Social Anxiety Disorder (SAD) is a prevalent mental health disorder characterized by a significant prevalence of 5% in recent years. Diverse therapeutic methods can be used to address social anxiety symptoms. Our study sets out to address the gap in literature in comparing two major therapeutic methods: CBT and ACT, respectively. Additionally, we used Virtual Reality (VR) methods to induce social anxiety in laboratory conditions to monitor scale-based progress as well as physiological indicators for all groups. The current paper conducts a 3-arm Quasi-Experimental Pilot Study which aims to compare the two therapeutic approaches via dedicated mobile applications. The main objective of the study is to compare the efficacy of the interventions in reducing social anxiety, including physiological symptoms. From the total number of randomized participants (N = 27, aged between 16 and 58, SD = 8.36), 22 completed the intervention, and displayed a significant decrease in social anxiety symptoms measured on LSAS-SR with a large effect size from pre- to post-measurements accompanied by significant changes in other variables assessed on a secondary note till follow-up, according to ANOVA. However, the results were not maintained in ITT analyses. ACT-informed digital interventions show potential benefits; however future rigorous trials considering limitations are necessary.
Cognitive behavior therapy (CBT) has strong research support for obsessive-compulsive disorder (OCD). However, less is known about long-term follow-up effects of CBT in OCD. A systematic review and meta-analysis was conducted of different types of CBT for OCD in adults and children/adolescents. Four databases were systematically searched for studies published until March 2025. The effectiveness of CBT, methodological quality, and moderators were examined at post and follow-up. Forty-seven studies were included, comprising 2,817 participants. Attrition was lower in child (6.5%) than in adult studies (14.2%). Very large within-group effect sizes (ES; Hedges's g) were obtained for OCD-severity at post-treatment (2.35), and follow-up (2.54), on average 2.5 years post-treatment. Adult studies maintained the ES from post to follow-up, whereas child studies showed a significant further improvement. Average response rates were 70% post-treatment and 69% at follow-up. Mean recovery rates were 48% post-treatment and 52% at follow-up. The degree of change in OCD severity during initial treatment was a strong moderator of the long-term follow-up ES. Exposure and response prevention, cognitive therapy, and the combination all yielded very large ESs with no significant difference between them. In conclusion, CBTs for OCD are effective and the effects are maintained at long-term follow-up.
A meaningful proportion of adults with anxiety and depression symptoms do not seek out psychological therapy. Studies show that higher treatment credibility (how logical therapy seems) and outcome expectations (perceptions of therapy effectiveness) are associated with greater treatment uptake. Most research has included individuals in therapy, who may perceive therapy as more logical and effective than those not seeking treatment. No studies have investigated these constructs in detail in the general community. This study examined perceptions of psychological therapy for anxiety and depression symptoms, and its relationship to treatment willingness in a community sample of Australian adults. Participant factors associated with credibility and expectations were explored. Participants (n = 911) completed an online survey covering demographic information, anxiety and depression symptoms, credibility and expectations, coping self-efficacy, and therapy willingness. Results indicated that participants held positive beliefs about therapy. Credibility and expectations uniquely predicted willingness to engage in therapy. Participant characteristics explained little variance in credibility and expectations. The findings have important implications for improving treatment uptake: credibility and expectations should be considered and could be targeted via public health interventions and in primary care settings. Research exploring optimal approaches for increasing credibility and expectations would be a valuable future direction.
Appearance-related safety behaviors (ARSBs) are maladaptive behavioral strategies employed to manage a perceived flaw in physical appearance or avoid judgment from others due to appearance. While a growing body of research have examined ARSBs using between-person designs, there is a lack of evidence examining how ARSBs may be associated with appearance concerns and social anxiety within-person. The present study preliminarily examined the validity of a daily measure of ARSBs and how daily ARSBs may be associated with same-day appearance concerns and social anxiety. Using a daily-diary approach, young undergraduate adults (N = 107) completed daily-diary surveys twice a week for one month (513 total surveys). Our measure of daily ARSBs converged with a baseline measure of ARSBs. Also, baseline ARSBs predicted daily ARSBs above and beyond daily anxiety and baseline appearance concerns. Within-person analyses also revealed that increases in ARSBs were associated with same day increases in appearance concerns and social anxiety. Baseline clinical symptoms moderated the observed daily relationships, indicating that they were either more pronounced or only present among individuals with elevated appearance concerns or social anxiety. Overall, the present study provides preliminary evidence that ARSBs are a salient factor for appearance concerns and social anxiety within-persons.
