Altered mechanisms of adaptation in social anxiety: differences in adapting to positive versus negative emotional faces.

Social anxiety is characterised by fear of negative evaluation and negative perceptual biases; however, the cognitive mechanisms underlying these negative biases are not well understood. We investigated a possible mechanism which could maintain negative biases: altered adaptation to emotional faces. Heightened sensitivity to negative emotions could result from weakened adaptation to negative emotions, strengthened adaptation to positive emotions, or both mechanisms. We measured adaptation from repeated exposure to either positive or negative emotional faces, in individuals high versus low in social anxiety. We quantified adaptation strength by calculating the point of subjective equality (PSE) before and after adaptation for each participant. We hypothesised: (1) weaker adaptation to angry vs happy faces in individuals high in social anxiety, (2) no difference in adaptation to angry vs happy faces in individuals low in social anxiety, and (3) no difference in adaptation to sad vs happy faces in individuals high in social anxiety. Our results revealed a weaker adaptation to angry compared to happy faces in individuals high in social anxiety (Experiment 1), with no such difference in individuals low in social anxiety (Experiment 1), and no difference in adaptation strength to sad vs happy faces in individuals high in social anxiety (Experiment 2).

Do treatment responders maintain their gains following a randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder?

To examine the maintenance effects of acceptance-based behavior therapy (ABBT) and applied relaxation (AR) for generalized anxiety disorder (GAD) 46 adults (69.6% female, 82.6% White) with high end-state functioning following an RCT comparing ABBT to AR were re-assessed at 12- and 24-month follow-up. End-state functioning was based on post-treatment scores within one standard deviation of the mean on three of five outcome measures [Clinician Severity Rating (CSR), Hamilton Anxiety, Penn State Worry Questionnaire (PSWQ), Depression Anxiety Stress Scale stress subscale (DASS-Stress), and State-Trait Anxiety Inventory (STAI)]. At 12 months, 93.8% of high endstate responders in ABBT and 95.5% in AR had maintained gains. At 24 months, 71.4% of responders from ABBT and 83.3% from AR maintained gains. Mixed-effects regression models revealed a significant effect for Time and Condition for DASS-Stress but not for Condition X Time. There was also a significant time effect for PSWQ, indicating PSWQ and DASS-Stress scores increased across follow-up. The rate of increase did not differ across conditions. Non-significant, small effects were found for all other outcomes indicating that symptoms did not significantly change across follow-up regardless of condition. While the results are limited by dropout rates, clients receiving ABBT or AR appear to maintain gains over long-term follow-up.

Interpersonal Problems, Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder.

OBJECTIVE: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. METHOD: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. RESULTS: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. CONCLUSIONS: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.

A contemporary view of applied relaxation for generalized anxiety disorder.

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.

An Acceptance-Based Behavioral Therapy for Individuals with Generalized Anxiety Disorder.

In response to clinical observations and research findings that individuals with Generalized Anxiety Disorder are reactive to their internal experiences, avoid and suppress painful emotions, thoughts, and sensations, and limit their involvement in meaningful activities, an Acceptance Based Behavioral Therapy (ABBT) was developed to specifically target these responses. ABBT incorporates acceptance and mindfulness strategies with more traditional behavior therapy techniques. Specifically, ABBT uses mindfulness and acceptance approaches as an alternate response to the rigid, avoidant responses characteristic of GAD. Likewise, therapy focuses on identifying and enacting behaviors that are congruent with what is personally meaningful to the client rather than engaging in actions that are motivated by avoidance of anxiety. This article provides a case conceptualization from an ABBT perspective for "William," the composite client presented in Robichaud (this issue). The article goes on to demonstrate how an ABBT approach to treatment may unfold session-by-session for "William."

A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series.

