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

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

Genetic and environmental aetiologies of associations between dispositional mindfulness and ADHD traits: a population-based twin study

© The Author(s) 2019. To get additional insight into the phenotype of attentional problems, we examined to what extent genetic and environmental factors explain covariation between lack of dispositional mindfulness and attention-deficit/hyperactivity disorder (ADHD) traits in youth, and explored the incremental validity of these constructs in predicting life satisfaction. We used data from a UK population-representative sample of adolescent twins (N = 1092 pairs) on lack of dispositional mindfulness [Mindful Attention Awareness Scale (MAAS)], ADHD traits [Conners’ Parent Rating Scale-Revised (CPRS-R): inattentive (INATT) and hyperactivity/impulsivity (HYP/IMP) symptom dimensions] and life satisfaction (Students’ Life Satisfaction Scale). Twin model fitting analyses were conducted. Phenotypic correlations (rp) between MAAS and CPRS-R (INATT: rp = 0.18, HYP/IMP: rp = 0.13) were small, but significant and largely explained by shared genes for INATT (% rp INATT–MAAS due to genes: 93%, genetic correlation rA = 0.37) and HYP/IMP (% rp HYP/IMP–MAAS due to genes: 81%; genetic correlation rA = 0.21) with no significant contribution of environmental factors. MAAS, INATT and HYP/IMP significantly and independently predicted life satisfaction. Lack of dispositional mindfulness, assessed as self-reported perceived lapses of attention (MAAS), taps into an aspect of attentional functioning that is phenotypically and genetically distinct from parent-rated ADHD traits. The clinically relevant incremental validity of both scales implicates that MAAS could be used to explore the underlying mechanisms of an aspect of attentional functioning that uniquely affects life satisfaction and is not captured by DSM-based ADHD scales. Further future research could identify if lack of dispositional mindfulness and high ADHD traits can be targeted by different therapeutic approaches resulting in different effects on life satisfactio

Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by symptoms of inattention and/or symptoms of hyperactivity and impulsivity. ADHD in adulthood is one of the most highly prevalent psychiatric conditions, affecting 3–4 % of adults in the USA. Adults with ADHD have been found to have impairment broadly in academic, behavioral, and social domains. Although stimulants and other medications have been shown to reduce core neurobiological symptoms for many adults with this disorder, many adults with ADHD continue to experience significant residual symptoms while on medications or cannot tolerate the medications due to side effects. Even those who do respond to medications typically have significant continued symptoms. As a result, many adults with ADHD may require psychosocial treatment. Traditionally there have been relatively few resources available to clinicians. In the last decade, however, several treatment approaches have received empirical support. The present chapter provides an overview of the diagnostic features and clinical presentations of adults with ADHD, an overview of the cognitive behavioral therapy developed through a series of research studies at Massachusetts General Hospital, and a case example illustrating the use of the techniques described

The Complicated Relationship Between Attention Deficit/Hyperactivity Disorder and Substance Use Disorders

Adolescents and young adults with substance use disorders (SUD) and attention deficit/hyperactivity disorder (ADHD) are increasingly presenting in clinical practice. The overlap and role of treatment for these co-occurring disorders remains unclear. A review of the literature was conducted to highlight and update recent evidence on the overlap of ADHD and SUD, the role of ADHD medication on later SUD, and the treatment of ADHD and SUD in adolescents and young adults. Recent work continues to highlight the high risk for comorbid ADHD in patients with SUD; and conversely, the high risk for SUD developing in ADHD across the lifespan, particularly in the context of comorbid conduct disorder. Although the data remains discordant, it appears that ADHD pharmacotherapy does not increase the risk for SUD. Medication treatment alone does not appear to be particularly effective in treating SUD in currently active substance abusing individuals with ADHD. Structured therapies may be effective in treating adolescents and young adults with ADHD and SUD. Further controlled trials evaluating the sequence and effect of structured psychotherapies and/or ADHD pharmacotherapy on SUD relapse in these groups are warranted

Attention-Deficit/Hyperactivity Disorder Symptom Profiles in Medication-Treated Adults Entering a Psychosocial Treatment Program

Although medications are the most widely studied effective treatments for adults with attention-deficit/hyperactivity disorder (ADHD), patients treated with medications often have significant residual symptoms that may be amenable to psychosocial intervention. Few studies, however, report on the structure and severity of specific residual ADHD symptoms in adult patients who have been treated with medications. This information may be important in identifying the most important psychosocial treatment targets for medicated adults with ADHD with residual symptoms. Identify which symptoms of ADHD are most frequent and severe for medication-treated adults. Identify meaningful factors underlying self-report and clinician ratings in this group. Self-reported and clinician-rated ADHD symptom data from 105 adults in the community already receiving medication treatment who were entering cognitive behavioral therapy studies were examined. First, we examined the frequency and severity of each of the 18 ADHD symptoms that were present in the sample. Second, we conducted exploratory factor analyses of self-reported and clinician-rated ADHD symptoms to best describe the structure of residual symptoms in medication-treated adults, Lastly, we examined the association of the resulting factor scores with clinician-rated global ADHD severity (Clinical Global Impressions) and functional impairment (Global Assessment of Functioning) scales to determine which factors relate to overall severity. The 2 most frequent (self-reported and clinician-rated) residual symptoms were disorganization (85%-88%) and distractibility (74%-83%). Exploratory factor analyses for both self-reported and clinician-rated data yielded a 3-factor model: (1) Hyperactivity/Restlessness, (2) Impulsivity/Poor Prospective Memory, and (3) Inattention. Using multiple regression, the Inattention factor from self-reported and clinician-rated data was most strongly, consistently, and uniquely related to clinician ratings of both illness severity and functioning. In this sample, disorganization and distractibility were the most frequent and clinically significant residual symptoms; therefore, these should be important targets in psychosocial treatments for this population. Scoring symptom rating scales in medication-treated adults with ADHD using Hyperactivity. Restlessness, Impulsivity/Poor Prospective Memory, and Inattention factors may be more informative with respect to evaluating psychosocial treatment outcome than overall scale scores alone