Depression and anxiety are common but most adults experiencing these symptoms do not receive psychological treatment. Ultra-brief psychological treatments are a time-limited and potentially lower cost option for those who would otherwise not receive treatment. This prospectively registered review examined the acceptability and efficacy of ultra-brief psychological treatments for adults with depression or anxiety symptoms. A systematic search was undertaken up to April 2025. All clinical trials examining an ultra-brief psychological treatment for adults with depression or anxiety symptoms were included. This review returned 16,670 results and included 34 studies (N = 3,679). High rates of uptake (91% [95% CI 86, 94]) and completion (96% [95% CI 90, 98]) were reported. Compared to control, treatment resulted in small to moderate reductions in depression g = 0.35 (k = 20, 95% CI 0.13, 0.56) and moderate reductions in anxiety g = 0.51 (k = 14, 95% CI 0.40, 0.61) at post-treatment. Within-group effects appear to be maintained at follow-up. Overall heterogeneity was high; several moderators of between-group and within-group effects were identified. Control groups and follow-up periods varied greatly. Ultra-brief treatments appear to be acceptable and associated with significant symptom improvements. Larger clinical trials with longer follow-up periods are needed.
Whiplash is an injury caused by a sudden acceleration-deceleration of the head, transferring energy to the spine. The clinical symptoms after the injury are known as whiplash-associated disorders (WAD), and the mechanisms of its chronicity and recovery remain unclear. We aimed to explore the relationship between post-traumatic stress disorder (PTSD) symptoms and anxiety with disability, pain catastrophizing, and illness perceptions in patients with chronic whiplash-associated disorders (cWAD). We carried out a multi-center cross-sectional study in which 120 participants with cWAD were recruited. Main outcomes included sociodemographic, PTSD symptoms, anxiety, pain catastrophizing, illness perceptions, and disability. A correlation and a multiple linear regression analysis were performed. In cWAD, PTSD symptoms correlated positively with anxiety (r = 0.667; p = 0.01). Anxiety also shows positive associations with the illness perceptions questionnaire (IPQ-R) identity subscale (r = 0.378; p = 0.01). In regression analyses, pain-related anxiety (PASS) was significantly associated with PTSD symptoms (IES-R), neck disability (NDI), and illness identity (IPQ-R Identity), explaining 58.5% of the variance (R2 = 0.585, p < 0.001). These findings highlight the relevance of PTSD symptoms and anxiety in relation to pain-related disability and illness perceptions in patients with cWAD.
This study explored the latent profiles of psychological flexibility and inflexibility, core processes in acceptance and commitment therapy (ACT). Psychological flexibility refers to the capacity to stay open to internal experiences and to pursue valued actions even in the presence of distress, whereas inflexibility involves rigid attempts to avoid or control them. Using a subgroup-based approach within a nomothetic framework, we investigated how the identified subgroups were associated with depression and anxiety. Participants comprised 1,000 Korean young adults (Mage = 28.68, SDage = 4.10). Latent profile analysis was conducted alongside the Bolck-Croon-Hagenaars (BCH) method to identify distinct profiles. Three latent profiles of ACT processes emerged (i.e. high flexibility, moderate flexibility, high inflexibility). Women were more likely to be classified in the high inflexibility profile. Participants in the high flexibility profile reported lower levels of depression and anxiety, whereas those in the high inflexibility profile had more severe symptoms. Interestingly, unexpected findings were obtained regarding experiential avoidance. The identification of distinct profiles suggests that psychological flexibility and inflexibility may be more polarized in the study sample, with individuals clustering into either adaptive or maladaptive coping styles. Cultural factors may also play a role in shaping the function and impact of experiential avoidance.
There is debate regarding how affective and cognitive styles may underpin traumatic symptomology, and the aim of this study was to examine a hierarchical model comprising negative affect and anxiety sensitivity explaining trauma symptoms in the acute period following trauma exposure, and over 12 months. Participants were n = 2987 patients recruited from emergency departments in the U.S. within 72 h of exposure to acute trauma, who completed self-report assessments of anxiety sensitivity, negative affect and traumatic symptomology at 2-week post-trauma; with n = 1374 of these participants also reporting traumatic symptomology again at 12-month post-trauma. Structural equation modelling was utilized to assess the hierarchical model at 2 weeks and then longitudinally at 12-month post-trauma. negative affect and anxiety sensitivity both showed direct effects on traumatic symptomology in the acute period (2 weeks) post-trauma and then upon traumatic symptomology at 12 months. Anxiety sensitivity was found to be the dominant factor in both models. These findings support assertions that these deeper affective and cognitive styles are important factors that can account for later traumatic symptoms and may also be useful intervention targets to reduce acute symptoms and later post-traumatic mental health problems.