Applied Relaxation (AR), which involves noticing early signs of anxiety and responding with a relaxation response, is an empirically supported treatment for Generalized Anxiety Disorder (GAD). However, research on hypothesized mechanisms of AR (e.g., reduced muscle tension) has been mixed, making it likely that additional mechanisms are contributing to the efficacy of AR. Stemming from more recent conceptualizations of GAD, it is hypothesized that mindfulness, decentering, and acceptance may be potential mechanisms of change in AR. Outcome, mechanism data, and case descriptions from three individuals diagnosed with GAD who received 16 weeks of AR as part of a larger randomized controlled trial are presented to demonstrate the ways that AR may lead to clinical improvement through mindfulness, decentering, and acceptance.

An evaluation of the construct validity of the Adult Rejection Sensitivity Questionnaire.

Rejection sensitivity (RS), the predisposition to defensively expect, readily perceive, and react strongly to interpersonal rejection (Downey & Feldman, 1996; Feldman & Downey, 1994), may be a transdiagnostic trait associated with a range of psychiatric symptoms and psychosocial dysfunction. Valid and reliable assessment of vulnerability factors is essential for individualized treatment and improving clinical outcomes. Limited research has examined the factor structure of the predominantly used self-report measure of RS, the Adult Rejection Sensitivity Questionnaire (A-RSQ; Berenson et al., 2009). Across two studies (Study 1: N = 346, 57.2% female, 76.6% White; 16.8% Hispanic/Latinx; Study 2: N = 540; 43.7% female, 80.2% White; 16.7% Hispanic/Latinx), we examined the factor structure of the A-RSQ in samples of adult U.S. residents and investigated associations with mental health correlates, including neuroticism, social anxiety, anxiety, depression, anhedonia, somatic arousal, and psychological distress. Study 2 also evaluated relations with interpersonal correlates, including introversion, submissiveness, and anxious and avoidant attachment. A two-factor solution with rejection expectancy and rejection concern representing separate factors consistently fit the data best. Distinct patterns of associations emerged suggesting that concern was more strongly associated with indicators of negative affect while expectancy was uniquely associated with diminished positive affect. Both concern and expectancy were associated with indicators of interpersonal dysfunction. Findings suggest that the current operationalization, and perhaps conceptualization, of RS as measured by the A-RSQ requires revision. Additionally, RS may be a clinically relevant transdiagnostic phenotype that influences symptom manifestation and psychosocial functioning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Decentering in Mindfulness and Cognitive Restructuring for Social Anxiety: An Experimental Study of a Potential Common Mechanism.

The present study examined whether cognitive restructuring (CR) or mindfulness led to increases in decentering and whether changes in decentering were related to changes in anxiety and willingness to approach anxiety-provoking situations. Forty-six individuals with social anxiety completed speaking tasks before and after receiving CR, mindfulness, or control instructions. Overall, anxiety decreased and willingness increased from the first to second speech, with no differences across conditions. Decentering (measured by the Toronto Mindfulness Scale [TMS]) increased, with those in the mindfulness condition reporting more decentering. There was a nonsignificant, medium-sized effect on decentering, as measured by the Experiences Questionnaire (EQ)-Decentering factor, with those in CR reporting more decentering. Increases in decentering were associated with changes in self-reported anxiety and willingness. Findings indicate that mindfulness and CR led to changes in decentering, and that changes in decentering were related to changes in some, but not all, measures of anxiety.

Examining the Interrelation Among Change Processes: Decentering and Anticipatory Processing Across Cognitive Behavioral Therapy for Social Anxiety Disorder.

