Examining co-occurring social anxiety in cognitive behavioral therapy for eating disorders: Does it change and does it moderate eating disorder outcomes?

OBJECTIVE: Eating disorders (EDs) often co-occur with social anxiety disorder (SAD). However, little research has examined the influence of SAD symptoms on ED treatment outcomes in the context of individual outpatient cognitive-behavior therapy for eating disorders (CBT-ED). It is plausible that SAD symptom severity could improve as a result of ED treatment, given the high overlap between EDs and SAD. We sought to test whether baseline SAD symptoms moderate early response to CBT-ED or post-treatment outcomes in CBT-ED, and the degree to which SAD symptoms improve during therapy despite SAD not being an explicit treatment target. METHOD: ED clients (N = 226) aged ≥16 years were treated with CBT-ED. Outcomes were ED symptoms, clinical impairment, and SAD symptoms measured at baseline, session 5 and post-treatment. RESULTS: Baseline SAD was a weak moderator of early and post-treatment ED symptoms and impairment. SAD symptoms improved moderately over treatment among clients who started with elevated levels of SAD symptomology. DISCUSSION: Clients with EDs can experience good therapeutic outcomes regardless of their social anxiety severity at pre-treatment. SAD symptoms reduced over CBT-ED, but protocol enhancements such as exposure-based strategies that directly target co-occurring social-evaluative concerns may help achieve larger reductions in SAD symptoms. PUBLIC SIGNIFICANCE: Eating disorders often co-occur with anxiety disorders such as social anxiety. We found people who had both social anxiety and an eating disorder benefited as much from eating disorder treatment as people who did not have social anxiety. People who were socially anxious became less anxious as a by-product of receiving eating disorder treatment. It may be possible to reduce social anxiety further by enhancing eating disorder treatment protocols.

Imagery-enhanced v. verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial.

BACKGROUND: Cognitive behavior therapy (CBT) is effective for most patients with a social anxiety disorder (SAD) but a substantial proportion fails to remit. Experimental and clinical research suggests that enhancing CBT using imagery-based techniques could improve outcomes. It was hypothesized that imagery-enhanced CBT (IE-CBT) would be superior to verbally-based CBT (VB-CBT) on pre-registered outcomes. METHODS: A randomized controlled trial of IE-CBT v. VB-CBT for social anxiety was completed in a community mental health clinic setting. Participants were randomized to IE (n = 53) or VB (n = 54) CBT, with 1-month (primary end point) and 6-month follow-up assessments. Participants completed 12, 2-hour, weekly sessions of IE-CBT or VB-CBT plus 1-month follow-up. RESULTS: Intention to treat analyses showed very large within-treatment effect sizes on the social interaction anxiety at all time points (ds = 2.09-2.62), with no between-treatment differences on this outcome or clinician-rated severity [1-month OR = 1.45 (0.45, 4.62), p = 0.53; 6-month OR = 1.31 (0.42, 4.08), p = 0.65], SAD remission (1-month: IE = 61.04%, VB = 55.09%, p = 0.59); 6-month: IE = 58.73%, VB = 61.89%, p = 0.77), or secondary outcomes. Three adverse events were noted (substance abuse, n = 1 in IE-CBT; temporary increase in suicide risk, n = 1 in each condition, with one being withdrawn at 1-month follow-up). CONCLUSIONS: Group IE-CBT and VB-CBT were safe and there were no significant differences in outcomes. Both treatments were associated with very large within-group effect sizes and the majority of patients remitted following treatment.

Positive outcomes from integrating telehealth into routine clinical practice for eating disorders during COVID-19.

BACKGROUND: The coronavirus pandemic (COVID-19) has required telehealth to be integrated into the delivery of evidence-based treatments for eating disorders in many services, but the impact of this on patient outcomes is unknown. OBJECTIVE: The present study examined the impact of the first wave of COVID-19 and rapid transition to telehealth on eating disorder symptoms in a routine clinical setting. METHOD: Participants were 25 patients with a confirmed eating disorder diagnosis who had commenced face-to-face treatment and rapidly switched to telehealth during the first wave of COVID-19 in Western Australia. Eating disorder symptoms, clinical impairment and mood were measured prospectively before and during lockdowns imposed due to COVID-19. HYPOTHESES: We predicted that patients would experience poorer treatment outcomes during COVID-19 and would perceive poorer therapeutic alliance and poorer quality of treatment compared to face-to-face therapy. RESULTS: Our hypotheses were not supported. On average, patients achieved large improvements in eating disorder symptoms and mood, and the magnitude of improvement in eating disorder symptoms was comparable to historical benchmarks at the same clinic. Patients rated the quality of treatment and therapeutic alliance highly. DISCUSSION: Providing evidence-based treatment for eating disorders via telehealth during COVID-19 lockdown is acceptable to patients and associated with positive treatment outcomes.

