Long-term outcome of Internet-delivered cognitive-behavioural therapy for social phobia: A 30-month follow-up

Internet-delivered guided cognitive behaviour therapy for social anxiety disorder has been found to generate promising short-term results, up to one year posttreatment. No study has however documented longer follow-up periods. In this 30-month follow-up we contacted 57 participants from the original study of which 77.2% (44/57) responded to the Internet-administered outcome measures and 66.7% (38/57) completed a telephone interview. Results showed large pretreatment to follow-up within-group effect sizes for the primary outcome measures (Cohen's d 1.10-1.71), and a majority (68.4%; 26/38) reported improvements in the interview. The findings suggest that the long-term effects seen in previous live treatment CBT trials can occur in Internet-delivered treatment as well.     

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child’s anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children’s anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.     

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%–50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9–14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.     

Treating Procrastination Using Cognitive Behavior Therapy: A Pragmatic Randomized Controlled Trial Comparing Treatment Delivered via the Internet or in Groups

Procrastination is a common problem among university students, with at least half of the population reporting great difficulties initiating or completing tasks and assignments. Procrastination can have a negative impact on course grades and the ability to achieve a university degree, but can also lead to psychological distress. Cognitive behavior therapy (CBT) is believed to reduce procrastination, but few studies have investigated its effectiveness in a regular clinical setting. The current study explored its effects using a pragmatic randomized controlled trial comparing treatment delivered during 8 weeks as self-guided CBT via the Internet (ICBT) or as group CBT. In total, 92 university students with severe procrastination were included in the study (registered as a clinical trial on Clinicaltrials.gov: NCT02112383). Outcome measures on procrastination, depression, anxiety, and well-being were distributed at pre- and posttreatment as well as 6-month follow-up. An outcome measure of procrastination was administered weekly. Linear mixed and fixed effects models were calculated, along with improvement and deterioration rates. The results showed large within-group effect sizes on procrastination, Cohen’s d of 1.29 for ICBT, 95% Confidence Interval (CI) [0.81, 1.74], and d of 1.24 for group CBT, 95% CI [0.76, 1.70], and small to moderate benefits for depression, anxiety, and well-being. In total, 33.7% were regarded as improved at posttreatment and 46.7% at follow-up. No differences between conditions were observed after the treatment period, however, participants in group CBT continued or maintained their improvement at follow-up, while participants in self-guided ICBT showed some signs of deterioration. The findings from the current study suggest that CBT might be an effective treatment for those struggling with severe procrastination, but that a group format may be better for some to sustain their benefits over time and that the clinical significance of the results need to be investigated further.     

Effectiveness of an Individualized Case Formulation-Based CBT for Non-responding Youths with Anxiety Disorders

The study examined the effectiveness of an individualized case formulation-based cognitive behavior therapy (CBT) for youths (9–17 years) with anxiety disorders and their parents after unsuccessful treatment with a manualized group CBT program (the Cool Kids). Out of 106 participant youths assessed at a 3-month follow-up after manualized CBT, 24 were classified as non-responders on the Clinical Global Impression-Improvement scale (CGI-I), and 14 of 16 non-responders with anxiety as their primary complaint accepted an offer for additional individual family CBT. The treatment was short-term (M sessions = 11.14) and based on a revised case formulation that was presented to and agreed upon by the families. At post-treatment, nine youths (64.3 %) were classified as responders on the CGI-I and six (42.9 %) were free of all anxiety diagnoses, while at the 3-month follow-up 11 (78.6 %) had responded to treatment and nine (64.3 %) had remitted from all anxiety diagnoses. Large effect sizes from pre- to post-individualized treatment were found on youths’ anxiety symptoms, self-reported (d = 1.05) as well as mother-reported (d = .81). There was further progress at the 3-month follow-up, while treatment gains remained stable from post-treatment to the 1-year follow-up. Results indicate that non-responders to manualized group CBT for youth anxiety disorders can be helped by additional CBT targeting each family’s specific needs.     