As evidence grows supporting certain mechanisms of change in psychological treatments and we improve statistical approaches to measuring them, it is important that we also explore how mechanisms and processes are related to each other, and how they together affect treatment outcomes. To answer these questions about interrelating processes and mechanisms, we need to take advantage of frequent assessment and modeling techniques that allow for an examination of the influence of one mechanism on another over time. Within cognitive behavioral therapy, studies have shown support for both decentering, the ability to observe thoughts and feelings as objective events in the mind, and anticipatory processing, the repetitive thinking about upcoming social situations, as potentially related mechanisms of change. Therefore, the current study examined weekly ratings of decentering and a single-item anticipatory processing question to examine the interrelation among these change mechanisms in 59 individuals who received a 12-weeks of Cognitive Behavioral Group Therapy for social anxiety disorder. Overall, these results found that both anticipatory processing and decentering changed over the course therapy for clients. Change in both anticipatory processing and decentering was related to outcome. The bivariate latent difference score analysis showed that anticipatory processing was a leading indicator of change in decentering, but not the reverse, indicating that change in anticipatory processing is leading to change in decentering. It may be that with the focus on cognitive reappraisal in this treatment, that reducing anticipatory processing is freeing up the cognitive resources for decentering to occur.

Changes in Decentering Across Cognitive Behavioral Group Therapy for Social Anxiety Disorder.

To further improve treatments, we need to better understand potential common treatment mechanisms, such as decentering, or the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with them (Safran & Segal, 1990). Therefore, this study examined whether 12 sessions of Cognitive Behavioral Group Therapy (CBGT) for 63 clients (57.6% female, 50.8% White) diagnosed with social anxiety disorder led to increases in decentering and whether increased decentering was associated with improved outcome. Furthermore, this study examined whether decentering was associated with outcome over and above a competing mechanism-cognitive reappraisal. Overall, results indicated that CBGT in this study led to similar outcomes compared to previous studies and decentering increased over CBGT (d's from 0.81 to 2.23). Change in decentering predicted improvement on most, but not all, measures of outcome and those who no longer met criteria for social anxiety disorder at posttreatment had significantly greater change in decentering across therapy and significantly higher decentering scores at post-treatment compared to those who retained a social anxiety disorder diagnosis at posttreatment. Finally, changes in decentering predicted outcome over and above changes in reappraisal on all outcome measures. These results largely support the role of decentering in CBGT for social anxiety; however, the implications of the inconsistencies in results based on which outcome measure was used are discussed.

Social Cost Bias, Probability Bias, and Self-Efficacy as Correlates of Behavioral Action in Social Anxiety.

The present study investigated the role of social cost bias, probability bias, and self-efficacy as correlates of behavioral action in a nonclinical sample of 197 individuals, using a series of vignettes and self-report measures. The findings indicated that, as hypothesized, social cost bias, probability bias, and self-efficacy were associated with social anxiety. While social anxiety was associated with behavioral action, the three cognitive factors were associated with behavioral action above and beyond the contribution of social anxiety. However, contrary to the hypothesis, self-efficacy was the only cognitive factor directly associated with behavioral action when all variables were in the model. This information has implications for potential methods and target mechanisms for increasing client engagement with exposures and behavioral experiments in treatments for social anxiety.

Surviving and Thriving During Stress: A Randomized Clinical Trial Comparing a Brief Web-Based Therapist-Assisted Acceptance-Based Behavioral Intervention Versus Waitlist Control for College Students.

The high rates of anxiety in college students and the many barriers to accessing evidence-based care in communities and on campuses indicate a clear need to explore ways to increase access to evidence-based treatments. Web-based interventions and preventions are one way to bridge this gap; they hold the potential to decrease mental health disparities and enhance student functioning. The current RCT examined the acceptability and efficacy of a 3-session web-based therapist-assisted acceptance-based behavioral intervention targeting anxiety (Surviving and Thriving During Stress) for college students versus a waitlist (WL) control condition, in a sample of racially and ethnically diverse college students. Overall, participants rated the program as helpful and acceptable. Mixed-effects regression models (MRMs) were run in SPSS to examine the effects of time, condition, and Condition × Time on outcomes and hypothesized mechanisms. Significant Condition × Time interactions for general anxiety, depression, and quality of life (QOL) emerged, suggesting that SATDS participants reported significantly greater changes on these outcomes from pre- to posttreatment versus WL. However, interaction effects were nonsignificant for anxious arousal and social anxiety. MRMs examining hypothesized mechanisms revealed significant Condition × Time interactions for experiential avoidance, decentering, and values-based living. However, interaction effects were nonsignificant for mindfulness. All significant gains were maintained at 1-month follow-up, with the exception of QOL. Results contribute to the growing literature on the acceptability and efficacy of web-based approaches, and suggest these approaches can be effective for diverse college students, and may provide a unique platform to increase access to evidence-based care.

