility; and distress tolerance. Data were analyzed with multilevel modeling of growth curves. Significant interaction effects of time and condition were observed for psychological flexibility, distress tolerance, psychological symptoms, and the obstruction subscale of valued living. No significant interaction effect was found for two delay discounting tasks nor the progress subscale of valued living. The ACT condition had a significantly larger reduction of problem behavior at post-assessment. The results support use of ACT as a transdiagnostic treatment for impulsive behaviors. The lack of change in delay discounting contrasts previous research.

Despite its prevalence and a growing body of research, significant gaps remain in the knowledge of trichotillomania (TTM). The current study sought to address this issue by examining personality characteristics, impulsivity, and experiential avoidance of those with TTM compared to an age and gender matched sample. 56 Female participants (28 with TTM and 28 non-clinical age-matched controls) completed the Personality Assessment Inventory (PAI), Barratt's Impulsivity Scale (BIS), and the Acceptance and Action Questionnaire (AAQ). Paired-sample t -tests compared each of the 28 individuals who met criteria for TTM to an age and gender matched individual who did not meet criteria for TTM or any Axis I condition. Significant differences were found between many of the PAI scales and subscales, impulsivity, and experiential avoidance. The TTM group displayed higher levels of pathology than the control group. The findings provide evidence that individuals with TTM demonstrate differing levels of personality characteristics compared to individuals without TTM and that treatment may benefit from acknowledging and targeting these areas.

Treatment effectiveness of exposure and response prevention for obsessive-compulsive disorder (OCD) might be attenuated in part because of the complex, heterogeneous nature of OCD. Previous studies have indicated relationships between thought control strategies and OCD severity. This study replicates and extends these findings by using a dimensional measure of OCD and examining changes in thought control strategies across treatment. Participants included 49 patients with OCD attending residential and intensive outpatient treatment. Statistical analyses revealed significant reduction in worry and punishment thought control strategies from pre- to posttreatment as well as relationships between reduced use of specific thought control strategies and specific types of OCD symptomatology. Findings suggest that developing and employing modified forms of treatment more aligned with individuals’ specific OCD symptomatology could be worthwhile to improve treatment of OCD.

Obsessive Compulsive Disorder (OCD) is among the most common psychiatric comorbidities with eating disorders (EDs) and most studies have only examined this relationship at a diagnostic level. More research is needed to determine whether specific symptom domains and cognitive patterns commonly observed in OCD are most salient among individuals with clinically significant EDs, and whether these symptoms appear to change and/or influence treatment outcomes. Thought Action Fusion (TAF) is one cognitive pattern that may underlie OCD-ED comorbidity. The current study assessed 112 adolescent and adult female patients at a residential ED treatment facility on levels of ED severity, OCD symptom severity, and TAF at pre- and post-treatment. All OCD symptom dimensions were positively correlated with ED severity at pretreatment, with Obsessing, Neutralizing and Ordering OCD symptoms being most elevated. TAF was also positively correlated with ED severity at pre-treatment, and higher levels of TAF at pretreatment significantly predicted greater ED severity at post-treatment after controlling for all other OCD symptoms. Improvements in TAF specific to thoughts about others also predicted improvements in ED severity after controlling for changes in OCD symptoms. Clinically, these results indicate that efforts targeting specific OCD symptom dimensions and TAF in addition to ED-focused treatment as usual may be beneficial for enhancing overall treatment outcomes.

Trichotillomania, or hair-pulling disorder, is characterized by the recurrent pulling out of one’s hair, leading to hair loss. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013), specifies additional diagnostic criteria for trichotillomania: (a) repeated attempts to reduce or stop hair pulling, (b) the hair pulling causes clinically significant distress or functional impairment, and (c) the hair pulling or hair loss is not due to a medical or other mental condition. Hair pulling can be observed in any region of the body, including the scalp, eyebrows, and axillary region.

Acceptance and commitment therapy (ACT) is a modern form of cognitive behavior therapy (CBT) with growing support for treating obsessive-compulsive disorder (OCD). We present a case wherein a client presented with scrupulosity-related OCD. We briefly review scrupulosity, explain the theory behind ACT, and present a case, the treatment process, and desired outcomes. Exposure and response prevention (ERP) is described from an ACT perspective and discussed as an option for people with OCD who may be reluctant to engage in more traditional forms of ERP.