Sudden Gains in Internet-Based Cognitive Behavior Therapy for Body Dysmorphic Disorder

Sudden gains have been associated with better short- and long-term treatment outcomes in a number of psychiatric disorders. However, no studies to date have evaluated sudden gains in body dysmorphic disorder (BDD). We used data from a previous randomized controlled trial evaluating the efficacy of an Internet-based cognitive-behavior treatment (CBT) for BDD. The sample consisted of 47 adults diagnosed with BDD. We compared the treatment outcomes of sudden gainers vs. gradual gainers (i.e., treatment responders with no sudden gains) and non-sudden gainers (i.e., gradual gainers plus nonresponders) at posttreatment and 3, 12, and 24 months after the end of the treatment. Twelve (25.5%) participants experienced a sudden gain. Compared to non-sudden gainers and to gradual gainers, sudden gainers showed significantly larger improvements on the Yale-Brown Obsessive-Compulsive Scale modified for BDD at posttreatment (g = 1.23 and g = .91, respectively), and at 3-month (g = 1.23 and g = 1.00, respectively), 12-month (g = 1.12 and g = .91, respectively), and 24-month follow-up (g = 1.11 and g = .97, respectively). This translated into higher rates of treatment responders and remitters in the sudden gainers across all time points. The occurrence of sudden gains in Internet-based CBT for BDD is associated with favorable short- and long-term treatment outcomes. This suggests that a sudden improvement during the treatment could be a marker of good prognosis, while non-sudden—including gradual—gainers are more likely to need continued support or booster sessions. Early identification of patients who are not progressing as expected and subsequent tailoring of the delivered intervention has the potential to improve treatment outcomes in this group.     

Internet-Delivered CBT for Children with Specific Phobia: A Pilot Study

Background: Cognitive behavior therapy (CBT) has been shown to be an effective treatment for specific phobia in youth, but not all affected seek or receive treatment. Internet-delivered CBT could be a way to increase the availability of empirically supported treatments. Aims: An open trial was conducted to evaluate Internet-delivered CBT for children with specific phobia. Method: Children (N = 30) aged 8–12, and their parents, with a principal diagnosis of specific phobia were recruited through media advertisement. Participants received six weeks of Internet-delivered CBT with therapist support. The treatment was aimed for the parents and the children, with the first part being only for the parents. The primary outcome measure was the Clinician Severity Rating (CSR), and secondary measures included clinician-rated global functioning and child- and parent-reported anxiety and quality of life. All assessments were made at pretreatment, posttreatment, and three-month follow-up. Results: At posttreatment, there were significant reductions on the CSR, with a large within-group effect size (Cohen's d = 1.0) and 35% of children no longer meeting criteria for specific phobia. Self-report measures from parents and children showed significant effects on anxiety, with small to moderate effect sizes. Effects were maintained at three-month follow-up. Conclusions: Results show that Internet-delivered CBT with therapist support for children with specific phobia has the potential to reduce symptom severity. Randomized controlled trials are needed to further evaluate this treatment format.     

Baseline Client Interpersonal Agency Moderates the Indirect Effect of Treatment on Long-term Worry in Variants of CBT for Generalized Anxiety Disorder

In a recent trial for generalized anxiety disorder (GAD), cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) promoted more long-term worry reduction than CBT alone (Westra, Constantino, & Antony, 2016). A follow-up analysis found that CBT vs. MI-CBT clients evidenced greater increases in friendly submissiveness (FS) across treatment, which in turn promoted lower long-term worry (Constantino, Romano, Coyne, Westra, & Antony, 2018). It was unsurprising that traditional directive CBT promoted more FS than when person-centered MI was integrated; however, given that problematic low agency characterizes GAD, that greater FS promoted better outcome was unexpected. To further unpack this unexpected result, we tested the following moderated mediation hypothesis: for clients with more vs. less problematic low agency at baseline, CBT would still promote more in-session FS than MI-CBT, but this increase would in turn predict increased worry over follow-up. Clients receiving CBT (n = 43) or MI-CBT (n = 42) rated their interpersonal problems at baseline and their worry after treatment and across 12-month follow-up. Therapists rated clients’ in-session FS multiple times. As predicted, multilevel modeling revealed that for clients with more problematic low agency, CBT vs. MI-CBT facilitated greater FS, which in turn related to increased worry across follow-up. For clients with more problematic high agency, CBT’s facilitation of greater FS related to reduced worry across follow-up. A baseline interpersonal problem characteristic of GAD may have implications for treatment matching and for appreciating different pathways to long-term improvement, or deterioration, for different GAD subgroups.     

