Publications by authors named "Melissa M Norberg"

65 Publications

The psychology of object attachment: Our bond with teddy bears, coffee mugs, and wedding rings.

Curr Opin Psychol 2021 Jun 8;39:v-x. Epub 2021 Mar 8.

J.L. Kellogg School of Management at Northwestern University, Evanston, United States.

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http://dx.doi.org/10.1016/j.copsyc.2021.03.002DOI Listing
June 2021

The Empirical Status of Cue Exposure and Response Prevention Treatment for Binge Eating: A Systematic Review.

Behav Ther 2021 03 17;52(2):442-454. Epub 2020 Jun 17.

Centre for Emotional Health, Macquarie University.

Approximately 50% of individuals fail to obtain treatment benefits when undergoing cognitive-behavioral therapy (CBT) for binge-eating behaviors, making it necessary to evaluate additional approaches. Cue exposure and response prevention (CERP) is one such approach, although its effectiveness across studies has been inconsistent. This may be due to inconsistent implementation of theoretically based CERP strategies. This possibility has not yet been systematically investigated. To address this gap, this review investigated which CERP strategies have been incorporated into treatment protocols for binge eating, and if the use of certain strategies improves treatment effectiveness. Relevant studies were identified through reference lists, grey literature, and searches of electronic databases using multiple search terms related to CERP and binge eating, which resulted in 18 eligible studies. Most studies were underpowered, many were of low methodological quality, and none of the included studies utilized all of the strategies that have been recommended to optimize CERP. Despite these weaknesses, CERP appeared to reduce the frequency of binge eating in the short and long term. This review underscores the need for higher quality research that utilizes larger samples and uniform outcome measures that are more strongly grounded in theory. Such research would help improve treatment outcomes for binge eating.
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http://dx.doi.org/10.1016/j.beth.2020.06.005DOI Listing
March 2021

Reevaluating Cue Exposure and Response Prevention in a Pilot Study: An Updated Treatment for Binge Eating Disorder.

Behav Ther 2021 01 19;52(1):195-207. Epub 2020 Apr 19.

Macquarie University.

Approximately half of individuals with binge eating disorder (BED) fail to improve when treated with cognitive behavioral therapy; thus, better treatments are needed. Cue exposure and response prevention (CERP) may be one option, but its full potential for reducing binge eating remains unknown because prior applications for binge eating have not utilized the broad range of strategies believed to optimize exposure therapy. The current single-subject AB design investigated the acceptability and effectiveness of a comprehensive CERP treatment among 8 women who met DSM-5 criteria for binge eating disorder. Changes in the number of binges were measured from baseline to the end of treatment, and desire to eat, salivation, and idiographic expectancies of aversive outcomes to food-cue exposure (idiographic CS-US expectancies), including expectancies about ability to tolerate distress when exposed to food cues were measured across the course of treatment. Statistical analysis revealed a significant reduction in the number of binges from baseline to the end of treatment. Across the course of treatment, desire to eat and idiographic CS-US expectancies reduced, and distress tolerance expectancies increased. No participants dropped out and all reported being maximally satisfied with the treatment. Based on these findings, future randomized-control trials with larger samples should examine the efficacy of CERP and mechanisms underlying change with the aim of establishing a more effective treatment for binge eating disorder.
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http://dx.doi.org/10.1016/j.beth.2020.04.003DOI Listing
January 2021

Motives for acquiring and saving and their relationship with object attachment.

Curr Opin Psychol 2021 Jun 17;39:1-5. Epub 2020 Jul 17.

Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney 2109, NSW, Australia. Electronic address:

Motives for acquiring and saving objects are closely linked to object attachment, but the nature of these associations has not been established. A better understanding of the motives for acquiring and saving possessions and how they relate to object attachment may reveal insights into the underpinnings of hoarding disorder. In turn, these insights can aid in identifying optimal targets for interventions for hoarding problems. In this paper, we propose a simple theoretical model of the dynamic associations among motives to acquire objects, object attachment, and motives to save objects, grounded in a review of the extant literature. Our hope is that this model provides a useful framework to structure future research.
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http://dx.doi.org/10.1016/j.copsyc.2020.07.007DOI Listing
June 2021

Development and psychometric evaluation of the Caffeinated Alcoholic Beverages Motives Questionnaire.

Psychol Addict Behav 2021 Mar 21;35(2):160-171. Epub 2020 May 21.

Department of Psychology, Macquarie University.

Caffeinated alcoholic beverage (CAB) consumption is a risky drinking practice for young people. The purpose of the current set of studies was to develop and psychometrically evaluate a theory-based CAB motives measure to understand what drives CAB consumption and its ensuing consequences. Using 4 different samples, we pilot tested the items of the Caffeinated Alcohol Beverages Motives Questionnaire (CABMQ) and then evaluated its factor structure and its convergent, concurrent, and discriminant validity. Factor analyses supported a 5-factor structure. The coping and conformity subscales assessed negative reinforcement from internal and external sources, respectively. The social subscale assessed positive reinforcement derived from external sources, whereas the intoxication and energy enhancement subscales assessed positive reinforcement derived from internal sources. Differential relationships between the intoxication and energy enhancement subscales and existing motives measures provided compelling support for their individual distinctiveness. Greater endorsement of all subscales was related to experiencing more adverse alcohol-related consequences, whereas all subscales but the conformity subscale were related to greater CAB consumption. After controlling for general drinking motives, coping motives, energy enhancement motives, intoxication enhancement motives, and social motives were significantly correlated with CAB use, whereas only energy enhancement motives were significantly correlated with alcohol-related consequences. In sum, these results show that the CABMQ helps us understand CAB use and its consequences, with the energy enhancement subscale being particularly helpful. Future research should examine if energy enhancement motives explain why CABs pose more risk than drinking alcohol on its own. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/adb0000607DOI Listing
March 2021

Community pharmacists as a resource in task-shifted interventions for depression.

