To the Editor: Medical students report high rates of mental illness and/or psychiatric symptoms, but few ultimately seek care. 1 Despite this concerning trend, current understanding of the underlying reasons why many medical students forgo treatment remains incomplete. To evaluate these trends in a pilot qualitative study, 7 medical students in their third and fourth years at the University of Minnesota participated in a group interview in March 2020 related to mental illness, perceptions of stigma, and access to care. The results highlight several themes related to mental health and help-seeking behaviors among medical students. Concerns regarding mental illness focused on fear of discrimination, limited time to pursue care, and worries about one’s own competency. Many concerns reflected specific pressures and expectations placed on medical students as learners within the clinical environment, such as hesitancy to request time off or worry about being denied time off for mental health care. As one participant stated, “It feels almost like weakness to reach out for help”—a perception that was echoed by many of the participants. When discussing specific barriers to students and physicians seeking care for mental illness, there was universal agreement among participants that discriminatory attitudes within the medical field play a role. Throughout the group interview, “stigma” was a salient component of many responses and was discussed as an underlying factor in minimizing one’s behavior, one’s reluctance to pursue care, as well as a factor that negatively affected peers who needed help for a mental illness. Despite this, participants strongly supported others seeking care openly, even though this differed starkly from what they would do themselves. Although the small sample size and qualitative nature of this study limit the breadth and strength of our conclusions, it provides an initial inquiry into the perceptions that drive the culture around mental health in the medical field. Career and academic demands are often blamed for physicians’ and medical students’ reluctance to pursue care for mental illness; the themes highlighted in this group interview, however, suggest that the issue is far more complex and intersectional than might otherwise be assumed. Given this complexity, approaches to ameliorating barriers to psychiatric care must be multifocal and prioritize input from all affected stakeholders. Proactive scheduling and leave policies that affirm and promote access to health care may provide the most immediate benefit for medical professionals across career stages. Initial approaches could include increased availability of in-house counselors, diversified care options to fit individual needs, and resources to assist in identifying and accessing care. Longitudinal efforts will need to emphasize cultural shifts to redefine the concept of professionalism in medicine; in particular, care for self and family, sustained well-being, and limit-setting must be central in this process of normalizing and encouraging access to mental health care. While this longitudinal component is necessarily nebulous, effective approaches could incorporate sharing personal stories and narratives of accessing health resources successfully, especially from those in power. Acknowledgments: The authors give special thanks to the University of Minnesota Office of Measurement Services for conducting the focus group and providing qualitative data analysis.

Approximately 40% of patients treated for depression do not respond to a trial of an antidepressant. The aim of the proposed study was to evaluate the efficacy and safety of switching to vilazodone in patients with major depressive disorder who are unresponsive or only partially responsive to a trial of citalopram. Seventy-nine adults with major depressive disorder were enrolled in an open-label study of citalopram (20 mg/day) for 6 weeks. Those still symptomatic after 6-weeks of citalopram were randomly assigned to either a higher dose of citalopram (40 mg/day) or to vilazodone in a double-blind trial for 6 weeks. Of those who received citalopram 20 mg/day for 6 weeks, 20.3% were 'responders' (defined as ≥50% reduction on the Montgomery-Åsberg Depression Rating Scale). Of the 42 who did not respond, 23 were assigned to citalopram 40 mg/day and 19 were randomized to 40 mg/day of vilazodone. Both groups showed decreases in all outcome measures, but there were no significant differences between groups. Initial nonresponders to a low dose of citalopram seem equally likely to respond to a higher dose of citalopram or to vilazodone. Whether to increase an selective serotonin reuptake inhibitor or switch to a different antidepressant may be best determined on the basis of their adverse event profile.