A longitudinal assessment of the bivalent fear of evaluation model with social interaction anxiety in social anxiety disorder.

BACKGROUND: The Bivalent Fear of Evaluation Model proposes that the fears of positive and negative evaluation each uniquely contribute to social anxiety severity. However, the debate continues as to whether these are distinct constructs, and, if so, the degree of influence each has on social anxiety severity. This study used a longitudinal evaluation of these relationships in a clinical sample to identify whether the two fears differentially change over time and differentially relate to social anxiety severity. METHODS: Individuals with a social anxiety disorder (N = 105) completed measures of fears of negative and positive evaluation weekly, and social interaction anxiety monthly, for 12 weeks. Temporal relationships were assessed using residual dynamic structural equation modeling. RESULTS: Fears of positive and negative evaluation both predicted the future status of the other (ϕ = 0.18, 95% credibility interval [0.10-0.28] and ϕ = 0.22 [0.12-0.35], respectively). Fear of negative evaluation (ϕ = 0.16 [0.05-0.28]) but not positive evaluation (ϕ < 0.01 [-0.09 to 0.10]) directly predicted future social anxiety severity. Fear of positive evaluation only indirectly predicted anxiety severity via fear of negative evaluation. CONCLUSIONS: Previous fears of negative evaluation could not fully explain future fears of positive evaluation (or vice-versa), which is consistent with the two constructs being likely distinct in social anxiety disorder. Given its more direct relationship with social anxiety severity, fear of negative evaluation should be targeted in treatment, as this could both directly reduce social anxiety severity and minimize the indirect impact of fear of positive evaluation.

Attenuated Psychophysiological Reactivity following Single-Session Group Imagery Rescripting versus Verbal Restructuring in Social Anxiety Disorder: Results from a Randomized Controlled Trial.

BACKGROUND: The effectiveness of psychotherapies for social anxiety disorder (SAD) is typically evaluated using self- and clinician-reported symptom change, while biomarkers of treatment response are rarely measured. The current study aimed to compare biomarkers of response following two brief group interventions for SAD. METHODS: This randomized controlled trial evaluated the effectiveness of single-session group interventions for SAD (n = 58) - imagery rescripting (IR) and verbal restructuring (VR) versus waitlist control (WC). The IR intervention guided participants to rescript autobiographical memories through visualization whilst the VR intervention focused on thought challenging. Trial outcomes included change in psychophysiological reactivity (heart rate variability (HRV) and electrodermal responding) to social stress, and symptom-based measures (social interaction anxiety, negative self-portrayal, cognitive avoidance, repetitive negative thinking, memory modification, anxious behaviors). RESULTS: Psychophysiological reactivity was selectively attenuated following IR treatment, compared to VR and WC groups. The specific influence of the imagery-based intervention in modulating autonomic reactivity was evident across HRV parameters, including the standard deviation of intervals between heartbeats (IR vs. WC, d = 0.67, p = 0.021; IR vs. VR, d = 0.58, p = 0.041), and high frequency power - an indicator of parasympathetically mediated emotion regulation (IR vs. WC, d = 0.75, p = 0.034; IR vs. VR, d = 0.95, p = 0.006). Few group differences were observed across self-report measures. CONCLUSION: The current study highlights the specificity of brief imagery-based interventions in influencing psychophysiological reactivity in SAD and establishes the sensitivity of objective markers of treatment response in quantifying change over symptom-based measurements.

A single session assessment and psychoeducational intervention for eating disorders: Impact on treatment waitlists and eating disorder symptoms.