Lancet Psychiatry 2020 05;7(5):e24

Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/S2215-0366(20)30096-1DOI Listing
May 2020

Trait Versus Task-Induced Emotional Reactivity and Distress Intolerance in Hoarding Disorder: Transdiagnostic Implications.

Behav Ther 2020 01 24;51(1):123-134. Epub 2019 May 24.

UNSW Sydney.

Evidence from analogue samples suggests that deficits in emotional functioning, namely elevated emotional reactivity and distress intolerance, are implicated in the development and maintenance of hoarding disorder. We aimed to extend previous research in this area by investigating emotional reactivity and distress intolerance in a sample of individuals diagnosed with hoarding disorder (n = 24) in comparison to clinical controls (n = 21) and nonclinical community controls (n = 26) using a combination of self-report, physiological, and behavioral measures. We found that trait distress intolerance was significantly and independently associated with greater hoarding severity. The hoarding and clinical control groups reported more trait emotional reactivity and distress intolerance than the community control group, but did not differ from each other on these traits. The hoarding group reported more subjective distress before beginning a frustrating behavioral task, but did not evidence more physiological arousal. Moreover, the hoarding group experienced similar increases in distress during the task and did not differ from either group in regard to time persisting on this task. The clinical control group, however, terminated the frustrating task significantly faster than the community control group, who tended to persist until the task timed out. Lastly, trait distress intolerance evidenced a small-to-moderate but nonstatistically significant independent relationship with task persistence time. Given the desynchrony between subjective distress and physiological arousal, we encourage researchers to utilize multimodal assessment in the future. We also suggest that clinicians start to use behavioral experiments, as has been done with other psychological disorders, to improve distress intolerance among persons who experience hoarding disorder.
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http://dx.doi.org/10.1016/j.beth.2019.05.010DOI Listing
January 2020

Determinants of object choice and object attachment: Compensatory consumption in compulsive buying-shopping disorder and hoarding disorder.

J Behav Addict 2020 04 1;9(1):153-162. Epub 2020 Apr 1.

School of Psychology,UNSW Sydney, Kensington, NSW,Australia.

Background And Aims: Individuals who meet criteria for compulsive buying-shopping disorder (i.e., acquiring problems only) or hoarding disorder (i.e., acquiring and discarding problems) may acquire possessions to compensate for unmet belonging needs, but may do so in different ways. Those with compulsive buying-shopping disorder may acquire objects that they believe will relieve the distress associated with unmet belonging needs (e.g., objects that distract or comfort), whereas those with hoarding disorder may acquire objects that they believe achieve belonging needs (e.g., objects that have interpersonal connotations). Accordingly, this study examined whether a belongingness threat would drive individuals who excessively acquire possessions to choose a human-like object (person-shaped tea holder) or a comfort item (box of chamomile tea).

Methods: One hundred seventy-five participants (57 self-reported excessive acquiring only; 118 self-reported excessive acquiring and difficulty discarding) recalled a time when they either felt supported or unsupported by a significant other before choosing an object to take home with them. Participants rated how anthropomorphic and comforting the objects were as well as how attached they became to their chosen object.

Results: Unsupported individuals were more likely to acquire the comfort item than supported individuals; however, individuals with both acquiring and discarding problems were more likely to acquire the human-like item than those with an acquiring problem only. Comfort and anthropomorphism ratings predicted object choice and attachment.

Discussions And Conclusion: The current findings extend the Compensatory Consumer Behavior Model to include what factors determine strategy choice and object attachment.
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http://dx.doi.org/10.1556/2006.8.2019.68DOI Listing
April 2020

Correction to: A smartphone app intervention for adult cannabis users wanting to quit or reduce their use: a pilot evaluation.

J Cannabis Res 2019 Nov 1;1(1):10. Epub 2019 Nov 1.

National Cannabis Prevention and Information Centre, UNSW Sydney, Kensington, NSW, Australia.

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http://dx.doi.org/10.1186/s42238-019-0010-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819332PMC
November 2019

A smartphone app intervention for adult cannabis users wanting to quit or reduce their use: a pilot evaluation.

J Cannabis Res 2019 Aug 16;1(1). Epub 2019 Aug 16.

National Cannabis Prevention and Information Centre, UNSW Sydney, Kensington, NSW, Australia.

Background: Smartphone applications (apps) offer a promising alternative to face-to-face treatment due to their ease of access and convenience. However, there is a lack of evidence-based apps for cannabis users wishing to reduce their use.

Objectives: The current study evaluated the feasibility and acceptability of a smartphone app intervention (called Assess, Plan, Track, and Tips [APTT]) for cannabis users wanting to reduce their use.

Method: The current study included 111 cannabis users (68% male, aged 18-50 yrs) who had used cannabis in the past month, were not currently in treatment, and who wanted to reduce/quit their use. Participants were given access to APTT for 1 month. Participants reported on their cannabis use and related problems, confidence in resisting use, severity of dependence, and stage of change at baseline, post-intervention (4 weeks), and at 1-month follow-up. At post-intervention, participants also reported on their usage and satisfaction with the app.

Results: The current study found that APTT was acceptable, with over 40% of participants using the app over 20 times over the course of a month. Participants showed a reduction in dependence and cannabis related problems over the course of the study. Further, participants' stage of change at baseline predicted changes in cannabis use.