Generalized Worry in Patients With Chronic Fatigue Syndrome Following Cognitive Behavioral Therapy: A Prospective Cohort Study in Secondary Care

Research has shown that generalized anxiety disorder is commonly associated with Chronic Fatigue Syndrome (CFS). This prospective cohort study aimed to investigate the prevalence of generalized worry in CFS patients and its relationship with fatigue, anxiety and social functioning, before and after Cognitive Behavioral Therapy (CBT). Our cohort consisted of 470 patients diagnosed with CFS who received CBT at a secondary care, specialist clinic. Patients completed self-report measures investigating levels of generalized worry, fatigue, work and social adjustment, anxiety and depression at baseline (pretreatment), discharge from treatment, 3-month and 6-month follow up (posttreatment). Analysis indicated a high prevalence of generalized worry (72.4%) at assessment. A significant reduction in worry following CBT (M = −3.42, p < .001, 95% CIs: 2.26, 4.57) was observed at discharge, which remained stable at follow-up. Severe baseline worriers had greater overall fatigue score (M = 3.74, p = .026, 95% CIs: .33, 7.15) and worse overall work and social adjustment than mild worriers across time-points (M = 5.42, p = .035 95% CIs: .27, 10.58). Avoidance behavior mediated the association between generalized worry and work and social adjustment (95% bootstrap CIs: 013, .080). The majority of patients with CFS had comorbid generalized worry and severe worriers reported greater fatigue, anxiety, and worse work and social adjustment. This suggests that CFS patients may benefit from targeting generalized worry during CBT.     

A Randomized Trial of Cognitive Behaviour Therapy and Cognitive Therapy for Children with Posttraumatic Stress Disorder Following Single-Incident Trauma

The present study compared the efficacy of trauma-focused cognitive behavior therapy (CBT) with trauma-focused cognitive therapy (without exposure; CT) for children and youth with posttraumatic stress disorder (PTSD). Children and youth who had experienced single-incident trauma (N = 33; 7–17 years old) were randomly assigned to receive 9 weeks of either CBT or CT which was administered individually to children and their parents. Intent-to-treat analyses demonstrated that both interventions significantly reduced severity of PTSD, depression, and general anxiety. At posttreatment 65% of CBT and 56% of the CT group no longer met criteria for PTSD. Treatment completers showed a better response (CBT: 91%; CT: 90%), and gains were maintained at 6-month follow-up. Maternal depressive symptoms and unhelpful trauma beliefs moderated children’s outcome. It is concluded that PTSD secondary to single-incident trauma can be successfully treated with trauma-focused cognitive behavioural methods and the use of exposure is not a prerequisite for good outcome.     

Virtual Reality One-Session Treatment of Child-Specific Phobia of Dogs: A Controlled,Multiple Baseline Case Series