Recent developments in the psychosocial treatment of adult ADHD

Adult attention-deficit/hyperactivity disorder (ADHD) is an increasingly recognized Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV psychiatric disorder associated with significant functional impairment in multiple domains. Although stimulant and other pharmacotherapy regimens have the most empirical support as treatments for ADHD in adults, many adults with the disorder continue to experience significant residual symptoms. In the present manuscript, we review the published studies examining group and individual psychosocial treatments for adult ADHD. We include a discussion of coaching interventions and how they differ from cognitive–behavioral therapy. We conclude that the available data support the use of structured, skills-based psychosocial interventions as a viable treatment for adults with residual symptoms of ADHD. Common elements across the various treatment packages include psychoeducation, training in concrete skills (e.g., organization and planning strategies) and emphasis on outside practice and maintenance of these strategies in daily life. These treatments, however, require further study for replication, extension and refinement. Finally, we suggest future directions for the application of psychosocial treatments to the problems of adults with ADHD

Life Impairments in Adults With Medication-Treated ADHD

Objective: In developing psychosocial approaches to augment outcomes for medication-treated adults with ADHD, it is important to understand what types of life-impairments are most affected by continued ADHD symptoms that occur despite medication treatment. This may assist in delineating targets for interventions, as well as assessments of functional outcomes that are sensitive to change in this population. Method: The sample consists of 105 adults with ADHD presenting for entry into clinical trials of CBT for residual ADHD. Life impairments are rated by a clinician using the LIFE-RIFT, which has subscales for work impairment, interpersonal impairment, life-satisfaction, and recreation, ADHD symptoms using the ADHD Rating Scale, overall ADHD severity using the clinical global impression, and associated distress using the Hamilton Depression and Anxiety Rating Scales. Results: The most problematic impairments are in the domain of work, followed by interpersonal. Generally, the subscales of the LIFE-RIFT are associated, at the bivariate level, with all 4 symptom indices. Work and interpersonal impairments are uniquely associated with overall severity of ADHD symptoms using both the CGI and the ADHD Rating Scale. However interpersonal and life-satisfaction impairments are uniquely associated with depression, and life-satisfaction is uniquely associated with anxiety. Conclusion: In medication-treated adults with ADHD, work and interpersonal impairments appear to be the most problematic areas of life-impairment, which are uniquely associated with ADHD severity. Life-satisfaction appears to be uniquely associated with distress as defined by anxiety and depression symptoms, with interpersonal impairments also playing a role. Psychosocial treatments for medication treated adults should target work and interpersonal domains and should include skills for managing associated distress

Description and Demonstration of CBT for ADHD in Adults

ADHD in adulthood is a valid, prevalent, distressing, and interfering condition. Although medications help treat this disorder, there are often residual symptoms after medication treatment, and, for some patients, they are contraindicated. Compared to other disorders, such as mood and anxiety disorders, there are few resources available for clinicians wishing to conduct cognitive-behavioral treatment for this problem. The present manuscript provides a description of our cognitive-behavioral approach to treat ADHD in adulthood, which we have developed and tested in our clinic (Safren, Otto, et al., 2005), and for which detailed therapist and client guides exist (Safren, Perlman, Sprich, & Otto, 2005; Safren, Sprich, Perlman, & Otto, 2005). To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment. This description and the accompanying demonstrations are intended as a practical guide to assist therapists wishing to conduct such a treatment in the outpatient setting

Cognitive-Behavioral Therapy for ADHD in Adolescents: Clinical Considerations and a Case Series

Although ADHD in adolescents is an impairing and prevalent condition, with community prevalence estimates between 2% and 6%, psychosocial treatments for adolescents compared to younger children are relatively understudied. Our group has successfully developed an evidence base for cognitive-behavioral therapy (CBT) for ADHD in medication-treated adults with ADHD with clinically significant symptoms. In the current paper, we describe an adaptation of this treatment to adolescents, and provide case reports on 3 adolescents who participated in an open pilot trial. The results suggest that the treatment approach was well tolerated by the adolescents and that they experienced clinical benefit. This early report of the approach in adolescents is promising and requires further efficacy testing