Conclusions/importance: These findings support the feasibility and acceptability of APTT as an engaging app for cannabis users wishing to better manage their use and support the need for future RCTs to assess the efficacy of mobile-based interventions for cannabis users.
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http://dx.doi.org/10.1186/s42238-019-0009-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819295PMC
August 2019

Why are caffeinated alcoholic beverages especially risky?

Addict Behav 2019 11 26;98:106062. Epub 2019 Jul 26.

Durham VA Medical Center, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.

Purpose: Evidence suggests that people drink more alcohol and experience more adverse alcohol-related consequences (ARCs) on occasions when they also consume caffeine. The current study examined whether this increase in risk is a result of caffeine attenuating the subjective effects of alcohol intoxication (i.e., the masking hypothesis).

Methods: Undergraduate students (n = 148) reported their drinking patterns using a modified Timeline Followback approach. For each recalled drinking occasion, alcohol consumption, caffeine consumption, perceived blood alcohol concentration, and ARCs were assessed. Generalized linear mixed models were used to examine the influence that alcohol and caffeine consumption had on perceived intoxication and the experience of ARCs.

Results: At the occasion level, greater caffeine consumption was associated with increased consumption of alcohol and increased ARCs. There was also a significant curvilinear relationship between the amount of alcohol consumed and perceived intoxication, such that the more alcohol was consumed on each occasion the less each additional drink increased perceived intoxication. Increased caffeine consumption weakened the association between alcohol consumption and perceived intoxication and it also weakened the association between alcohol consumption and ARCs. Specifically, the weakest relationship between ARCs and alcohol consumption existed at the highest level of caffeine consumption (240+ mg). Caffeine increased subjective intoxication.

Conclusions: These findings do not support the masking hypothesis. Caffeine was strongly associated with ARCs when consumed at high doses and this effect does not appear to be the result of drinking more alcohol or underestimating one's blood alcohol content. Efforts to reduce caffeinated alcohol beverage use are greatly needed.
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http://dx.doi.org/10.1016/j.addbeh.2019.106062DOI Listing
November 2019

Applying attachment theory to indecisiveness in hoarding disorder.

Psychiatry Res 2019 03 15;273:318-324. Epub 2019 Jan 15.

Centre for Emotional Health, Department of Psychology, Macquarie University; Sydney, New South Wales 2109, Australia. Electronic address:

Research shows that individuals who experience distress when discarding their possessions are more indecisive than individuals who do not experience such difficulty. These individuals report more intense emotional responses and greater intolerance to distress when faced with a discarding task. The aim of this study was to determine whether an insecure attachment style contributes to indecisiveness among individuals with discarding difficulties and whether this association is mediated by emotional reactivity and distress intolerance. This study used a within-group cross-sectional design. One hundred fifty-six participants with clinically significant discarding problems (82.7% female; Mean age = 21.96, SD = 7.38) from a population of university students and community members completed self-report questionnaires that assessed severity of hoarding behaviours, insecure attachment styles, emotional reactivity, distress intolerance, and indecisiveness. Analyses revealed that an anxious attachment style was associated with greater indecisiveness, and this relationship was mediated by emotional reactivity, but not distress intolerance. Furthermore, avoidant attachment was not related to indecisiveness. Clinical interventions should consider the role of attachment styles in hoarding disorder and address emotional reactivity difficulties in treatment through the use of discarding exposures, as emotion plays an important role in these decision-making processes.
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http://dx.doi.org/10.1016/j.psychres.2019.01.055DOI Listing
March 2019

Hoarding symptoms and workplace impairment.

Br J Clin Psychol 2019 Sep 11;58(3):342-356. Epub 2018 Dec 11.

Centre for Emotional Health, Macquarie University, Sydney, New South Wales, Australia.

Objectives: A prior study found that over 50% of treatment-seeking individuals who hoard incur at least one psychiatric work impairment day (i.e., they are unable to work or are less effective at work due to poor mental health) each month. The aim of the current study was to assess work-related variables associated with workplace impairment in a non-treatment-seeking sample.

Design: Cross-sectional. Self-report questionnaires were administered via Amazon's Mechanical Turk.

Methods: One hundred and eighty-five employed individuals who reported elevated hoarding symptoms completed questionnaires regarding hoarding symptoms, work engagement, psychiatric work impairment, work control, attention and concentration difficulties at work, and quality of workplace relationships.

Results: Greater workplace control and higher quality workplace relationships were associated with greater work engagement. Greater hoarding symptoms and attention difficulties at work were associated with more psychiatric work impairment days. Work engagement statistically mediated the association between the quality of workplace relationships and work impairment, though mediation was also significant when reversing the mediating and outcome variables.

Conclusions: Among a community sample of employed individuals, greater hoarding symptoms were associated with greater psychiatric work impairment. Work-related variables, such as co-worker relationships and attention difficulties, contributed additional variance above that accounted for by hoarding symptoms. There were significant associations between co-worker relationships, work engagement, and workplace impairment, though the direction of the mediation model is unclear. Future research should examine factors associated with unemployment in hoarding disorder.

Practitioner Points: Clinicians should be aware that greater hoarding severity directly contributes to greater workplace impairment. Clinicians should consider prioritizing the reduction in clutter in living areas that impact one's daily activities and subsequent ability to attend work. Clinicians should assess and treat workplace impairment by helping individuals achieve greater control at work, developing higher quality interpersonal relationships, and improving their attentional abilities.
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http://dx.doi.org/10.1111/bjc.12212DOI Listing
September 2019

Object attachment: Humanness increases sentimental and instrumental values.

