Research

Aaron S. Breslow, Michelle Lopez, Barbara Warren, Jules Levin, Anjali Sharma, Dana Watnick, Ginette Sims, Elizabeth Cavic, Obioesio Bassey, Marla R. Fisher, and Laurie J. Bauman

Older women with HIV face challenges to their quality of life, including neurocognitive decline, early-onset menopause, and chronic health issues. Chief among these concerns is depression, the most common psychiatric comorbidity among people living with HIV, with rates twice as high among women as men. However, tailored interventions among older women living with HIV and depression are lacking. Following the ADAPT-ITT framework to adapt existing interventions for cultural relevance among groups of people living with HIV, the study team revised an evidence-based intervention, the ‘Stress Management and Relaxation Training/Expressive Supportive Therapy Women’s Project (SMART/EST),’ for online implementation. Working with two community stakeholders, the study team conducted focus groups, theater testing, and manual adaptation. This resulted in the development of e-SMART/EST, an online teletherapy group co-facilitated by a Licensed Psychologist and a credentialed Peer Counselor. The adapted, eight-session weekly intervention was tested with an exploratory pilot sample of eight older women (55 years and older) with HIV and depression. Participants rated the acceptability, feasibility, and appropriateness of the intervention, as well as symptoms of depression and HIV-related quality of life before and after the group. The e-SMART/EST Women’s Project demonstrated high acceptability, feasibility, and appropriateness. Engagement was high, as women attended an average of 6.8 sessions. In qualitative interviews, participants reported peer co-facilitation, culturally relevant themes (e.g., HIV-related minority stress, critical consciousness, grief, and sex and pleasure), mindfulness techniques, and cohesion with other women as main favorable elements of the intervention. Barriers to online implementation included technological issues, distractions due to remote participation, and hindered emotional attunement compared with in-person group therapy. Findings support further research to test similar interventions in full-scale trials with older women living with depression and HIV

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Ryan Herman, Elizabeth Cavic, Jae A. Puckett, Davy Ran, M. Paz Galupo, J Garrett-Walker, and Cindy B. Veldhuis

Introduction: There has been increasing attention to—and debate about—best practices related to gender measurement. We add to this conversation by testing whether an approach of providing participants with an extensive list of gender options and then having them self-select into a more limited group of choices (that cohere with the research questions) could be useful.

Methods:In this study of adults (N=1813), in 2021–2022, we measured gender using a three-part approach: the Gender EXPAND (EXPANsive responsive genDer) approach. Participants were frst asked if they identifed as transgender. They were then asked their current gender (check all that apply: woman, trans woman, trans feminine, man, trans man, trans masculine, nonbinary or genderqueer, agender, and an option to write in a response). Participants then selected a gender that best ft for them from a limited set of options (transgender, cisgender, nonbinary, unsure).

Results: We evaluated researcher reclassifcation from the expanded list of gender options compared to participant self-selection from the limited gender categories. We miscategorized 10.5% of participants when reclassifying their gender from the extensive list of options compared to their self-identification as transgender. We miscategorized 11.2% of participants compared to participants’ self-selection as cisgender, transgender, nonbinary, or unsure.

Conclusions: Participants generally responded well to the Gender EXPAND approach and our transparency in our explanations for our questions. This approach should be refned to reduce misclassifcation, potentially through diferent reclassifcation processes or modifed response categories.

Policy Implications: Measurement of gender has downstream implications for representation in data, which informs policy. Inadequate measurement can lead to inaccurate data and undercounting of gender diverse individuals and further marginalizes transgender and nonbinary people at a time when stigma and anti-transgender legislation is at an all-time high.

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Brandon Velez, Jillian R. Scheer, Christian N. Adames, Elizabeth Cavic, and Aaron S. Breslow

Developing affirming interventions for transgender and nonbinary (TNB) therapy clients requiresunderstanding their experiences with microaggressions in psychotherapy, yet no self-report measure of anti-TNB microaggressions in this context exists. Moreover, few studies have tested the associations betweenanti-TNB microaggressions and therapy processes. To better address the burden of unmet mental health careneeds among TNB people, this three-study investigation designed and tested the psychometric propertiesof the Gender Identity and Expression Microaggressions in Therapy Scale (GIEMTS), a measure of TNBindividuals’encounters with microaggressions in psychotherapy. Study 1 (N=225) identified a four-factormodel, comprising the themes of Educational Burdening, Lack of Affirmation, Inflation, and Invalidation.These subscales exhibited strong internal consistency reliabilities and demonstrated convergent anddiscriminant validity. The results of Study 2 (N=435) replicated the four-factor structure throughconfirmatory factor analysis. However, bifactor analysis revealed that the Educational Burdening, Inflation,and Invalidation subscale scores were mostly accounted by a General Anti-TNB Microaggressions scalescore–though Lack of Affirmation showed evidence of its independence. Also in Study 2, both scales wereuniquely negatively associated with the working alliance. Study 3 (N=151) found evidence for the test–retest reliability of GIEMTS scores over a 2–3-week period. Overall, the GIEMTS emerged as a robust andpsychometrically sound instrument that captures the experiences of TNB individuals in therapy settings.The study concludes with valuable recommendations for training and clinical practice to bolster TNB mental health.