OBJECTIVE: Long waitlists are common in eating disorder services and can have a detrimental impact on patients. We examined the effect on waitlist length, attendance, and eating disorder symptoms, of a 75-90 min single session intervention (SSI), attended a median of 16 days after referral to a specialist eating disorders clinic. METHOD: Sequential referrals (N = 448) to a public outpatient eating disorders program were tracked from referral until a decision was made on patients entering treatment. One group ("SSI cohort") received a protocol incorporating assessment and psychoeducation about eating disorders before being placed on a waitlist, after which they received further assessment and entered treatment. Data on patient flow indices were collected from this cohort and compared to data from a "Pre-SSI" cohort who had not received the SSI. Symptom change was examined in the SSI cohort. RESULTS: Waitlist length reduced and the proportion of referrals attending assessment and being allocated to treatment increased. Eating disorder symptoms and impairment decreased. Underweight patients (Body Mass Index [BMI] < 18.5 kg/m2 ) gained weight. DISCUSSION: These findings suggest that a single session psychoeducational assessment may reduce waiting times, increase the likelihood of patients entering treatment, and facilitate early reductions in eating disorder symptoms. However, there may be other explanations for the changes observed.

Validation of the clinical perfectionism questionnaire in an eating disorder sample: A bifactor approach.

OBJECTIVE: Clinical perfectionism is involved in the etiology and maintenance of eating disorders. Limited research has examined the factor structure of the Clinical Perfectionism Questionnaire (CPQ) in clinical eating disorder samples. The aim of this research was to examine the validity and reliability of the CPQ in a mixed eating disorder sample. METHOD: Patients (N = 211) with an eating disorder completed the CPQ at pretreatment. A bifactor model was tested that included a general clinical perfectionism factor and two group factors; overevaluation of striving and concern over mistakes. The unique contributions that general and group factors make to the prediction of eating disorder symptoms were also investigated. Unidimensional, correlated two-factor, and bifactor models were tested using confirmatory factor analysis. RESULTS: A bifactor structure for a revised 10-item version of the CPQ provided the best fit, with a strong and reliable general clinical perfectionism factor. The general clinical perfectionism factor and the overevaluation of striving group factor explained reliable variance in the CPQ, and but only the general factor predicted eating disorder symptoms. DISCUSSION: The results suggested that a total score is generally appropriate for assessing clinical perfectionism in a clinical eating disorder sample.

Therapist adherence in the strong without anorexia nervosa (SWAN) study: A randomized controlled trial of three treatments for adults with anorexia nervosa.

OBJECTIVE: To develop a psychotherapy rating scale to measure therapist adherence in the Strong Without Anorexia Nervosa (SWAN) study, a multi-center randomized controlled trial comparing three different psychological treatments for adults with anorexia nervosa. The three treatments under investigation were Enhanced Cognitive Behavioural Therapy (CBT-E), the Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), and Specialist Supportive Clinical Management (SSCM). METHOD: The SWAN Psychotherapy Rating Scale (SWAN-PRS) was developed, after consultation with the developers of the treatments, and refined. Using the SWAN-PRS, two independent raters initially rated 48 audiotapes of treatment sessions to yield inter-rater reliability data. One rater proceeded to rate a total of 98 audiotapes from 64 trial participants. RESULTS: The SWAN-PRS demonstrated sound psychometric properties, and was considered a reliable measure of therapist adherence. The three treatments were highly distinguishable by independent raters, with therapists demonstrating significantly more behaviors consistent with the actual allocated treatment compared to the other two treatment modalities. There were no significant site differences in therapist adherence observed. DISCUSSION: The findings provide support for the internal validity of the SWAN study. The SWAN-PRS was deemed suitable for use in other trials involving CBT-E, MANTRA, or SSCM.

Opportunities lost? Rates and predictors of attrition in an eating disorders outpatient service.

OBJECTIVE: To examine rates and predictors of attrition from referral through to treatment completion in an outpatient public psychology service's eating disorder program in Perth, Western Australia. METHOD: The proportion (number) of clients (N = 671; mean age = 23.8 years) transitioning between stages of pre-treatment and treatment was identified. Associations between demographic, treatment and clinical variables and attrition were investigated using logistic regression. RESULTS: Only 34% (n = 230) of referred patients started treatment and 16% (n = 107) completed treatment. Referral acceptance was correlated with provisional diagnoses that meet the service's inclusion criteria, and attendance at an initial assessment was correlated with younger age. Treatment commencement was correlated with the presence of a co-occurring depressive or anxiety disorder, and no previous suicide attempts. Completing a full course of treatment was correlated with no previous hospitalisation for psychiatric issues, no previous suicide attempts, a history of psychiatric medication use, and treatment with family-based therapy. DISCUSSION: High rates of attrition were found from referral to treatment completion. A suggested framework for defining the different stages of attrition is proposed to allow for consistency of attrition reporting across the mental health field. Future studies are needed to identify why clients disengage following referral, assessment, and treatment commencement, to inform strategies to engage and sustain engagement and to optimise outcomes.