J Behav Addict 2018 Dec 12;7(4):1132-1142. Epub 2018 Oct 12.

1 Department of Psychology, Centre for Emotional Health, Macquarie University , Sydney, NSW, Australia.

Background And Aims: People who hoard form intense attachments to their possessions and save items for sentimental and instrumental reasons. Feeling socially excluded may encourage these individuals to anthropomorphize objects (i.e., perceive them as human-like) to fulfill unmet belonging needs, which may increase the sentimental and instrumental values of objects, and then lead to stronger object attachment.

Methods: We randomly assigned 331 participants with excessive acquisition tendencies to be excluded, included, or overincluded in an online ball-tossing game before presenting them with five objects that had human characteristics. Participants then completed measures assessing anthropomorphism, sentimental and instrumental values, and object attachment.

Results: Inconsistent with this study hypothesis, socially excluded participants did not rate unowned objects as more human-like than the included or overincluded participants; however, stronger anthropomorphism predicted greater instrumental and sentimental values, which then predicted greater object attachment.

Discussion And Conclusions: Sentimental and instrumental values may explain how stronger anthropomorphism may lead to greater object attachment. Learning that leads to anthropomorphism may help us better understand object attachment.
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http://dx.doi.org/10.1556/2006.7.2018.98DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376393PMC
December 2018

The Scarier the Better: Maximizing Exposure Therapy Outcomes for Spider Fear.

Behav Cogn Psychother 2018 Nov 13;46(6):754-760. Epub 2018 Jul 13.

Illawarra Anxiety Clinic,Mount Pleasant,NSW,Australia.

Background: While exposure therapy effectively reduces anxiety associated with specific phobias, not all individuals respond to treatment and some will experience a return of fear after treatment ceases.

Aims: This study aimed to test the potential benefit of increasing the intensity of exposure therapy by adding an extra step that challenged uncontrollability (Step 15: allowing a spider to walk freely over one's body) to the standard fear hierarchy.

Method: Fifty-one participants who had a severe fear of spiders completed two 60-min exposure sessions 1 week apart in a context that was either the same or different from the baseline and follow-up assessment context. Participants were categorized into groups based on the last hierarchy step they completed during treatment (Step 14 or fewer, or Step 15).

Results: Those who completed Step 15 had greater reductions in fear and beliefs about the probability of harm from baseline to post-treatment than those who completed fewer steps. Although completing Step 15 did not prevent fear from returning after a context change, it allowed people to maintain their ability to tolerate their fear, which earlier steps did not. Despite some fear returning after a context change, individuals who completed Step 15 tended to report greater reductions in fear from baseline to the follow-up assessment than participants who completed 14 or fewer steps.

Conclusions: Overall, these results suggest that more intensive exposure that directly challenges harm beliefs may lead to greater changes in fear and fear beliefs than less intensive exposure.
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http://dx.doi.org/10.1017/S1352465818000437DOI Listing
November 2018

The role of distress tolerance, anxiety sensitivity, and intolerance of uncertainty in predicting hoarding symptoms in a clinical sample.

Psychiatry Res 2018 09 31;267:94-101. Epub 2018 May 31.

Department of Psychology, Macquarie University, Australia.

Hoarding disorder (HD) is characterized primarily by difficulty discarding possessions, leading to severe clutter and significant distress and impairment. Although promising psychological treatments have emerged, treating HD remains a clinical challenge. A greater understanding of the role of psychological vulnerability factors in predicting hoarding symptoms in a clinical HD sample could further enhance treatments. To investigate the role of proposed individual difference factors (i.e., distress tolerance, anxiety sensitivity, intolerance of uncertainty), we administered a diagnostic and self-report battery to 73 individuals diagnosed with HD who were seeking treatment for hoarding at a community clinic. Results indicated that when controlling for depression and anxiety symptoms, only distress tolerance predicted the severity of hoarding symptoms. Furthermore, meditation analyses revealed that the impact of distress tolerance on hoarding severity was partially mediated by hoarding beliefs. These results have important theoretical and clinical implications for HD.
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http://dx.doi.org/10.1016/j.psychres.2018.05.084DOI Listing
September 2018

Scared and surrounded by clutter: The influence of emotional reactivity.

J Affect Disord 2018 08 10;235:285-292. Epub 2018 Apr 10.

Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, New South Wales 2109, Australia. Electronic address:

Background: Home visits can improve treatment outcomes for hoarding disorder, but factors influencing the success of home visits remain unknown. As home visits expose individuals to clutter and fear, the present study examined the effect that fear and emotional reactivity have on the relationship between clutter and discarding behaviour.

Methods: Participants with at least subclinical discarding problems (n = 143) were asked to save or discard personal possessions of varying value following an emotional induction that took place in either a tidy or cluttered context. Participants also completed questionnaires assessing hoarding severity, emotional state, and emotional reactivity, as defined by one's sensitivity, persistence, and intensity of reactions to emotional stimuli.

Results: As expected, participants discarded more items in the presence of clutter and when feeling fearful. However, emotional reactivity moderated the relations between environmental context, acute emotional state, and discarding. Low sensitivity, low persistence, and high emotional intensity negatively influenced discarding in the cluttered context. When feeling fearful, low dispositional emotional intensity negatively influenced discarding in the tidy context.

Limitations: Individuals in the tidy environment reported higher levels of fear and anxiety than individuals in the cluttered environment after the fear induction. These differences could have contributed to the difference noted between the two contexts when examining the effect of emotional intensity tendencies.