Stress-related disorders like depression and anxiety highlight the need for prevention, prompting increased research into various risk and protective factors associated with psychological distress. This study aimed to identify key factors and their strongest associations with distress symptoms within a comprehensive network model of self-reported and behaviorally measured variables. We analyzed interactions between cognitive biases, emotion regulation strategies, emotions, beliefs, and symptoms of depression, anxiety, and stress in a cross-sectional sample of 489 participants (78% female) from the general Romanian population using network analysis. Findings indicate that negative emotions, stress, and positive reappraisal were the most highly connected variables to the rest of the network (based on expected influence centrality index). Bridge analyses suggest that stress statistically connects between functional and dysfunctional negative emotions and their associations with mental health factors. Additionally, positive emotions, interpretation bias, and rational beliefs are key in this interplay. These results highlight stress and negative emotions as highly connected nodes in the estimated psychological network, which may guide hypothesis generation for future longitudinal and intervention research.
Despite smoking at lower rates, Black adults who smoke face disproportionate tobacco-related health disparities, including higher nicotine dependence, exposure, and lower cessation rates compared to other racial groups. Smoking motives play a critical role in smoking maintenance and relapse. Anxiety sensitivity (AS), a transdiagnostic cognitive-affective construct, has emerged as a strong predictor of smoking motives (habit, affect reduction, sensorimotor, and stimulant motives) among Black adults who smoke. However, mechanisms underlying this relationship remain unclear. False safety behaviors (FSB), or behaviors used to alleviate symptoms of anxiety and stress in response to phobic stimuli (i.e. false threats), may serve as a mechanism between AS and smoking motives. The current study examined the indirect effects of FSB in the relationship between AS and smoking motives (habitual, addictive, negative affect reduction, pleasure, stimulation, and sensorimotor) among Black adults who smoke. Participants included 78 (28.2% female; Mage = 43.5 years, SD = 11.7 years) Black adults who reported current daily smoking. Results showed that AS was indirectly associated with all smoking motives through FSB (all p's < .001-.02). The current results highlight the importance of FSB utilization as a targetable mechanism for smoking cessation treatments for Black adults who smoke and who experience elevated AS.
The purpose of the present study was to explore the experiences and management of migraine pain in patients with chronic migraine. Ten patients with chronic migraine participated in open interviews grounded in functional behavioral analysis within a cognitive-behavioral framework. The interviews were analyzed using systematic text condensation. Participants' experiences and management of pain during a migraine attack were categorized into four concepts: Migraine Pain Signal, Hope of False Alarm, Guiding Assumption, and Delayed Medical Management. The experiences of pain during a migraine attack in are individual; however, common patterns in pain management can be identified. The participants in this study often found it challenging to differentiate migraine pain from other types of pain, automatically dismissed migraine pain signals, utilized non-medical management as their first intervention, and only resorted to their prescribed acute medication when it was no longer optimally effective. Delayed medical intervention and a lack of rest at the onset of the migraine attack in the pain phase can expose participants to significant moderate to severe migraine pain for several days, Clinically, this knowledge can be important as one of several risk markers for the progression from episodic to chronic migraine and for developing individually tailored rehabilitation strategies.
Online-delivered parent management training (PMT) has been shown to effectively improve parenting strategies and reduce externalizing behavior problems (EBPs) in children. However, most existing programs are extensive and primarily target families with moderate to severe difficulties, leaving few accessible and cost-effective options for those with mild to moderate problems. This randomized controlled trial evaluated the efficacy of BIP SAMBA, a brief online-delivered and therapist-guided PMT program developed for parents of children with mild to moderate EBPs. A community sample of parents of N = 30 children aged 5-10 were randomly assigned (1:1) to either BIP SAMBA or to a waitlist control condition. Parents in the intervention group reported significantly greater reduction of EBPs compared to the waitlist group (b = 19.02, ƒ2 = 0.29, p = .013), reflecting a moderate effect size. Parents in the intervention group also developed more involvement in their children's everyday activities. Program adherence was high with 93% of participants completing all core modules. Gains were maintained or had continued to improve at the 1-month follow-up. These findings suggest that BIP SAMBA could be a promising early-stage intervention for families with less severe forms of EBPs. The trial was pre-registered at Clinicaltrials.gov (NCT04670185).