ObjectiveAttention-deficit hyperactivity disorder (ADHD) has been associated with various manifestations of impulsivity in adults, including elevated rates of other impulsive disorders, substance use, questionnaire-based impulsivity scores, and inhibitory dysregulation on neurocognitive tests. The relationship between ADHD and all these other forms of impulsivity has yet to be explored within the context of a single comprehensive study.MethodsA total of 423 young adults, who gambled ≥5 times in the preceding year, were recruited using media advertisements and undertook detailed assessment including structured psychiatric interview, questionnaires, and neurocognitive tests. Participants with ADHD symptoms were identified using the Adult ADHD Self-Report Scale Screener (ASRS-V1.1) and were compared to controls using multivariate analysis of variance (MANOVA).ResultsADHD symptoms were found in 20.3% of the sample, but only 7.3% of these subjects had ever received a formal diagnosis. ADHD symptoms were associated with significantly lower quality of life, lower self-esteem, higher emotional dysregulation, higher impulsivity questionnaire scores, more problematic Internet use, greater occurrence of psychiatric disorders, and impaired stop-signal reaction times. Of these variables, stop-signal reaction times and Barratt attentional impulsiveness were the strongest predictors of group classification.ConclusionsADHD symptoms are common and under-diagnosed in young adults who gamble, and are most strongly linked with certain other types of impulsivity (questionnaire- and cognitive-based measures) and with emotional dysregulation, suggesting that these are each important considerations in understanding the pathophysiology of the disorder, but also potential treatment targets. It is necessary to question whether treatment for adult ADHD could be enhanced by considering self-esteem, emotional reactivity, and impaired inhibitory control as specific treatment targets, in addition to the core diagnostic symptoms of the disorder.

ObjectiveGambling is a commonplace phenomenon, existing along a continuum from occasional gambling to functionally impairing gambling disorder. The internet may act as a conduit for some gambling behaviors. The impact of problematic internet use on clinical and cognitive features relevant to gambling has received little research attention.MethodsA total of 206 adults aged 18–30 years who gamble at least five times per year were recruited from the general community and undertook detailed clinical and cognitive assessments. Problematic internet use was defined using a total score of 5 or more on Young’s Diagnostic Questionnaire (YDQ). Linear regression was employed to evaluate the relative contribution of addictive-related, impulsive-related, and compulsive-related measures in predicting YDQ total scores in gamblers.ResultsGamblers with problematic internet use (18% of the sample) reported lower quality of life, lower self-esteem, elevated rates of intermittent explosive disorder, gambling disorder symptoms, attention deficit hyperactivity disorder (ADHD) symptoms, antisocial personality disorder, and posttraumatic stress disorder (PTSD), as well as relative deficits in decision making and spatial working memory. In linear regression, the extent of problematic internet use was most significantly associated with increased gambling disorder symptoms and increased ADHD symptoms.ConclusionsProblematic internet use in gamblers is associated with worse quality of life, more problem/pathological gambling symptoms, more psychiatric morbidities, and select cognitive impairment. Refinement of the definition of problematic internet use and exploration of its clinical and cognitive associations are likely to be highly relevant to the treatment of problematic gambling.

a Department of Psychiatry, University of Cambridge, UK b Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK c Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, USA d SU/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, University of Stellenbosch, South Africa e Department of Psychiatry and Mental Health, University of Cape Town, South Africa

While it is well established that gambling disorder is associated with alcohol use disorder, less is known regarding whether sub-clinical alcohol consumption increases gambling behavior. This study examined the effects of varying levels of alcohol consumption on clinical and cognitive measures. The sample consisted of 572 non-treatment seeking gamblers age 18-29 who were divided into three groups: non-current drinkers, current drinkers who did not qualify for an alcohol use disorder, and those with an alcohol use disorder (AUD). All subjects were assessed on gambling pathology, severity and impulsivity using the Structured Clinical Interview for Gambling Disorder, Yale Brown Obsessive Compulsive Scale for Pathologic Gambling and the Barratt Impulsive Scale-11 and select cognitive tests. In all of the clinical measures, controlling for age, gender and education, the AUD group was significantly more likely than the non-current and current drinkers to be a pathologic gambler and to be impulsive, compulsive and depressed. On cognitive tasks, controlling for age, gender and education, the AUD group had significantly worse strategy use on a spatial working memory task than both other groups. This study suggests that the relationship between alcohol and gambling may only exist when pathology in both alcohol consumption and gambling behavior is present. Examining this relationship with alcohol consumption as a continuous variable would provide additional insight into the potential effects alcohol consumption has on gambling behavior.