Conclusions: Providing treatment in an environment more representative of the cluttered home can improve discarding or at the very least give therapists a more accurate picture of what clients do in the context that matters most.
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http://dx.doi.org/10.1016/j.jad.2018.04.066DOI Listing
August 2018

Solving the problem of cannabis quantification.

Lancet Psychiatry 2018 04;5(4):e8

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.

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http://dx.doi.org/10.1016/S2215-0366(18)30088-9DOI Listing
April 2018

Anxious attachment and excessive acquisition: The mediating roles of anthropomorphism and distress intolerance.

J Behav Addict 2018 Mar 15;7(1):171-180. Epub 2018 Feb 15.

2 School of Psychology, UNSW Sydney , Kensington, NSW, Australia.

Background and aims Most individuals with hoarding disorder (HD) are prone to excessively acquiring new possessions. Understanding the factors that contribute to this collecting behavior will allow us to develop better treatment approaches for HD. The aim of this study was to test our assumption that an anxious attachment style is associated with a tendency to anthropomorphize comforting objects and an inability to tolerate distress, which in turn leads to excessive acquisition. Methods A total of 361 participants with subclinical to clinical acquisition problems (77.8% female) completed a series of self-report measures. Results As expected, greater anxious attachment was related to greater distress intolerance and stronger tendencies to anthropomorphize inanimate objects. In turn, greater distress intolerance and anthropomorphism were related to more excessive buying and greater acquisition of free items. Examination of the pathways and indirect effects showed support for double mediation rather than serial mediation, as distress intolerance did not predict anthropomorphism. Discussion and conclusion These novel findings, if replicated, suggest that adding treatment modules that target improving distress tolerance and reducing anthropomorphism to standard treatment for HD may lead to further reductions in excessive acquiring.
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http://dx.doi.org/10.1556/2006.7.2018.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035017PMC
March 2018

Psychometric validation of the Anticipated Effects of Alcohol Mixed with Energy Drinks Scale.

Psychol Assess 2017 Dec 2;29(12):1505-1516. Epub 2017 Mar 2.

Department of Psychology, University of Arkansas.

Young people are increasingly consuming alcohol mixed with energy drinks (AmEDs). As coingestion of these beverages results in greater adverse consequences than from drinking alcohol alone, we need to understand what factors contribute to and deter coingestion. Existing studies in this area have not utilized a theoretically based or empirically validated measure of outcome expectancies for drinking AmEDs. Our study modified Morean, Corbin, and Treat's (2012) Anticipated Effects of Alcohol Scale to assess the expected effects of drinking AmEDs. We evaluated the factor structure and concurrent validity of the Anticipated Effects of Alcohol Mixed with Energy Drinks (AEAMEDS) among 549 university students, aged 18-25, who had a lifetime history of consuming alcohol (231 had consumed AmEDs in the past 90 days). Exploratory and confirmatory factor analysis supported a 4-factor structure. Consistent with hypotheses, stronger high arousal/positive expectancies and weaker low arousal/negative expectancies were associated with greater AmED use. At the bivariate level, stronger low arousal/positive expectancies were associated with greater quantities of AmED use, but this relationship disappeared when taking into account other outcome expectancies. Moreover, students expected low arousal/positive expectancies to be less intense when consuming AmEDs than alcohol alone, but ratings for all other AmED expectancies were equivalent to consuming alcohol alone. These findings contribute to our knowledge of risk and protective factors for AmED use. (PsycINFO Database Record
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http://dx.doi.org/10.1037/pas0000451DOI Listing
December 2017

Comparison of brief versus extended personalised feedback in an online intervention for cannabis users: Short-term findings of a randomised trial.

J Subst Abuse Treat 2017 05 2;76:43-48. Epub 2017 Feb 2.

National Cannabis Prevention and Information Centre, UNSW Australia, Sydney, NSW 2052, Australia. Electronic address:

Previous studies have shown brief online self-help interventions to be a useful method of treating cannabis use and related problems; however, no studies have compared the effects of brief versus extended feedback for online brief intervention programs.

Objectives: The current study was a two arm randomised trial aimed at testing the short term effectiveness of a brief and extended feedback version of Grassessment, a brief online intervention for cannabis users that provides individualised feedback regarding use, motives, and harms.

Methods: Participants (n=287) reporting at least one symptom of DSM IV cannabis abuse or dependence were recruited using online and offline advertising methods. Participants were randomised to receive either a brief or extended feedback version of the Grassessment program and were required to complete a one month follow up questionnaire.

Results: One hundred and ninety four participants completed the one month follow up. Wilcoxon analyses showed a significant decrease in past month quantity and frequency of cannabis use (ps<0.001; r=-0.41 and -0.40 respectively) and lower severity of dependence scores (p=0.002; r=-0.31) among those in the brief feedback condition. Participants in the extended feedback group also demonstrated significant decreases in patterns of use (ps<0.002; r=-0.39 and -0.33) but not severity of dependence (p=0.09; r=0.18). A Generalized Estimating Equation (GEE) analysis showed no significant interaction between length of feedback received and past month cannabis use frequency (p=0.78), quantity (p=0.73), or severity of dependence (p=0.47).

Conclusion: This study adds support for the use of brief online self-complete interventions to reduce cannabis use and related problems in the short term. The findings suggest that in the case of the brief online screening and feedback program Grassessment, extended feedback does not lead to superior outcomes over brief feedback.
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http://dx.doi.org/10.1016/j.jsat.2017.01.009DOI Listing
May 2017

Craving cannabis: a meta-analysis of self-report and psychophysiological cue-reactivity studies.

Addiction 2016 11 4;111(11):1923-1934. Epub 2016 Aug 4.

