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Hoarding disorder (HD) is a new psychiatric diagnosis in Diagnostic and Statistical Manual of Mental Disorders–Fifth edition and preliminary evidence suggests that cognitive-behavioral treatments are effective in treating this condition. However, it has been demonstrated that individuals with HD generally display poor compliance during treatment, which may lead to poor outcomes. Treatment compliance can be conceptualized as either within-session or between-session compliance, but currently there are no validated measures of within-session or between-session compliance specifically for HD. The aim of this study was to provide an initial validation of the CBT Compliance Measure and the Patient Exposure/Response Prevention Adherence Scale for Hoarding in a sample of participants with HD who were undergoing group cognitive behavioral therapy (CBT) for HD ( N = 70). Both measures, which were administered at each relevant treatment session, demonstrated a unidimensional structure, good reliability, as well as predictive validity, and are thus promising in the measurement of within-session and between-session compliance with CBT for HD.

Objective: PTSD is often associated with heightened physiological reactivity during fear conditioning procedures, but results vary across studies. The present study examined whether anxiety sensitivity (AS), or the fear of arousal-related sensations, strengthens the relationship between PTSD symptoms and skin conductance responses (SCR) during fear conditioning and extinction. Because gonadal hormones implicated in fear learning processes fluctuate across the menstrual cycle, the stability of these relationships in women was examined in two distinct menstrual cycle phases. Method: Thirty-two trauma-exposed women with (n=16) and without PTSD (n=16) completed the Clinician-Administered PTSD Scale, Anxiety Sensitivity Inventory, and a fear conditioning and extinction paradigm during the mid-luteal (mLP) and early-follicular (eFP) menstrual cycle phases. Results: In the mLP, stronger SCR to stimuli paired with shock (CS+) during fear acquisition significantly predicted greater PTSD symptoms only when AS was high and after removing an outlier. This appeared driven by effects on Numbing and Hyperarousal symptom clusters. Other hypothesized interactions between AS and CS responses were not significant. However, in the eFP, differential SCR between the CS+ and CS- during extinction predicted significantly greater PTSD symptoms, and there was a trend for this effect being stronger as AS increased. Conclusions: Results offer preliminary evidence that high AS contributes to a stronger relationship between physiological responses during fear acquisition and PTSD symptoms, at least among women in the mLP. Further research investigating the impact of individual differences in traits such as AS on the relationship between conditioned fear responses and PTSD symptoms is warranted.

Background Investigations of neuropsychological functioning in obsessive-compulsive disorder (OCD) have produced mixed results for deficits in executive functioning (EF), attention, and memory. One potential explanation for varied findings may relate to the heterogeneity of symptom presentations, and different clinical or neurobiological characteristics may underlie these different symptoms. Methods We investigated differences in neuropsychological functioning between two symptoms groups, obsessing/checking (O/C) and symmetry/ordering (S/O), based on data suggesting an association with different motivations: harm avoidance and incompleteness, respectively. Ten studies (with 628 patients) were included and each investigation assessed at least one of 14 neuropsychological domains. Results The S/O domain demonstrated small, negative correlations with overall neuropsychological functioning, performance in EF, memory, visuospatial ability, cognitive flexibility, and verbal working memory. O/C symptoms demonstrated small, negative correlations with memory and verbal memory performance. A comparison of functioning between symptom groups identified large effect sizes showing that the S/O dimension was more strongly related to poorer neuropsychological performance overall, and in the domains of attention, visuospatial ability, and the subdomain of verbal working memory. Conclusions Findings support existing evidence suggesting that different OCD symptoms, and their associated core motivations, relate to unique patterns of neuropsychological functioning, and, potentially dysfunction in different neural circuits.

Obsessive-compulsive disorder (OCD) is a heterogeneous illness and evidence suggests that different clinical characteristics may relate to varying treatment outcomes. This study was designed to identify subgroups based on core motivational domains in a clinical sample of individuals with OCD, and to compare groups on clinical characteristics. Cluster analyses identified four subgroups including groups with relatively high or low levels of both harm avoidance (HA) and incompleteness (INC) motivations. A subgroup was identified that demonstrated a "traditional profile" marked by high motivation to avoid harm, and elevated levels of beliefs about responsibility/overestimation of threat. The model also contained a subgroup characterized by high incompleteness, low motivation to avoid harm, and higher levels of perfectionistic beliefs and intolerance of uncertainty. Findings reemphasize that current cognitive and behavioral models of OCD may be enhanced by integrating incompleteness/NJREs.