Patterns of Anxious Arousal During a Speech Task Between Nonanxious Controls and Individuals With Social Anxiety Disorder Pre- and Posttreatment.

Although research indicates that anxious arousal in response to feared stimuli is related to treatment outcome (Heimberg et al., 1990), less is known about the patterns of anxious arousal. We identified patterns of anxious arousal in individuals with social anxiety disorder (SAD) at pre- (n= 61) and posttreatment (n= 40; 12-session CBGT, Heimberg & Becker, 2002), and in non-anxious controls (NACs; n= 31) using an assessment speech task administered at pretreatment (SAD) or the pretreatment equivalent (NACs), as well as at posttreatment (SAD only). We identified nine patterns of anxious arousal across groups that we further clustered into three groups: fear habituation, fear plateau, and fear increase. Chi-square and adjusted standardized residual analyses revealed that individuals in the pretreatment SAD group displayed the fear habituation patterns significantly more than chance and the fear plateau patterns significantly less than chance. In contrast, NACs displayed the fear plateau patterns significantly more than chance and the fear habituation patterns significantly less than chance. At posttreatment, treatment non-responders displayed fear habituation patterns significantly more than chance, whereas treatment responders displayed the fear habituation patterns significantly less than chance. Findings indicate that fear habituation during an anxiety-provoking assessment task is not necessary for treatment response.

What's in a Face? How Face Gender and Current Affect Influence Perceived Emotion.

Faces drive our social interactions. A vast literature suggests an interaction between gender and emotional face perception, with studies using different methodologies demonstrating that the gender of a face can affect how emotions are processed. However, how different is our perception of affective male and female faces? Furthermore, how does our current affective state when viewing faces influence our perceptual biases? We presented participants with a series of faces morphed along an emotional continuum from happy to angry. Participants judged each face morph as either happy or angry. We determined each participant's unique emotional 'neutral' point, defined as the face morph judged to be perceived equally happy and angry, separately for male and female faces. We also assessed how current state affect influenced these perceptual neutral points. Our results indicate that, for both male and female participants, the emotional neutral point for male faces is perceptually biased to be happier than for female faces. This bias suggests that more happiness is required to perceive a male face as emotionally neutral, i.e., we are biased to perceive a male face as more negative. Interestingly, we also find that perceptual biases in perceiving female faces are correlated with current mood, such that positive state affect correlates with perceiving female faces as happier, while we find no significant correlation between negative state affect and the perception of facial emotion. Furthermore, we find reaction time biases, with slower responses for angry male faces compared to angry female faces.

Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder.

As a field, we lack information about specific mechanisms that are responsible for changes that occur over the course of treatments for anxiety disorders (Kazdin, 2007). Identifying these mechanisms would help streamline evidence-based approaches, increase treatment response rates, and aid in the dissemination and implementation of evidence-based approaches in diverse contexts. The current study examined reductions in experiential avoidance (EA; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), attempts to control or eliminate distressing internal experiences, regardless of behavioral consequences, as a potential mechanism of change in participants with a principal diagnosis of generalized anxiety disorder (GAD) receiving either acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Participants' EA scores across treatment on the Acceptance and Action Questionnaire (AAQ) were used to calculate slopes, which were used as predictors in a series of linear regressions. Greater change in EA across treatment significantly predicted change in worry (PSWQ) and quality of life (QOLI) across both treatments. These results contribute to the body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches.