School of Psychology, UNSW Australia, Sydney, NSW, Australia.

Aims: To estimate the magnitude of cannabis cue-reactivity responses in people who regularly use cannabis.

Methods: EMBASE, PUBMED, PsycINFO, PsycEXTRA and Project CORK were searched for within-subject comparison studies published between January 2000 and December 2014. Eligible studies compared regular cannabis users' subjective craving or psychophysiological responding when exposed to cannabis cues to their responses to neutral cues and/or to their responses during a baseline assessment. Eligible studies presented original data and were written in English. Fourteen studies met inclusion criteria, but data were not available for two. The 12 included studies contained 393 participants (12-97 participants per study; mean age range: 16.4-32.6 years). Standardized effects sizes were computed for heart rate, skin conductance, skin temperature, blood pressure, event-related potentials (Pz P300) and self-reported craving (Visual Analogue Scales and Marijuana Craving Questionnaire) and synthesized using a multivariate meta-regression model.

Results: On average, cannabis users experienced moderate cue-reactivity, as determined by comparisons with baseline conditions [d = 0.59, 95% confidence interval (CI) = 0.43, 0.74, P < 0.001] and with neutral cue comparisons (d = 0.47, 95% CI = 0.32, 0.62, P < 0.001). This model, which excluded studies at a greater than low risk of bias and included PzP300 studies as a moderator (due to having larger effect sizes), had a moderately low level of heterogeneity of effect size (I  = 45.6%, Q = 56.97, P = 0.003) and showed no evidence of publication bias. Cue-reactivity was most noticeable (large effect size) when assessed by Pz P300 waves (d = 1.71, 95% CI = 0.77, 2.64, P = 0.0003; I  = 86%, Q = 36.30, P < 0.001) and least noticeable (trivial effect size) when examining heart rate (d = 0.14, 95% CI = -0.34, 0.62, P = 0.58; I  = 80%, Q = 20.0, P < 0.001). These subgroup models demonstrated high heterogeneity of effect size.

Conclusions: Regular cannabis users experience moderate to extremely intense cue-reactivity, such that their attentional biases towards cannabis cues are much stronger than their perceptions of craving for the drug.
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http://dx.doi.org/10.1111/add.13472DOI Listing
November 2016

Pregaming and Emotion Regulation's Relationship to Alcohol Problems in College Students: A Cross-Sectional Study.

Subst Use Misuse 2016 07 12;51(8):1024-33. Epub 2016 Apr 12.

b Department of Psychological Science , University of Arkansas , Fayetteville , Arkansas , USA.

Background: Pregaming is a high-risk drinking behavior associated with increased alcohol consumption and alcohol-related problems. Quantity of alcohol consumed does not fully explain the level of problems associated with pregaming; yet, limited research has examined factors that may interact with pregaming behavior to contribute to the experience of alcohol-related problems.

Objectives: The current study examined whether use of two emotion regulation strategies influence pregaming's contribution to alcohol-related problems.

Methods: Undergraduates (N = 1857) aged 18-25 years attending 19 different colleges completed an online survey in 2008-2009. Linear mixed models were used to test whether emotion regulation strategies moderate the association between pregaming status (pregamers vs. non/infrequent pregamers) and alcohol-related problems, when controlling for alcohol consumption, demographic covariates, and site as a random effect.

Results: Greater use of cognitive reappraisal was associated with decreased alcohol problems. Expressive suppression interacted with pregaming status. There was no relationship between pregaming status and alcohol problems for students who rarely used expression suppression; however, the relationship between pregaming status and alcohol problems was statistically significant for students who occasionally to frequently used expression suppression.

Conclusions/importance: Findings suggest that the relationship between pregaming and alcohol-related problems is complex. Accordingly, future studies should utilize event-level methodology to understand how emotion regulation strategies influence alcohol-related problems. Further, clinicians should tailor alcohol treatments to help students increase their use of cognitive reappraisal and decrease their use of suppression.
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http://dx.doi.org/10.3109/10826084.2016.1152498DOI Listing
July 2016

Gender matters: the relationship between social anxiety and alcohol-related consequences.

PLoS One 2014 26;9(12):e115361. Epub 2014 Dec 26.

Department of Psychology, Virginia Tech, Blacksburg, Virginia, United States of America.

Background And Objectives: Identification of risk factors for alcohol-related consequences is an important public health concern. Both gender and social anxiety have been associated with alcohol-related consequences broadly, but it is unknown whether these variables are differentially related to specific types of alcohol-related consequences for American college students.

Methods: In the present study, 573 undergraduate students (M(age) = 19.86 years, SD = 1.40; range 18 to 25; 68.9% female) completed an on-line assessment of social anxiety, alcohol use, and four types of alcohol-related consequences (personal, social, physical, and role). Poisson regressions were run to examine social anxiety, gender, and the interaction between social anxiety and gender as predictors of each type of alcohol-related consequences.

Results: After controlling for alcohol use, social anxiety was positively associated with all four types of consequences, and females endorsed higher rates of physical, personal, and role consequences. The interaction between social anxiety and gender was statistically significant only for physical consequences, with social anxiety having a stronger effect for males.

Discussion And Conclusions: These findings, which diverge somewhat from those of a prior study with Australian college students, are discussed in the context of a biopsychosocial model of social anxiety and substance use problems.

Scientific Significance: This study highlights the importance of further investigating cultural differences in the relationships among social anxiety, gender, and alcohol-related consequences.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0115361PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277359PMC
August 2015

A systematic review of mindfulness and acceptance-based treatments for social anxiety disorder.