BackgroundRepetitive transcranial magnetic stimulation (rTMS) holds promise for treating generalised anxiety disorder (GAD) but has only been studied in uncontrolled research.AimsThis is the first randomised controlled trial (clinicaltrials.gov: NCT01659736) to investigate the efficacy and neural correlates of rTMS in GAD.MethodTwenty five participants (activen= 13; sham,n= 12) enrolled. rTMS was targeted at the right dorsolateral prefrontal cortex (DLPFC, 1 Hz, 90% resting motor threshold).ResultsResponse and remission rates were higher in the activev.sham groups and there were significant group × time interactions for anxiety, worry and depressive symptoms, favouring activev.sham. In addition, right DLPFC activation during a decision-making gambling task increased at post-treatment for active rTMS only, and changes in neuroactivation correlated significantly with changes in worry symptoms.ConclusionsFindings provide preliminary evidence that rTMS may improve GAD symptoms in association with modifying neural activity in the stimulation site.

Background The Overall Anxiety Severity and Impairment Scale (OASIS) is a brief, transdiagnostic measure used to assess anxiety severity and related interference. The OASIS has demonstrated strong psychometric properties in previous investigations, however, it has yet to be validated using a transdiagnostic clinician-rated measure. Methods We evaluated the factor structure, convergent and discriminant validity, and illness severity cut-scores of the OASIS in a sample of outpatients (N=202). Results A confirmatory factor analysis indicated an unidimensional structure provided the best fit. The OASIS demonstrated good convergent validity and internal consistency. Using the Clinical Global Impression-Severity Scale (CGI-S), ROC curves showed OASIS scores of 6, 10 and 12 to indicate moderate, marked and severe illness severity, respectively. Conclusions The OASIS is a unidimensional self-report measure with good convergent validity and data from the current study provide illness severity cut-scores.

Although hoarding disorder (HD) is characterized by self- and clinician-reported difficulties with cognitive functioning, studies of neuropsychological performance have yielded little evidence of consistent, clinical-level cognitive impairments. The aim of this study was to quantify this inconsistency and to examine whether this pattern is unique to HD. Fifty-three adults (20 with HD, 19 with obsessive compulsive disorder (OCD) and minimal hoarding symptoms, and 14 with OCD and a high degree of hoarding symptoms (OCD-H)) completed self-report and objective neuropsychological tests of inhibition, attention, and memory. The three groups differed significantly on self-reported attention and memory deficits, with the HD group reporting greater difficulties. However, the groups performed comparably on objective neuropsychological tests of inhibition, attention, immediate and delayed nonverbal memory, and immediate verbal memory. The OCD-H group demonstrated a greater rate of impairment on a test of delayed verbal memory. The HD group was characterized by lower concordance rates between self-report and objective memory impairment. The groups did not differ significantly in concordance rates for self-report and objective measures of attention and inhibition. Understanding the discrepancy between self-report and objective neuropsychological measures may help to better characterize the role of cognitive processes in HD.

Background Recent evidence suggests that repetitive transcranial magnetic stimulation (rTMS) might be effective in treating generalized anxiety disorder (GAD). Cognitive models of GAD highlight the role of intolerance of uncertainty (IU) in precipitating and maintaining worry, and it has been hypothesized that patients with GAD exhibit decision‐making deficits under uncertain conditions. Improving understanding of the neural mechanisms underlying cognitive deficits associated with IU may lead to the identification of novel rTMS treatment targets and optimization of treatment parameters. The current report describes two interrelated studies designed to identify and verify a potential neural target for rTMS treatment of GAD. Methods Study I explored the integrity of prefrontal cortex (PFC) and amygdala neural networks, which underlie decision making under conditions of uncertainty, in GAD. Individuals diagnosed with GAD (n = 31) and healthy controls (n = 20) completed a functional magnetic resonance imaging (fMRI) gambling task that manipulated uncertainty using high versus low error rates. In a subsequent randomized‐controlled trial (Study II), a subset of the GAD sample (n = 16) completed the fMRI gambling task again after 30 sessions of active versus sham rTMS (1 Hz, right dorsolateral prefrontal cortex) to investigate the modulation of functional networks and symptoms. Results In Study I, participants with GAD demonstrated impairments in PFC‐PFC and PFC‐amygdala functional connectivity (FC) mostly during the high uncertainty condition. In Study II, one region of interest pair, dorsal anterior cingulate (ACC) – subgenual ACC, showed “normalization” of FC following active, but not sham, rTMS, and neural changes were associated with improvement in worry symptoms. Conclusions These results outline a possible treatment mechanism of rTMS in GAD, and pave the way for future studies of treatment optimization.