What explains the failure to identify replicable moderators of symptom change in social anxiety disorder?

Trials of cognitive behaviour therapy (CBT) for social anxiety disorder (SAD) have struggled to identify replicable moderators of treatment outcome. This could be due to a genuine lack of effects, or a spurious finding caused by methodological factors such as inadequate testing of theory-driven moderators, use of small homogenous samples, failure to model non-linear relationships, and over-reliance on significance testing. We probed explanations for the field's failure to detect moderators by testing whether 15 theory-driven and atheoretical variables moderated treatment outcome in a large heterogeneous sample treated with group CBT for SAD. Moderation was not assessed by only using p-values for linear models, but also by considering effect sizes, plots, and non-linear relationships. Despite using a comprehensive approach to assess moderation, only two variables - the baseline severity of SAD symptoms and fear of negative evaluation (FNE) - were found to moderate social anxiety symptom trajectories. FNE had a non-linear relationship with symptom change that would have been missed using common research methods. Our findings suggest both a genuine lack of effects and limitations of research methods have contributed to the field's inability to identify moderators. We provide suggestions that may increase the likelihood of future researchers detecting genuine effects.

Measurement Invariance of Disorder-Specific and Transdiagnostic Measures of Repetitive Negative Thinking.

BACKGROUND: Repetitive negative thinking is conceptualized to be a transdiagnostic process linked to the development and maintenance of psychopathology. Prior research distinguishes between disorder-specific exemplars (worry, rumination) and transdiagnostic measures of repetitive negative thinking with differences across disorders reported. However, establishing the measurement invariance of these measures is necessary to support meaningful comparisons across clinical groups. METHOD: Bayesian structural equation modelling was used to assess the approximate invariance of the Ruminative Response Scale, Penn State Worry Questionnaire, and the Repetitive Thinking Questionnaire across individuals with a principal diagnosis of either depressive disorder, social anxiety disorder, or generalized anxiety disorder. RESULTS: All scales demonstrated approximate measurement invariance across the three disorder groups. The depressive disorder group reported a higher level of rumination than the generalized anxiety disorder group (Δµ = 0.25, 95% Credibility Interval [0.06, 0.45]), with no difference between the generalized anxiety disorder and social anxiety disorder groups. The depressive disorder and generalized anxiety disorder groups did not differ in their levels of trait repetitive negative thinking, but the social anxiety disorder group was markedly lower than the generalized anxiety disorder group (Δµ = -0.21 [-0.37, -0.05]). Similarly, levels of worry did not differ between the generalized anxiety disorder and depressive disorder group but were lower in the social anxiety disorder group than the generalized anxiety disorder group (Δµ = -0.23 [-0.41, -0.06]). CONCLUSIONS: The Ruminative Response Scale, Penn State Worry Questionnaire, and Repetitive Thinking Questionnaire are measuring trait repetitive negative thinking in a consistent manner across individuals with a principal diagnosis of depressive disorder, social anxiety disorder, or generalized anxiety disorder. This supports their use in transdiagnostic contexts and indicates that it is appropriate to directly compare the scores on these measures between diagnostic groups.

Impacts of imagery-enhanced versus verbally-based cognitive behavioral group therapy on psychophysiological parameters in social anxiety disorder: Results from a randomized-controlled trial.

Social anxiety disorder (SAD) is associated with marked physiological reactivity in social-evaluative situations. However, objective measurement of biomarkers is rarely evaluated in treatment trials, despite potential utility in clarifying disorder-specific physiological correlates. This randomized controlled trial sought to examine the differential impact of imagery-enhanced vs. verbal-based cognitive behavioral group therapy (IE-CBGT, n = 53; VB-CBGT, n = 54) on biomarkers of emotion regulation and arousal during social stress in people with SAD (pre- and post-treatment differences in heart rate variability (HRV) and skin conductance). We acquired psychophysiological data from randomized participants across four social stress test phases (baseline, speech preparation, speech, interaction) at pre-treatment, and 1- and 6-months post-treatment. Analyses revealed that IE-CBGT selectively attenuated heart rate as indexed by increases in median heart rate interval (median-RR) compared to VB-CBGT at post-treatment, whereas one HRV index showed a larger increase in the VB-CBGT condition before but not after controlling for median-RR. Other psychophysiological indices did not differ between conditions. Lower sympathetic arousal in the IE-CBGT condition may have obviated the need for parasympathetic downregulation, whereas the opposite was true for VB-CBGT. These findings provide preliminary insights into the impact of imagery-enhanced and verbally-based psychotherapy for SAD on emotion regulation biomarkers.