Behavioral addictions are defined as behaviors characterized by the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. These disorders share many similarities with substance addictions but may have unique treatment considerations. This category of disorders includes many separate behaviors, but some of the most common are gambling disorder, Internet addiction, compulsive buying, and compulsive sexual behavior. Although research remains limited on the neurobiology and treatment of these disorders, some limited evidence to date can help guide initial treatment recommendations. Additional research will be necessary to clarify the optimal treatment approach for these disorders, however. This review provides a general discussion of available research related to these four disorders, including neurobiological, epidemiologic, and treatment considerations. Key words: behavioral addiction, gambling, Internet, neurobiology, phenomenology, sex, shopping, treatment

This chapter discusses research findings regarding body dysmorphic disorder (BDD) and eating disorders, and it provides guidelines for distinguishing between them. BDD and eating disorders show many similarities, including negative and distorted body image, decreased quality of life, compensatory behaviors such as dieting, and abnormalities in visual processing. Patients with BDD express specific concerns with different parts of their bodies and physical appearance; common examples are complexion, nose, breasts/genitals, and hair. In patients who have prominent concerns about weight and body fat and shape, however, the diagnosis of BDD can be complicated because such concerns can occur as a symptom of BDD but also overlap with those in eating disorders such as anorexia nervosa and bulimia nervosa. BDD and eating disorders are often comorbid, which is accompanied by notably higher rates of suicidality and psychiatric hospitalization than occur in patients with either disorder alone. BDD and eating disorders represent distinct pathologies, and it is important to distinguish between them, particularly given the increased risk of suicidality when the disorders are comorbid.

Chronic disruptive and impulsive behaviors, such as kleptomania, pyromania, and intermittent explosive disorder, are significant concerns for clinicians treating psychiatric disorders due to their persistence and potential legal ramifications. To date, only a few studies have assessed treatment options for pyromania, oppositional defiant disorder, intermittent explosive disorder, kleptomania, disruptive mood dysregulation disorder, and conduct disorder. This review discusses the clinical presentation of these disorders and the available literature on their treatment, focusing primarily on randomized controlled studies. Due to the paucity of available clinical studies for these disorders, however, case studies and open trials are mentioned for reference. Summaries of supported pharmaceutical and psychological interventions are provided for each disorder. Key words: adolescents, aggression, crime, fire setting, impulsivity, stealing, theft, treatment

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.

Objectives: Problem gamblers with symptoms of antisocial personality disorder (ASPD) may represent a distinct problem gambling subtype, but the neurocognitive profile of individuals affected by both disorders is poorly characterized.Method: Non-treatment-seeking young adults (18-29 years) who gambled >= 5 times in the preceding year were recruited from the general community. Problem gamblers (defined as those meeting >= 1 DSM-5 diagnostic criteria for gambling disorder) with a lifetime history of ASPD (N = 26) were identified using the Mini International Neuropsychiatric Interview (MINI) and compared with controls (N = 266) using questionnaire-based impulsivity scales and objective computerized neuropsychological tasks. Findings were uncorrected for multiple comparisons. Effect sizes were calculated using Cohen's d.Results: Problem gambling with ASPD was associated with significantly elevated gambling disorder symptoms, lower quality of life, greater psychiatric comorbidity, higher impulsivity questionnaire scores on the Barratt Impulsiveness Scale (d = 0.4) and Eysenck Impulsivity Questionnaire (d = 0.5), and impaired cognitive flexibility (d = 0.4), executive planning (d = 0.4), and an aspect of decision-making (d = 0.6). Performance on measures of response inhibition, risk adjustment, and quality of decision making did not differ significantly between groups.Conclusions: These preliminary fmdings, though in need of replication, support the characterization of problem gambling with ASPD as a subtype of problem gambling associated with higher rates of impulsivity and executive function deficits. Taken together, these results may have treatment implications. (C) 2017 Elsevier Inc. All rights reserved.