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Aaron Samuel Breslow, Sherry Simkovic, Peter J. Franz, Elizabeth Cavic, Qi Liu, Natalie Ramsey, Jonathan E. Alpert, Benjamin Lê Cook, and Vilma Gabbay

Objective: Racial and ethnic disparities in exposure to COVID-19-related stressors, pandemic-related distress, and adverse mental health outcomes were assessed among health care workers in the Bronx, New York, during the first wave of the pandemic.

Methods: The authors analyzed survey data from 992 health care workers using adjusted logistic regression models to assess differential prevalence of outcomes by race/ethnicity and their interactions.

Results: Compared with their White colleagues, Latinx, Black, Asian, and multiracial/other health care workers reported significantly higher exposure to multiple COVID-19- related stressors: redeployment, fear of being sick, lack of autonomy at work, and inadequate access to personal protective equipment. Endorsing a greater number of COVID19-related stressors was associated with pandemic-related distress in all groups and with adverse mental health outcomes in some groups; it was not related to hazardous alcohol use in any of the groups. These associations were not significantly different between racial and ethnic groups. Latinx health care workers had significantly higher probabilities of pandemicrelated distress and posttraumatic stress than White colleagues. Despite greater exposure to COVID-19-related stressors, Black, Asian, and multiracial/other health care workers had the same, if not lower, prevalence of adverse mental health outcomes. Conversely, White health care workers had a higher adjusted prevalence of moderate to severe anxiety compared with Asian colleagues and greater hazardous alcohol use compared with all other groups.

Conclusions: Health care workers from racial and ethnic minority groups reported increased exposure to COVID-19- related stressors, suggestive of structural racism in the health care workforce. These results underscore the need for increased support for health care workers and interventions aimed at mitigating disparities in vocational exposure to risk and stress.

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Aaron S. Breslow, Melissa Fazzari, Peter J. Franz, David B. Hanna, Uriel R. Felson, Elizabeth Cavic, Marla R. Fisher, and Laurie Bauman.

Hospitalizations among people living with HIV (PLWH) are frequent and costly. This study examined the association between psychiatric, HIV-related, and demographic factors and hospitalization rates among PLWH using data from the Einstein–Rockefeller-City University of New York Center for AIDS Research Clinical Cohort Database. Of the 10,215 PLWH included in the sample, 45% had at least one non-psychiatric hospitalization between 2009 and 2018, with signifcant risk factors including prior psychiatric outpatient visits, depression, or alcohol-related disorder diagnoses, female sex, older age, CD4 count<500 cells/uL, and detectable viral load. Additionally, 14% had an HIV-related hospitalization, with signifcant risk factors including prior psychiatric outpatient visits, alcohol- and substance-related disorder diagnoses, female sex, older age, CD4 count<500 cells/uL, and detectable viral load. The study emphasizes the need for tailored interventions, including integrated treatment and comprehensive case management, for PLWH with comorbid psychiatric disorders, women, and older adults

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Emily J. Ricketts, Tara S. Peris, Jon E. Grant, Stephanie Valle, Elizabeth Cavic, Juliette E. Lerner, Christine Lochner, Dan J. Stein, Darin D. Dougherty, Joseph O’Neill, Douglas W. Woods, Nancy J. Keuthen, and John Piacentini

Body-focused repetitive disorders (BFRBDs) are understudied in youth and understanding of their underlying mechanisms is limited. This study evaluated BFRBD clinical characteristics, and two factors commonly implicated in their maintenance – emotion regulation and impulsivity – in 53 youth aged 11 to 17 years: 33 with BFRBDs and 20 controls. Evaluators administered psychiatric diagnostic interviews. Participants rated BFRBD severity, negative affect, quality of life, family functioning, emotion regulation, distress tolerance, and impulsivity. Youth with BFRBDs showed poorer distress tolerance and quality of life, and higher impulsivity and negative affect than controls, with no differences in family impairment. BFRBD distress/impairment, but not BFRBD severity, correlated with anxiety and depression, and poorer distress tolerance. Findings suggest youth with BFRBDs show clinical patterns aligning with prior research; highlight the role of distress tolerance in child BFRBDs; and suggest the utility of acceptance and mindfulness-based therapies for unpleasant emotions in BFRBDs. Continued research should evaluate factors underlying BFRBDs in youth.

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Marta Migó, Amy Peters, Tina Chou, Tara Peris, Emily Ricketts, Jon Grant, Elizabeth Cavic, John Piacentini, Darin Dougherty, Thilo Deckersbach,

Background: Impulse-control disorders, such as Trichotillomania (TTM) and skin-picking disorder (SPD), are associated with reduced flexibility and increased internally focused attention, which may negatively impact learning and flexible accommodation of new information. Using a Bayesian Learning Model, we evaluated the neural basis of learning and accommodation in individuals with TTM and SPD.