J Clin Psychol 2015 Apr 21;71(4):283-301. Epub 2014 Dec 21.

The University of Sydney.

Context: The cultivation of mindfulness and acceptance has been theoretically and empirically associated with psychological ancillary well-being and has demonstrated efficacy in the treatment of various disorders. Hence, mindfulness and acceptance-based treatments (MABTs) have recently been explored for the treatment of social anxiety disorder (SAD). This review aims to evaluate the benefits of MABTs for SAD.

Methods: Systematic review of studies investigating an MABT for individuals with SAD, using PsycInfo, Medline, PubMed, and Cochrane Central Register of Controlled Trials.

Results: Nine studies were identified. Significant improvements in symptomatology were demonstrated following the MABT, but benefits were equivalent or less than yielded by cognitive-behavioral therapy (CBT).

Limitations: The few treatment studies available were compromised by significant methodological weaknesses and high risk of bias across domains. Studies were largely uncontrolled with small sample sizes. The hybrid nature of these interventions creates ambiguity regarding the specific utility of treatment components or combinations.

Conclusions: MABTs demonstrate significant benefits for reducing SAD symptomatology; however, outcomes should be interpreted with caution until appropriate further research is conducted. Furthermore, the benefit of MABTs above and beyond CBT must be considered tentative at best; thus, CBT remains best practice for first-line treatment of SAD.
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http://dx.doi.org/10.1002/jclp.22144DOI Listing
April 2015

Brief interventions to reduce Ecstasy use: a multi-site randomized controlled trial.

Behav Ther 2014 Nov 10;45(6):745-59. Epub 2014 Jul 10.

National Cannabis Prevention and Information Centre, UNSW Medicine, Sydney.

Studies examining the ability of motivational enhancement therapy (MET) to augment education provision among ecstasy users have produced mixed results and none have examined whether treatment fidelity was related to ecstasy use outcomes. The primary objectives of this multi-site, parallel, two-group randomized controlled trial were to determine if a single-session of MET could instill greater commitment to change and reduce ecstasy use and related problems more so than an education-only intervention and whether MET sessions delivered with higher treatment fidelity are associated with better outcomes. The secondary objective was to assess participants' satisfaction with their assigned interventions. Participants (N=174; Mage=23.62) at two Australian universities were allocated randomly to receive a 15-minute educational session on ecstasy use (n=85) or a 50-minute session of MET that included an educational component (n=89). Primary outcomes were assessed at baseline, and then at 4-, 16-, and 24-weeks postbaseline, while the secondary outcome measure was assessed 4-weeks postbaseline by researchers blind to treatment allocation. Overall, the treatment fidelity was acceptable to good in the MET condition. There were no statistical differences at follow-up between the groups on the primary outcomes of ecstasy use, ecstasy-related problems, and commitment to change. Both intervention groups reported a 50% reduction in their ecstasy use and a 20% reduction in the severity of their ecstasy-related problems at the 24-week follow up. Commitment to change slightly improved for both groups (9%-17%). Despite the lack of between-group statistical differences on primary outcomes, participants who received a single session of MET were slightly more satisfied with their intervention than those who received education only. MI fidelity was not associated with ecstasy use outcomes. Given these findings, future research should focus on examining mechanisms of change. Such work may suggest new methods for enhancing outcomes. Australia and New Zealand Clinical Trial Registry: ACTRN12611000136909.
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http://dx.doi.org/10.1016/j.beth.2014.05.006DOI Listing
November 2014

The effect of the ecstasy 'come-down' on the diagnosis of ecstasy dependence.

Drug Alcohol Depend 2014 Jun 3;139:26-32. Epub 2014 Mar 3.

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.

Background: The existence of an ecstasy-dependence syndrome is controversial. We examined whether the acute after-effects of ecstasy use (i.e. the 'come-down') falsely lead to the identification of ecstasy withdrawal and the subsequent diagnosis of ecstasy dependence.

Methods: The Structured Clinical Interview for DSM-IV-TR Disorders: Research Version (SCID-RV) was administered to 214 Australian ecstasy users. Ecstasy withdrawal was operationalised in three contrasting ways: (i) as per DSM-IV criteria; (ii) as the expected after-effects of ecstasy (a regular come-down); or (iii) as a substantially greater or longer come-down than on first use (intense come-down). These definitions were validated against frequency of ecstasy use, readiness to change and ability to resist the urge to use ecstasy. Confirmatory factor analyses were used to see how they aligned with the overall dependence syndrome.

Results: Come-down symptoms increased the prevalence of withdrawal from 1% (DSM-IV criterion) to 11% (intense come-downs) and 75% (regular come-downs). Past year ecstasy dependence remained at 31% when including the DSM-IV withdrawal criteria and was 32% with intense come-downs, but increased to 45% with regular come-downs. Intense come-downs were associated with lower ability to resist ecstasy use and loaded positively on the dependence syndrome. Regular come-downs did not load positively on the ecstasy-dependence syndrome and were not related to other indices of dependence.

Conclusion: The acute after-effects of ecstasy should be excluded when assessing ecstasy withdrawal as they can lead to a false diagnosis of ecstasy dependence. Worsening of the ecstasy come-down may be a marker for dependence.
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http://dx.doi.org/10.1016/j.drugalcdep.2014.02.697DOI Listing
June 2014

Nabiximols as an agonist replacement therapy during cannabis withdrawal: a randomized clinical trial.

JAMA Psychiatry 2014 Mar;71(3):281-91

School of Psychology, University of Sydney, Sydney, Australia.