Background A subset of patients given a clinical diagnosis of major depressive disorder (MDD) are described as having “anxious depression,” a presentation that, in some studies, has been an indicator of poor response to pharmacotherapy. The aim of this study was to determine if anxious depression is associated with attenuated response to repetitive transcranial magnetic stimulation (rTMS), an FDA-approved treatment for MDD. Methods Participants were 32 adult outpatients with treatment resistant MDD who were referred for rTMS. The Hamilton Rating Scale for Depression (HAMD) was administered to assess treatment response, and anxious depression was defined as a score of seven or above on the anxiety/somatization factor of the HAMD. A quarter of the sample met the anxious depression criterion at pretreatment. Results Both depression (total score) and anxiety symptoms improved from pre- to post-treatment with moderate to large treatment effects. Patients with and without anxious depression demonstrated similar rates of improvement in depression. Patients with versus without anxious depression demonstrated larger improvements in anxiety. Limitations The sample size was small, and assessments did not include structured diagnostic interview or independent measures of anxiety symptoms. Conclusions For the sample as a whole, there were significant improvements in both depression and anxiety. Anxious depression was not associated with attenuated treatment response to rTMS.

Three hundred sixty-two adult patients were administered the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND). Of these, 121 provided interrater reliability data, and 115 provided test–retest reliability data. Participants also completed a battery of self-report measures that assess symptoms of anxiety, mood, and obsessive-compulsive and related disorders. Interrater reliability of DIAMOND anxiety, mood, and obsessive-compulsive and related diagnoses ranged from very good to excellent. Test–retest reliability of DIAMOND diagnoses ranged from good to excellent. Convergent validity was established by significant between-group comparisons on applicable self-report measures for nearly all diagnoses. The results of the present study indicate that the DIAMOND is a promising semistructured diagnostic interview for DSM-5 disorders.

Traditionally, hoarding symptoms were coded under obsessive-compulsive disorder (OCD), however, in DSM-5 hoarding symptoms are classified as a new independent diagnosis, hoarding disorder (HD). This change will likely have a considerable impact on the self-report scales that assess symptoms of OCD, since these scales often include items measuring symptoms of hoarding. This study evaluated the psychometric properties of one of the most commonly used self-report measures of OCD symptoms, the Obsessive-Compulsive Inventory-Revised (OCI-R), in a sample of 474 individuals with either OCD (n = 118), HD (n = 201), or no current or past psychiatric disorders (n = 155). Participants with HD were diagnosed according to the proposed DSM-5 criteria. For the purposes of this study the OCI-R was divided into two scales: the OCI-OCD (measuring the five dimensions of OCD) and the OCI-HD (measuring the hoarding dimension). Evidence of validity for the OCI-OCD and OCI-HD was obtained by comparing scores with the Saving Inventory Revised (SI-R), the Hoarding Rating Scale (HRS) and the Beck Anxiety Inventory (BAI). Receiver operating curves for both subscales indicated good sensitivity and specificity for cut-scores determining diagnostic status. The results indicated that the OCI-OCD and OCI-HD subscales are reliable and valid measures that adequately differentiate between DSM-5 diagnostic groups. Implications for the future use of the OCI-R in OCD and HD samples are discussed.

Internet-guided self-help (iGSH) has amassed significant empirical support for a variety of psychiatric conditions; however, it is not known who responds best to these treatments. This open trial examined the clinical outcomes and predictors of a 17-week iGSH program for obsessive-compulsive disorder (OCD). Therapist support was provided either in person or by phone 9 times for an average of 13minutes per session. Twenty-four patients initiated treatment, and 17 of these (70.8%) completed. Results of the intent-to-treat sample indicated statistically significant improvements at posttreatment with large treatment effects for OCD symptoms as assessed by the Yale Brown Obsessive-Compulsive Scale (d=0.87), and small to moderate improvements in depression (d=0.19), functioning (d=0.53), and quality of life (d=-0.18). These outcomes were largely maintained over a 6-month follow-up. Readiness to reduce avoidance of OCD triggers and attendance to therapist sessions were moderately associated with posttreatment response, and correctly classified the responder status (defined as clinically significant change) of nearly 9 out of 10 patients at posttreatment. These same variables did not predict responder status at 6-month follow-up. These results lend further empirical support to iGSH as a treatment for OCD and provide direction on the development of predictor models to identify patients who are and are not likely to acutely respond to iGSH.