Methods: Participants were 26 healthy controls (HC) and 127 individuals with TTM and SPD recruited from three sites (age 18 e 57, 16% male). During fMRI, participants completed a shape-button associative learning and reversal task. Bilateral anatomical ROIs were defined, a-priori, in the basal ganglia, with exploratory analyses in the hippocampus, dorsolateral prefrontal cortex (dlPFC), and dorsal anterior cingulate cortex (dACC). An independent samples t-test comparing the groups in the Initial Learning-Reversal contrast was conducted in SPM8, with site as a covariate. Significant results achieved a false discovery rate correction of p < 0.05 with a minimum cluster size (k) of 16 voxels in the basal ganglia, and 15 voxels in the dlPFC and dACC.

Results: Relative to HC, patients demonstrated reduced activation during initial learning than reversal learning in the right basal ganglia (BA 48). Similarly, patients demonstrated reduced activation in several clusters in the dlPFC (BA 6/46 bilaterally, left BA 8) and dACC (left BA 24/32, right cingulate sulcus).

Conclusions: Individuals with TTM and SPD exhibit altered activation within the basal ganglia, dlPFC, and dACC during associative learning compared to controls, reflecting reduced frontal-subcortical activation during initial learning.

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Elizabeth Cavic, Stephanie Valle, Samuel R. Chamberlain, and Jon E. Grant

Background: Trichotillomania (TTM) is characterized by recurrent hair pulling and associated hair loss. Skin picking disorder (SPD) is characterized by recurrent skin picking and associated scarring or tissue damage. Both disorders are also accompanied by psychological distress and poor sleep. Very little, however, is known about lifestyle variables that may contribute to symptom severity in these disorders.

Methods: We recruited 87 adults as part of a cross-sectional study of 3 groups (TTM, SPD, and non-affected). Clinical subjects (n=69) were compared with controls (n=18) on sleep quality as measured by Pittsburgh Sleep Quality Index (PSQI). We used partial least squares regression to identify which variables were significantly associated with poor sleep quality among those participants with TTM or SPD.

Results: Clinical subjects had significantly poorer sleep quality than controls. Sleep quality was significantly related to older age, worse perceived stress, lower distress tolerance and greater impulsivity in adults with BFRBs. Poor sleep quality was associated with worse hair pulling symptom severity but not skin picking severity. Higher levels of comorbid mental disorders was also associated with worse sleep, above and beyond the impact of these other variables.

Conclusions: Poor sleep quality appears to be related to multiple variables. Further research is needed to determine causality and to tailor treatment to specific patient needs.

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Mauro Pettorruso, Stephanie Valle, Elizabeth Cavic, Giovanni Martinotti, Massimo di Giannantonio, Jon E. Grant

Problematic Internet Use (PIU) encloses excessive online activities (like video gaming, social media use, webstreaming, pornography viewing, buying). Despite its psychological burden, risk factors related to PIU remain still unclear. In the present study we explored the role of personality traits and emotion dysregulation as potential vulnerability factors for PIU. In a sample of American young adults with different PIU risk levels (established through the Internet Addiction Diagnostic Questionnaire), we administered the Tridimensional Personality Questionnaire (TPQ), the Difficulties in Emotion Regulation Scale (DERS), the Barratt Impulsiveness Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale. PIU participants were more likely to report lower TPQ scores in novelty seeking, harm avoidance and reward dependence. Moreover, DERS total scores significantly differed across PIU-risk groups, along with a progressively higher occurrence of depression, anxiety and impulsivity. These results preliminarily support the hypothesis of PIU as a mainly behavior aimed at ‘escaping’ from negative affects. Besides confirming the role of some personality traits and emotional dysregulation, we propose the concept of risk-trajectories to monitor and prevent the emergence of PIU. Gaining more insight into PIU vulnerability factors may allow us to establish targeted interventions to cope with emotion dysregulation and negative affects.

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Jon E. Grant, Stephanie Valle, Elizabeth Cavic, Sarah A. Redden, and Samuel R. Chamberlain

Background: Binge-eating disorder (BED) is associated with impaired quality of life and has a number of untoward public health associations. There are few established pharmacological treatments for BED, and available options are not suitable for all individuals. Vortioxetine is a recently developed pharmacological agent with effects on the serotonergic but also other neurochemical systems, which has yet to be evaluated in this context.

Method: Eighty adults with BED were recruited for a double-blind, placebo-controlled study. Participants received 12-week treatment with vortioxetine (10 mg/day for1 week, then increasing to 20 mg/day) or placebo in a parallel design. The primary efficacy outcome measures were binge-eating frequency and weight. Safety data were collected. Effects of active versus placebo treatment were characterized using linear repeated measures models.

Results: Both vortioxetine and placebo treatment were associated with significant reductions in binge-eating frequency. Vortioxetine did not differentiate significantly from placebo on any efficacy measure. Frequency of adverse events did not differ between groups.

Discussion: Vortioxetine was not more effective than placebo in the treatment ofBED. The ability to detect pharmacological treatment benefit may have been hindered by the relatively high placebo response and drop out. Future work should seek to better understand and predict placebo response in BED, with a view to more targeted treatment interventions and, potentially, sample enrichment.

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