Self-efficacy in bipolar disorder: Development and validation of a self-report scale.

BACKGROUND: Successful management of bipolar disorder (BPD) typically involves individuals undertaking a complex array of self-management tasks (e.g., taking medication, monitoring symptoms, following a regular sleep routine). Many people with BPD doubt they can successfully undertake these tasks. This low sense of self-efficacy may lead to the perpetuation of BPD symptoms, poor quality of life, and low adherence to treatment. Research on self-efficacy in BPD has been hampered by the lack of a short, reliable and valid self-report scale that is practical to use in clinical and research settings. We sought to develop such a scale. METHODS: BPD patients (N = 303) completed a new battery of items measuring their self-efficacy for performing BPD self-management tasks. Modern psychometric techniques such as bifactor analyses were used to refine the scale, determine an appropriate scoring algorithm, and establish reliability and validity. RESULTS: The Bipolar Self-Efficacy Scale (BPSES) comprises 17 items. BPSES scores were reliable, sensitive to change, and correlated with theoretically related constructs such as social adjustment and positive affect. BPSES scores had substantially higher associations with depression and quality of life than an alternative instrument that measured self-efficacy in general, rather than self-efficacy specifically related to bipolar disorder self-management. LIMITATIONS: Patients were required to be medically managed while attending adjunctive psychological treatment of BPD. CONCLUSIONS: The BPSES is a brief scale that can be used to reliably and validly measure bipolar self-efficacy. It may be fruitful to use the scale in clinical practice, and studies investigating treatment outcomes, mechanisms, and moderators.

Modern robust statistical methods: an easy way to maximize the accuracy and power of your research.

Classic parametric statistical significance tests, such as analysis of variance and least squares regression, are widely used by researchers in many disciplines, including psychology. For classic parametric tests to produce accurate results, the assumptions underlying them (e.g., normality and homoscedasticity) must be satisfied. These assumptions are rarely met when analyzing real data. The use of classic parametric methods with violated assumptions can result in the inaccurate computation of p values, effect sizes, and confidence intervals. This may lead to substantive errors in the interpretation of data. Many modern robust statistical methods alleviate the problems inherent in using parametric methods with violated assumptions, yet modern methods are rarely used by researchers. The authors examine why this is the case, arguing that most researchers are unaware of the serious limitations of classic methods and are unfamiliar with modern alternatives. A range of modern robust and rank-based significance tests suitable for analyzing a wide range of designs is introduced. Practical advice on conducting modern analyses using software such as SPSS, SAS, and R is provided. The authors conclude by discussing robust effect size indices.

Bigger is better: Full-length versions of the Social Interaction Anxiety Scale and Social Phobia Scale outperform short forms at assessing treatment outcome.

The Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS) are 20-item companion measures of social anxiety symptoms frequently used to evaluate outcome in treatment trials. The SIAS-6, SPS-6, and Social Interaction Phobia Scale (SIPS) are promising short forms of the SIAS and SPS. The current study evaluated whether it is sound to use these short scales instead of the full-length instruments to measure outcome in social anxiety disorder (SAD) treatment studies, using data from a trial in which 255 adults with SAD were treated with traditional or imagery-enhanced group cognitive-behavioral therapy. Several deficiencies with the short forms were identified including ceiling effects, inflated variances, imprecise effect size estimates, and a loss of statistical power when testing for between-treatment differences. Using the short forms can alter the substantive findings of a treatment trial, as genuine differences in efficacy between treatments can be missed. We recommend treatment outcome be measured using the full SIAS and SPS rather than the SIPS, SIAS-6, and SPS-6. The full-length instruments provide precise estimates of treatment effects and maximize the chance of detecting between-treatment differences when they exist. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Transportability of imagery-enhanced CBT for social anxiety disorder.