This chapter summarizes the clinical characteristics and treatment of trichotillomania and skin picking disorder (excoriation), collectively known as body focused repetitive behavior disorders. These two conditions are found in the new chapter on OCD and related disorders in DSM-5; skin picking disorder is a new DSM diagnosis. They are conceptualized as related to OCD due to the repetitive nature of the symptomatology, but they also differ in important ways. The neural underpinnings of these disorder are only beginning to come into focus, and much work is needed. The best-proven psychotherapy for these conditions is a form of CBT known as habit reversal therapy. Principles of pharmacotherapy are not clearly established, though there have been promising early studies of a number of agents.

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Although gambling disorder (GD) is often characterized as a problem of impulsivity, compulsivity has recently been proposed as a potentially important feature of addictive disorders. The present analysis assessed the neurocognitive and clinical relationship between compulsivity on gambling behavior. A sample of 552 non-treatment seeking gamblers age 18-29 was recruited from the community for a study on gambling in young adults. Gambling severity levels included both casual and disordered gamblers. All participants completed the Intra/Extra-Dimensional Set Shift (IED) task, from which the total adjusted errors were correlated with gambling severity measures, and linear regression modeling was used to assess three error measures from the task. The present analysis found significant positive correlations between problems with cognitive flexibility and gambling severity (reflected by the number of DSM-5 criteria, gambling frequency, amount of money lost in the past year, and gambling urge/behavior severity). IDED errors also showed a positive correlation with self-reported compulsive behavior scores. A significant correlation was also found between IDED errors and non-planning impulsivity from the BIS. Linear regression models based on total IDED errors, extra-dimensional (ED) shift errors, or pre-ED shift errors indicated that these factors accounted for a significant portion of the variance noted in several variables. These findings suggest that cognitive flexibility may be an important consideration in the assessment of gamblers. Results from correlational and linear regression analyses support this possibility, but the exact contributions of both impulsivity and cognitive flexibility remain entangled. Future studies will ideally be able to assess the longitudinal relationships between gambling, compulsivity, and impulsivity, helping to clarify the relative contributions of both impulsive and compulsive features.

BACKGROUND Trichotillomania (TTM) appears to be a fairly common disorder, yet little is known about sex differences in its clinical presentation. Long thought to be a primarily female disorder, males with TTM may have unique clinical presentations. METHODS Participants with TTM (N = 462) were examined on a variety of clinical measures including symptom severity, functioning, and psychiatric comorbidity. Clinical features were compared between males (n = 27) and females (n = 435). RESULTS There were many similarities in the clinical presentations of males and females with TTM. Males with TTM, however, were more likely to pull from their face, arms, and torso, and were more likely to suffer from a co-occurring substance use disorder. Females were more likely to be younger and less likely to be married. CONCLUSIONS This study suggests that, although few males seek treatment for TTM, sex differences may be an important clinical factor when assessing and treating this disorder. Further research is needed to validate these findings and identify whether treatments should be tailored differently for males and females with TTM.

Clemens W. Janssen, PhD; Christopher A. Lowry, PhD; Matthias R. Mehl, PhD; John J. B. Allen, PhD; Kimberly L. Kelly, MPA; Danielle E. Gartner, BA; Angelica Medrano, BA; Tommy K. Begay, PhD; Kelly Rentscher, MA; Joshua J. White, BS; Andrew Fridman, BS; Levi J. Roberts, BA; Megan L. Robbins, PhD; Kay-u Hanusch, MSc; Steven P. Cole, PhD; Charles L. Raison, MD