Specific phobia (SP) typically onsets in childhood and frequently predicts other mental health disorders later in life. Fortunately, childhood SP can be effectively treated with cognitive behavior therapy (CBT), including the exposure-based one-session treatment (OST) approach. Despite empirical support for CBT and OST, clinicians, for various reasons, frequently fail to implement exposure-based therapy in routine clinical practice, including perceived difficulties in implementing exposure. Virtual reality (VR) exposure therapy may overcome some of these challenges and provides an alternative modality of therapy. This preliminary study examined the efficacy of VR OST for 8 children with a SP of dogs (aged 8–12 years) (M = age 10.25; SD = 2.11) using a multiple-baseline controlled case series. Following a stable baseline period of either 2, 3, or 4 weeks, it was expected that specific phobia severity would significantly decline after VR OST and remain improved over the 3-week maintenance phase. Assessments were conducted posttreatment and at 1-month follow up (study end-point). It was found that phobia symptoms remained relatively stable across the baselines, with significant reductions from pretreatment to posttreatment and to follow-up on clinician severity ratings (pre- to post- g = 1.12; pre- to follow-up g = 2.40), target symptom ratings (g = 1.14; 1.29), and behavioral avoidance (g = -1.27; -1.96). The treatment was also associated with clinically significant outcomes, whereby at one-month follow up, 75% of children were considered “recovered” and 88% completed the BAT (interacted with their feared stimuli). This study provides support for the effectiveness of VR OST.     

Quantity and Quality of Homework Compliance: A Meta-Analysis of Relations With Outcome in Cognitive Behavior Therapy

Homework assignments have been shown to produce both causal and correlational effects in prior meta-analytic reviews of cognitive behavior therapy (CBT), but this research area has been characterized by a focus on the amount of compliance (i.e., quantity), and little is known about the role of skill acquisition (i.e., quality). A landmark study by Neimeyer and Feixas (1990) showed stronger homework-outcome relations when quality was assessed, but previous reviews have not considered whether the same pattern is evident across studies. Seventeen studies of CBT (N = 2,312 clients) published following calls for research on homework quality were included in the current meta-analysis. In the present review, homework compliance relations were demonstrated when outcome was assessed at posttreatment (quality Hedges’ g = 0.78, 95% Confidence Interval [CI] = 0.03 to 1.53, k = 3, n = 417; quantity g = 0.79, 95% CI = 0.57 to 1.02, k = 15, n = 1537) and at follow-up (quality g = 1.07, 95% CI = 0.06 to 2.08, k = 3, n = 417; quantity g = 0.51, 95% CI = 0.28 to 0.74, k = 7, n = 1291). All effect sizes were different from 0, ps < .05. Differences that were obtained in homework-outcome relations among sources of compliance data (client, therapist, objective) were tentative due to overlapping CIs, but suggest a potential moderating effect. If confirmed by further research, the present findings would suggest that trial methods capable of assessing both quantity and quality have been an important omission in research on homework-outcome relations in CBT.     

Long-term stability of cognitive behavioral therapy effects for panic disorder with agoraphobia: A two-year follow-up study

Objective

Cognitive-behavioral therapy (CBT) aims to help patients establish new behaviors that will be maintained and adapted to the demands of new situations. The long-term outcomes are therefore crucial in testing the durability of CBT.

Method

A two-year follow-up assessment was undertaken on a subsample of n = 146 PD/AG patients from a multicenter randomized controlled trial. Treatment consisted of two variations of CBT: exposure in situ in the presence of the therapist (T+) or on their own following therapist preparation (T−).

Results

Both variations of CBT had high response rates and, overall, maintained the level of symptomatology observed at post-treatment with high levels of clinical significance. Effect sizes 24 months following treatment were somewhat lower than at the 6-month follow up. Once patients reached responder status, they generally tended to remain responders at subsequent assessments. Differences were observed for patients that obtained additional treatment during the follow-up period. Expert opinion and subjective appraisal of treatment outcome differed. No robust baseline predictors of 2-year outcome were observed.