Pilot and open trials suggest that imagery-enhanced group cognitive behaviour therapy (CBT) is highly effective for social anxiety disorder (SAD). However, before being considered reliable and generalisable, the effects of the intervention need to be replicated by clinicians in a setting that is independent of the protocol developers. The current study compared outcomes from clients with a principal diagnosis of SAD at the Australian clinic where the protocol was developed (n = 123) to those from an independent Canadian clinic (n = 46) to investigate whether the large effects would generalise. Trainee clinicians from the independent clinic ran the groups using the treatment protocol without any input from its developers. The treatment involved 12 2-h group sessions plus a one-month follow-up. Treatment retention was comparable across both clinics (74% vs. 78%, ≥9/12 sessions) and the between-site effect size was very small and non-significant on the primary outcome (social interaction anxiety, d = 0.09, p = .752). Within-group effect sizes were very large in both settings (ds = 2.05 vs. 2.19), and a substantial minority (41%-44%) achieved clinically significant improvement at follow-up. Replication of treatment effects within an independent clinic and with trainee clinicians increases confidence that outcomes are generalisable.

Severe and enduring anorexia nervosa? Illness severity and duration are unrelated to outcomes from cognitive behaviour therapy.

OBJECTIVE: The present study aimed to examine whether Anorexia Nervosa (AN) illness severity or duration is associated with retention or treatment response in outpatient, enhanced cognitive-behavioral therapy (CBT-E). METHOD: Patients with a confirmed AN diagnosis (N = 134) completed measures of eating disorder symptoms and quality of life, and had their BMI objectively measured before, during, and after treatment. We evaluated whether illness severity or duration predicted treatment outcomes, using longitudinal regression models. RESULTS: Greater levels of illness severity and duration were not associated with poorer treatment outcomes. CONCLUSIONS: Patients with more severe or long-standing AN illness did just as well in CBT-E as any other patient starting treatment. Therefore, classifying individuals as "severe and enduring" appears to lack clinical utility in CBT-E. Clinicians should continue to administer evidence-supported treatments such as CBT-E for patients with AN, regardless of duration or severity of AN illness. (PsycINFO Database Record

Assessing the efficacy of imagery-enhanced cognitive behavioral group therapy for social anxiety disorder: Study protocol for a randomized controlled trial.

Cognitive behavior group therapy (CBGT) is effective for social anxiety disorder (SAD), but a substantial proportion of patients do not typically achieve normative functioning. Cognitive behavioral models of SAD emphasize negative self-imagery as an important maintaining factor, and evidence suggests that imagery is a powerful cognitive mode for facilitating affective change. This study will compare two group CBGT interventions, one that predominantly uses verbally-based strategies (VB-CBGT) and another that predominantly uses imagery-enhanced strategies (IE-CBGT), in terms of (a) efficacy, (b) mechanisms of change, and (c) cost-effectiveness. This study is a parallel groups (two-arm) single-blind randomized controlled trial. A minimum of 96 patients with SAD will be recruited within a public outpatient community mental health clinic in Perth, Australia. The primary outcomes will be self-reported symptom severity, caseness (SAD present: yes/no) based on a structured diagnostic interview, and clinician-rated severity and life impact. Secondary outcomes and mechanism measures include blind observer-rated use of safety behaviors, physiological activity (heart rate variability and skin conductance level) during a standardized speech task, negative self-beliefs, imagery suppression, fear of negative and positive evaluation, repetitive negative thinking, anxiety, depression, self-consciousness, use of safety behaviors, and the EQ-5D-5L and TiC-P for the health economic analysis. Homework completion, group cohesion, and working alliance will also be monitored. The outcomes of this trial will inform clinicians as to whether integrating imagery-based strategies in cognitive behavior therapy for SAD is likely to improve outcomes. Common and distinct mechanisms of change might be identified, along with relative cost-effectiveness of each intervention.

The search for universal transdiagnostic and trans-therapy change processes: Evidence for intolerance of uncertainty.

The search for universal processes associated with symptom change across emotional disorders and different forms of psychotherapy offers hope of increased theoretical parsimony and treatment efficiencies. This study investigated whether intolerance of uncertainty (IU) is a universal process by examining whether changes in IU were associated with changes in symptoms across three different cognitive behavior therapy protocols for depression (n=106), social anxiety disorder (n=88), or generalized anxiety disorder (n=62) in a community mental health clinic. IU was associated with reductions in repetitive negative thinking in all treatments, which is consistent with IU being a transdiagnostic and 'trans-therapy' process of change. Changes in IU were also associated with symptom relief in the social anxiety disorder and generalized anxiety disorder groups, but not in the depression group. Implications of these findings are discussed within the broader literature of transdiagnostic approaches to emotional disorders.