Anxiety and related disorders are highly prevalent and costly to society. Fortunately, a large number of randomized controlled trials have demonstrated the efficacy of cognitive behavioral therapy (CBT) in the treatment of anxiety and related disorders. A smaller number of effectiveness studies have also demonstrated that similar outcomes to randomized controlled trials can be obtained in "real-world" settings. There is minimal research, however, into long-term outcomes in effectiveness research. This study describes the outcomes of 98 individuals with anxiety and related disorders treated in an outpatient, fee-for-service setting using a case formulation CBT approach. Participants were followed up each year after their discharge, for a period of 3 years. The results indicate that patients maintained their treatment gains, with large effect sizes obtained from pre-treatment to each follow-up time point (d=1.11-1.60). The results provide preliminary evidence to suggest that individuals treated with CBT in "real-world" settings maintain their treatment gains in the long-term.

Objectives The factor structure and clinical correlates of the Geriatric Anxiety Inventory were determined within a sample of patients with cognitive impairment. Methods Using a cross-sectional design, data were collected within an outpatient Memory Disorders Center. Clinical participants were diagnosed with either mild dementia (N = 45) or cognitive impairment, no dementia (N = 55). A comparison group of participants without subjective memory complaints (N = 50) was also included. The Geriatric Anxiety Inventory was administered and scored as both the 20-item version and 5-item short form. Measures of cognitive status, depressive symptoms, and functioning were also completed. Results Clinical participants reported more severe anxiety than did participants in the comparison group; however, the two patient groups did not differ. Principal components analysis revealed a four-factor structure of the Geriatric Anxiety Inventory. Item endorsement on factors characterized by excessive worry and difficulty making decisions were associated with a nearly twofold (odds ratio [OR]: 1.86) and nearly sixfold (OR: 5.70) odds of having cognitive impairment, respectively. The short-form version was composed of a single factor, and item endorsement was associated with a twofold increased odds of having cognitive impairment (OR: 2.02). Conclusion Psychometric properties of the Geriatric Anxiety Inventory are acceptable among patients with cognitive impairment. Anxiety symptoms were common, and symptoms characterized by excessive worry and difficulty making decisions demonstrated the strongest associations with cognitive status.

Social anxiety disorder (SAD) is a highly prevalent and often disabling disorder. This paper reviews the pharmacological treatment of SAD based on published placebo-controlled studies and published metaanalyses. It addresses three specific questions : What is the first-line pharmacological treatment of SAD? How long should treatment last? What should be the management of treatment-resistant cases? Based on their efficacy for SAD and common co-morbid disorders, tolerability and safety, selective serotonin reuptake inhibitors (SSRIs) and venlafaxine should be considered the first-line treatment for most patients. Less information is available regarding the optimal length of treatment, although individuals who discontinue treatment after 12–20 wk appear more likely to relapse than those who continue on medication. Even less empirical evidence is available to support strategies for treatment-resistant cases. Clinical experience suggests that SSRI non-responders may benefit from augmentation with benzodiazepines or gabapentin or from switching to monoamine oxidase inhibitors, reversible inhibitors of monoamine oxidase A, benzodiazepines or gabapentin. Cognitive-behavioural is a well-established alternative first line therapy that may also be a helpful adjunct in non-responders to pharmacological treatment of SAD. Received 24 May 2011 ; Reviewed 22 June 2011 ; Revised 16 December 2011 ; Accepted 18 January 2012 ; First published online 21 March 2012

Publisher Summary Pharmacotherapy is a reasonable option for most individuals with social anxiety disorder (SAD), given the degree of associated impairment and the efficacy of established medication treatments for the disorder. Pharmacological approaches to SAD have been shown to substantially reduce avoidance and psychological distress. Furthermore, both cognitive and physical symptoms of anxiety can interfere with optimal performance and ultimately lead to avoidance of feared situations; thus, medications that can directly decrease anxiety and physical symptoms typical of the disorder may help improve performance in social or professional situations. Finally, tendencies toward shyness and excessive concerns about social comparisons are likely to be strongly biologically based, given the early onset of behaviorally inhibited temperament, evidence of a significant genetic contribution from twin and family studies, and the biological salience of social hierarchies in the evolution of humans as a group-living species. These findings support the use of biologically based treatments. A number of medications have been studied for the treatment of SAD. Early reports suggested the potential value of MAOI, reversible inhibitors of MAO-A (RIMAs), and benzodiazepines. Most clinical trials have included predominantly or exclusively patients with the generalized type of SAD. This chapter presents a review of the research progress on pharmacotherapy for SAD over time.