Importance: There are no medications approved for treating cannabis dependence or withdrawal. The cannabis extract nabiximols (Sativex), developed as a multiple sclerosis treatment, offers a potential agonist medication for cannabis withdrawal.

Objective: To evaluate the safety and efficacy of nabiximols in treating cannabis withdrawal.

Design, Setting, And Participants: A 2-site, double-blind randomized clinical inpatient trial with a 28-day follow-up was conducted in New South Wales, Australia. Participants included 51 DSM-IV-TR cannabis-dependent treatment seekers.

Interventions: A 6-day regimen of nabiximols (maximum daily dose, 86.4 mg of Δ9-tetrahydrocannabinol and 80 mg of cannabidiol) or placebo with standardized psychosocial interventions during a 9-day admission.

Main Outcomes And Measures: Severity of cannabis withdrawal and cravings (Cannabis Withdrawal Scale), retention in withdrawal treatment, and adverse events. Secondary outcomes include postwithdrawal cannabis use, health outcomes, and psychosocial outcomes.

Results: Nabiximols treatment significantly reduced the overall severity of cannabis withdrawal relative to placebo (F8,377.97 = 2.39; P = .01), including effects on withdrawal-related irritability, depression, and cannabis cravings. Nabiximols had a more limited, but still positive, therapeutic benefit on sleep disturbance, anxiety, appetite loss, physical symptoms, and restlessness. Nabiximols patients remained in treatment longer during medication use (unadjusted hazard ratio, 3.66 [95% CI, 1.18-11.37]; P = .02), with 2.84 the number needed to treat to achieve successful retention in treatment. Participants could not reliably differentiate between nabiximols and placebo treatment (χ21 = 0.79; P = .67), and those receiving nabiximols did not report greater intoxication (F1,6 = 0.22; P = .97). The number (F1,50 = 0.3; P = .59) and severity (F1,50 = 2.69; P = .10) of adverse events did not differ significantly between groups. Both groups showed reduced cannabis use at follow-up, with no advantage of nabiximols over placebo for self-reported cannabis use (F1,48 = 0.29; P = .75), cannabis-related problems (F1,49 = 2.33; P = .14), or cannabis dependence (F1,50 < 0.01; P = .89).

Conclusions And Relevance: In a treatment-seeking cohort, nabiximols attenuated cannabis withdrawal symptoms and improved patient retention in treatment. However, placebo was as effective as nabiximols in promoting long-term reductions in cannabis use following medication cessation. The data support further evaluation of nabiximols for management of cannabis dependence and withdrawal in treatment-seeking populations.

Trial Registration: anzctr.org.au Identifier: ACTRN12611000398909.
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http://dx.doi.org/10.1001/jamapsychiatry.2013.3947DOI Listing
March 2014

Cannabis use among treatment-seeking smokers: motives and the moderating effects of anxiety sensitivity.

Am J Addict 2014 Jan-Feb;23(1):7-14. Epub 2013 May 24.

National Cannabis Prevention and Information Centre, University of New South Wales, Australia.

Background And Objectives: Concurrent use of cannabis and tobacco is associated with poor tobacco cessation outcomes. As little research has examined why treatment-seeking tobacco users engage in cannabis use, the objective of this study was to discover if emotional vulnerability and cannabis use motives are associated with concurrent users' cannabis use.

Methods: One hundred thirty-eight (n = 138) daily cigarette smokers seeking smoking cessation treatment completed measures of anxiety sensitivity, cannabis use motives, and cannabis use.

Results: Stronger coping, enhancement, social, and expansion motives were associated with using greater amounts of cannabis per use occasion. In a model accounting for all these motives, anxiety sensitivity moderated the relationship between enhancement motives and cannabis use.

Discussion And Conclusions: Clinical interventions for concurrent tobacco-cannabis users may be advanced by targeting low anxiety sensitive individuals' use of cannabis to increase excitement and fun. Such an approach may consist of having clients identify and engage in healthier pleasurable activities and by teaching clients to accept the trade-off between perceived less pleasurable, but healthier activities and cannabis use.
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http://dx.doi.org/10.1111/j.1521-0391.2013.12054.xDOI Listing
January 2015

Applying technology to the treatment of cannabis use disorder: comparing telephone versus Internet delivery using data from two completed trials.

J Subst Abuse Treat 2014 Jan 16;46(1):78-84. Epub 2013 Sep 16.

National Cannabis Prevention and Information Centre, University of New South Wales, PO Box 684, Randwick NSW, 2031, Australia. Electronic address:

Technology-based interventions such as those delivered by telephone or online may assist in removing significant barriers to treatment seeking for cannabis use disorder. Little research, however, has addressed differing technology-based treatments regarding their comparative effectiveness, and how user profiles may affect compliance and treatment satisfaction. This study addressed this issue by examining these factors in online (N=225) versus telephone (N=160) delivered interventions for cannabis use, using data obtained from two previously published randomized controlled trials conducted by the current authors. Several differences emerged including stronger treatment effects (medium to large effect sizes in the telephone study versus small effect sizes in the Web study) and lower dropout in the telephone intervention (38% vs. 46%). Additionally, around half of the telephone study participants sought concurrent treatment, compared with 2% of participants in the Web study. Demographics and predictors of treatment engagement, retention and satisfaction also varied between the studies. Findings indicate that both telephone and Web-based treatments can be effective in assisting cannabis users to quit or reduce their use; however, participant characteristics may have important implications for treatment preference and outcome, with those who elect telephone-based treatment experiencing stronger outcomes. Thus, participant preference may shape study populations, adherence, and outcome.
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http://dx.doi.org/10.1016/j.jsat.2013.08.007DOI Listing
January 2014