Research suggests that online pornography use can have harmful consequences for some individuals, but the psychological processes that contribute to problematic viewing are unclear. This study sought to evaluate the role of experiential avoidance in the negative consequences of online pornography viewing in a small cross-sectional survey sample of 91 male college students who reported viewing. Results indicated that viewing pornography for experientially avoidant motivations was related to more frequent viewing and predicted self-reported negative consequences of viewing over and above other motivations (e.g., sexual pleasure, curiosity, excitement seeking). Although more frequent viewing was related to more self-reported negative consequences, this relation was consistently mediated by viewing for experiential avoidance in this sample. Study limitations included a homogeneous sample of primarily white students, a relatively low rate of reported pornography viewing, and use of only self-report assessment. Results suggest that viewing to avoid unwanted emotions might account for both frequent viewing and its negative consequences, highlighting a promising target for future interventions seeking to reduce problematic pornography viewing.

Obsessive-compulsive disorder (OCD) is a debilitating condition that does not always respond well to treatment. People with OCD often require a great deal of assistance from caregivers or family members, which is referred to as family accommodations. Caregivers may experience a great deal of stress, depression, and other problems as a result of caring for their loved one with OCD. They may have decreased relationship satisfaction due to the accommodations required by their family member. The present study examines the experience family members have of caring for someone with OCD and how it relates to caregiver burden, relationship satisfaction, and level of family accommodations. Participants for this study included 50 caregivers of individuals with OCD. Analyses were primarily correlational in nature. Results found that high relationship satisfaction was correlated with caregiver burden and OCD severity.

The purpose of this study was to examine the effects of changes in body image psychological flexibility over the course of treatment on various outcome variables.Participants included 103 female, residential patients diagnosed with an eating disorder. Pretreatment and posttreatment data were collected that examined body image psychological flexibility, general psychological flexibility, symptom severity, and other outcome variables.Changes in body image psychological flexibility significantly predicted changes in all outcome measures except for obsessive-compulsive symptoms after controlling for body mass index, depression, and anxiety. Additionally, these results were maintained after controlling for general psychological flexibility, contributing to the incremental validity of the BI-AAQ.This study suggests that changes in body image psychological flexibility meaningfully predict changes in various treatment outcomes of interest, including eating disorder risk, quality of life, and general mental health. Findings indicate that body image psychological flexibility might be a viable target for eating disorder treatment.

The aim of this study was to investigate a new measure, the Wetterneck-Hart OCD Screener (WHOS), as a self-report screening tool for obsessive-compulsive disorder (OCD). The authors examined relationships between the WHOS and severity scores of OCD measures taken via three methods of data collection: online, at OCD consumer conferences, and from an intensive, residential OCD program. Severity measures included the Yale-Brown Obsessive-Compulsive Scale-Self Report (Y-BOCS-SR), the Dimensional Obsessive-Compulsive Scale (DOCS), and the Obsessive-Compulsive Inventory-Revised (OCI-R). A total of 525 participants took the measures: 298 from online websites, 100 from OCD conferences, and 127 from a residential OCD program. Significant differences were found between the OCD and non-OCD groups classified by the WHOS for each of the OCD severity measures. The authors conclude that the WHOS is useful in predicting the presence of clinically severe OCD symptoms and could be employed in clinical and research endeavors.

Background Functional analytic psychotherapy (FAP) is a contextual behavior therapy that targets idiographic behaviors relevant to interpersonal functioning. FAP often targets issues with intimacy, defined as behavior exchanges that are vulnerable to interpersonal punishment. While existing measures examine similar constructs to FAP’s conceptualization of intimacy, the literature lacks a FAP-consistent self-report measure that adequately captures intimacy-related behavior with the capacity to assess behavior change and aid in clinical outcome research.

Technology-based self-help treatment programs for OCD have the potential to offer low to no cost treatment to those who may not have access to OCD treatment providers, to compliment on-going therapy and to assist individuals in maintaining treatment gains. To date, the quality of these programs is largely unassessed. This review examines the currently available technology-based self-help treatment programs for OCD. Search results from Google.com , the Apple App Store, and the Google Play Store were reviewed, with 15 programs included in the final review. Research support for the programs was generally nonexistent or very limited. Seven of the programs were deemed empirically-based, despite little to no research support, due to incorporating quality psychoeducation and exposure and response prevention (ERP) elements. The unique strengths of each of these programs are reviewed. The eight non-empirically-based programs varied in quality and function, but many included potentially useful components. Directions and considerations for future tech-based treatment programs are discussed.