Differences Among Lesbian, Gay, Bisexual, Heterosexual Individuals, and those Who Reported an Other Identity on an Open-Ended Response on Levels of Social Anxiety.

Previous research suggests that individuals with a marginalized sexual orientation report higher levels of emotional distress (Cochran, 2001; Mayer, 2003), including higher prevalence of social anxiety (Gilman et al., 2001; Potoczniak, Aldea, & DeBlaere, 2007; Safren & Pantalone, 2006) than heterosexuals. The present study builds on previous research by examining results across sexual minority identities, including an additional write-in response option. One hundred eighty individuals participated in an online study in which they indicated their sexual orientation and completed measures of social anxiety. Results indicated that in a sample recruited in a liberal urban population, lesbian/gay, and heterosexual individuals rated similar levels of social anxiety across four Liebowitz Social Anxiety Scale subscales (fear, avoidance, social, and performance; Liebowitz, 1987). Alternatively, individuals who identified as bisexual, or indicated a write-in sexual orientation rated significantly higher levels of social anxiety than the heterosexual, and lesbian/gay groups. Findings highlight the importance of offering a write-in sexual identity option, as well as looking at differences among group experiences across sexual minorities. Future studies should investigate potential group differences in social anxiety across sexual orientations in larger samples so that comparisons can be made among subgroups of the write-in response group, as well as investigate potential contributors to these group differences.

Decentering as a potential common mechanism across two therapies for generalized anxiety disorder.

OBJECTIVE: The purpose of this study was to examine decentering as a potential mechanism of action across 2 treatments for generalized anxiety disorder: an acceptance-based behavioral therapy (ABBT) and applied relaxation (AR). METHOD: Sixty-four individuals who completed at least half of the 16 total sessions of either ABBT or AR (65.6% female; 79.7% identified as White; average age = 34.41 years) completed measures of decentering (Experiences Questionnaire) and of symptoms of anxiety (Depression Anxiety Stress Scale-Stress subscale) at 5 time points over the course of therapy, and a measure of worry (Penn State Worry Questionnaire) at pre- and posttreatment. RESULTS: Initial growth curve models showed that decentering increased significantly over therapy (z = 7.09), and this increase was associated with a decrease in worry symptoms (Penn State Worry Questionnaire) at posttreatment (z = -8.51). The rate of change did not significantly vary across treatments, Δχ2/Δdf = 0.16/1, p = .69. Further, a series of bivariate latent difference score models indicated that the best-fitting model was one in which decentering was a leading indicator of change in symptoms (DASS-Stress). Allowing this coupling to vary across treatments did not significantly improve the fit of the model, Δχ2/Δdf = 0.71/1, p = .40. CONCLUSIONS: In this sample, results suggest that increased decentering was associated with decreases in anxiety and that changes in decentering appear to precede changes in symptoms within both ABBT and AR, indicating that decentering may be an important common mechanism of action. (PsycINFO Database Record

Mental Health Literacy for Anxiety Disorders: How perceptions of symptom severity might relate to recognition of psychological distress.

PURPOSE: Improving mental health literacy is an important consideration when promoting expedient and effective treatment seeking for psychological disorders. Low recognition serves as a barrier to treatment (Coles and Coleman, 2010), and this article examines recognition by lay individuals of severity for three psychological disorders: social anxiety, generalized anxiety, and major depression using a dimensional approach. DESIGN: Vignettes of mild/subclinical, moderate, and severe cases of each disorder were rated for severity by a team of expert assessors and 270 participants (mean age = 26.8; 76.7% women). FINDINGS: Difference ratings were calculated comparing participants' responses to scores from the assessors. A within-groups factorial ANOVA with LSD follow-up was performed to examine the effects of Diagnosis and Severity on difference ratings. Both main effects [Diagnosis, F(2, 536)=35.26, Mse=1.24; Severity, F(2, 536)=9.44, Mse=1.93] and the interaction were significant [F(4, 1072)=13.70, Mse=1.13] all p's < 0.001. Social anxiety cases were underrated in the mild/subclinical and moderate cases, generalized anxiety cases were underrated at all three severities, and major depression cases were overrated at all three severities. SOCIAL IMPLICATIONS: Judgments of severity may underlie the low recognition rates for social anxiety disorder and generalized anxiety disorder. Future efforts should focus on improved recognition and education regarding anxiety disorders in the population, particularly before they become severe. VALUE: This project demonstrates the importance of considering judgments of symptom severity on a continuum, and in a range of cases, rather than just the ability to correctly label symptoms, when determining whether or not people recognize psychological disorders.