Conclusion

Most patients maintain clinically meaningful changes two years following treatment across multiple outcome measures. Approximately 1/3 of patients continued to experience meaningful residual problems.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial

The aim of this study was to assess the effectiveness of a cognitive behavioral therapy (CBT) stepped care model (psychoeducation, guided Internet treatment, and face-to-face CBT) compared with direct face-to-face (FtF) CBT. Patients with panic disorder or social anxiety disorder were randomized to either stepped care (n = 85) or direct FtF CBT (n = 88). Recovery was defined as meeting two of the following three criteria: loss of diagnosis, below cut-off for self-reported symptoms, and functional improvement. No significant differences in intention-to-treat recovery rates were identified between stepped care (40.0%) and direct FtF CBT (43.2%). The majority of the patients who recovered in the stepped care did so at the less therapist-demanding steps (26/34, 76.5%). Moderate to large within-groups effect sizes were identified at posttreatment and 1-year follow-up. The attrition rates were high: 41.2% in the stepped care condition and 27.3% in the direct FtF CBT condition. These findings indicate that the outcome of a stepped care model for anxiety disorders is comparable to that of direct FtF CBT. The rates of improvement at the two less therapist-demanding steps indicate that stepped care models might be useful for increasing patients’ access to evidence-based psychological treatments for anxiety disorders. However, attrition in the stepped care condition was high, and research regarding the factors that can improve adherence should be prioritized.     

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.     

Efficacy of Cognitive Therapy for Body Dysmorphic Disorder: A Randomized Controlled Pilot Trial

Dysfunctional cognitive processes and maladaptive interpersonal patterns have been postulated to maintain body dysmorphic disorder (BDD). The present trial evaluated CT for BDD (CT-BDD), which includes modules targeting maladaptive cognitive processing in BDD, as well as elements of schema therapy related to interpersonal problems. We investigated whether (a) CT-BDD is effective, as compared with a wait-list (WL) group at Week 12; (b) outcome of CT-BDD is maintained at posttreatment and 3- and 6-months follow-up; and (c) whether changes in shame and insight mediate changes in BDD symptom severity. Forty adults with BDD were randomized to 36 weeks immediate CT-BDD (n = 21), or to 12-week WL (n = 19). At Week 12, immediate CT-BDD was significantly superior to WL in clinician-rated BDD symptom severity, insight, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. Changes in outcomes were associated with moderate to large effect sizes at Week 12. Reductions in shame and increase in insight separately mediated changes in BDD symptom severity during treatment at Week 12. From baseline to posttreatment, significant improvements occurred within CT-BDD in clinician-rated symptom severity, insight, depression, global functioning, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. At posttreatment, improvements were associated with large effect sizes and were maintained at 3- and 6-month follow-up. Preliminary results support the efficacy of CT-BDD. Addressing interpersonal problems in addition to cognitive dysfunctions may increase the benefit of CBT for BDD patients.     

Anxiety Sensitivity and Interoceptive Exposure: A Transdiagnostic Construct and Change Strategy

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N = 54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS.     

A Pilot Randomized Clinical Trial of a Novel,Culturally Adapted,Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.     

Behavioral Experiments for Intolerance of Uncertainty: Challenging the Unknown in the Treatment of Generalized Anxiety Disorder

Intolerance of uncertainty (IU) is implicated in the development and maintenance of generalized anxiety disorder (GAD). Although an efficacious cognitive-behavioral treatment (CBT) targeting IU and associated factors has been established, approximately 20–30% of participants do not achieve full remission by posttreatment. IU remains elevated in these individuals. In addition, GAD treatments need greater parsimony and efficiency. To that end, we developed a novel, focused CBT protocol exclusively targeting IU via behavioral experiments. Treatment consists of three modules applied over 12 sessions: (a) psychoeducation and uncertainty awareness training, (b) behavioral experiments targeting IU, and (c) relapse prevention. The present article describes each treatment component, as well as additional considerations for therapists. We conducted a preliminary investigation of efficacy with seven (N = 7) participants with a primary diagnosis of GAD. Results indicated substantial decreases in GAD symptoms, general psychopathology, and IU by posttreatment that were generally maintained at 6-month follow-up. Six of seven participants demonstrated moderate to high end-state functioning at posttreatment and 6-month follow-up. Research and clinical implications are discussed.