Relationships Between Amount of Post-Intervention of Mindfulness Practice and Follow-up Outcome Variables in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder: The Importance of Informal Practice.

Because most behavioral treatments are time-limited, skills and practices that foster long-term maintenance of gains made during treatment are of critical importance. While some studies have found mindfulness practice to be associated with improvements in outcome variables over the course of treatment (Vettese et al., 2009), very little is known about the effects of continued mindfulness practice following treatment termination. The current study examined the relationships between separate single item measurements of three types of mindfulness practices (formal, informal, and mindfulness of breath in daily life) and longer-term outcomes in worry, clinician-rated anxiety severity, and quality of life following treatment with an acceptance-based behavior therapy (ABBT) for Generalized Anxiety Disorder (GAD) in two separate treatment studies. Results from Study 1 showed that at 9-month follow-up, amount of informal mindfulness practice was significantly related to continued beneficial outcomes for worry, clinician-rated anxiety severity, and quality of life. Similarly, in Study 2, at 6-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for anxiety severity and worry, and at 12-month follow-up informal mindfulness practice was significantly related to continued beneficial outcomes for quality of life and worry, and mindfulness of breath was significantly related to quality of life. When results from the final time point in both studies were combined, informal practice was significant related to all three outcome variables, and mindfulness of breath was significantly related to worry and quality of life. Formal practice was not significantly related to outcomes in either study, or in the combined sample. These findings support the further study of informal mindfulness practices as important tools for continued beneficial clinical outcomes following treatment for people with a principal diagnosis of GAD.

A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder.

OBJECTIVE: To examine whether an empirically and theoretically derived treatment combining mindfulness- and acceptance-based strategies with behavioral approaches would improve outcomes in generalized anxiety disorder (GAD) over an empirically supported treatment. METHOD: This trial randomized 81 individuals (65.4% female, 80.2% identified as White, average age 32.92) diagnosed with GAD to receive 16 sessions of either an acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Assessments at pretreatment, posttreatment, and 6-month follow-up included the following primary outcome measures: GAD clinician severity rating, Structured Interview Guide for the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Depression Anxiety Stress Scale, and the State-Trait Anxiety Inventory. Secondary outcomes included the Beck Depression Inventory-II, Quality of Life Inventory, and number of comorbid diagnoses. RESULTS: Mixed effect regression models showed significant, large effects for time for all primary outcome measures (ds = 1.27 to 1.61) but nonsignificant, small effects for condition and Condition × Time (ds = 0.002 to 0.20), indicating that clients in the 2 treatments improved comparably over treatment. For secondary outcomes, time was significant (ds = 0.74 to 1.38), but condition and Condition × Time effects were not (ds = 0.004 to 0.31). No significant differences emerged over follow-up (ds = 0.03 to 0.39), indicating maintenance of gains. Between 63.3 and 80.0% of clients in ABBT and 60.6 and 78.8% of clients in AR experienced clinically significant change across 5 calculations of change at posttreatment and follow-up. CONCLUSION: ABBT is a viable alternative for treating GAD. (PsycINFO Database Record (c) 2013 APA, all rights reserved).