Misophonia is characterized by intense emotional and physiological responses to specific auditory triggers, typically repetitive, human-generated sounds. Treatment research in misophonia is nascent, with several studies showing promising outcomes across a range of treatments. While these findings suggest that misophonia symptoms are responsive to psychological interventions, more research is needed to identify which treatments are most effective, and for whom. This study examined baseline prognostic factors of treatment outcome from a randomized controlled trial for adults with misophonia, comparing acceptance and commitment therapy to progressive relaxation training for misophonia. Using multilevel modeling, the following baseline variables were tested as prognostic factors of clinician- and self-reported misophonia symptoms over time: age, age of misophonia onset, number of comorbid psychological diagnoses, psychological flexibility, and baseline misophonia severity. While exploratory, the findings suggest that older age, earlier age of onset and greater comorbidity, psychological inflexibility, and baseline symptom severity have small-to-moderate clinical and statistical effects on the longitudinal maintenance of treatment gains. Together, these findings highlight the complexity of treating misophonia and identifying potential treatment responders early on.
Safety behavior is used to prevent or minimize perceived threats and contributes to the maintenance of anxiety disorders. Various types of safety behavior (e.g. cognitive, interoceptive strategies, aids, substances) are prevalent. Although assumed to be counterproductive during exposure-based CBT, little is known about its frequency and course across exposure exercises and its relation to treatment outcome. This study examined safety behavior during exposure-based CBT in a large multicenter outpatient sample and investigated its association with treatment outcome and clinical and exposure characteristic correlates. Safety behavior was dichotomously assessed after each exposure exercise using standardized worksheets (7,301) from 639 patients with panic disorder/agoraphobia, social anxiety disorder, or multiple specific phobia. Despite instructions to refrain from it, approximately half of patients reported safety behavior during their first exposure, most frequently cognitive strategies. It decreased significantly across exercises. More frequent safety behavior was associated with less symptom improvement and occurred more often with higher anticipatory and actual fear. Decline was steeper in therapist-guided than self-directed exposures, although therapist-guided exposures occurred first. Safety behavior is common early in exposure-based CBT and decreases across exposure exercises. Continuous monitoring appears important given its associations with clinical variables, exposure characteristics, and treatment outcome.Trial registration: NIMH Protocol Registration System (01EE1402A), German Register of Clinical Studies (DRKS00008743).
Digital mental health interventions (DMHIs) are a promising resource for adults with chronic health conditions (CHCs). However, DMHI adherence is a challenge, with ongoing questions about how best to characterize and address the multifaceted features of engagement. This secondary exploratory analysis sought to characterize DMHI engagement variables including session completion, engagement in interactive exercises, time in sessions, and self-reported completion of homework assignments and to test which engagement variables predicted improvements in outcomes. A sample of 50 adults with a CHC randomized to an acceptance and commitment therapy-based DMHI were examined in this secondary analysis. Although adherence to DMHI sessions was only moderate (M = 4.04 sessions completed of 6), other engagement variables in sessions that participants completed were high. Time in sessions and homework completion were the most consistent predictors of improvements over time, especially for changes from baseline to one-month follow-up, such that only those highly engaged improved on well-being, mental health outcomes, and psychological flexibility. Session completion was the least consistent predictor of changes in outcomes. Overall, results suggest that it may be more important how users engage in DMHIs than the number of sessions completed, highlighting the importance of examining and addressing multiple features of engagement.
Exposure and response prevention (EX/RP) is a first-line, evidence-based treatment for obsessive-compulsive disorder (OCD), yet its widespread implementation remains limited. Major barriers to EX/RP access are the intervention's intensity and lack of qualified providers. There is a growing need for scalable, technology-supported interventions that reduce treatment burden while preserving core therapeutic components. Therefore, we developed Beating OCD and Learning Digitally (BOLD), a self-guided EX/RP web application delivered with minimal therapist support. This small open trial (N = 16) evaluated the acceptability, feasibility, and preliminary outcomes of BOLD in adults with OCD. We found that BOLD significantly reduced OCD symptoms with large effect sizes among treatment completers (d = -1.27). Half of participants completed the full intervention and reported high satisfaction and gains in self-efficacy. Two-thirds (62.5%) of treatment completers were classified as treatment responders. When compared to a matched sample receiving traditional EX/RP, BOLD showed comparable treatment outcomes. Time-effectiveness analysis indicated that BOLD required 73.39% less therapist contact time to achieve equivalent symptom reduction than traditional EX/RP. These findings highlight BOLD's potential as a scalable, cost-effective intervention for OCD. Researchers should refine BOLD by optimizing engagement and reducing barriers to participation and investigate its effectiveness in a full-power randomized controlled trial.
Anxiety sensitivity (AS) is a transdiagnostic vulnerability factor that reflects the misinterpretation of anxiety-related sensations as harmful or dangerous. AS is believed to increase posttraumatic stress disorder (PTSD) symptom severity, in part, by amplifying acute reactivity to trauma reminders. While AS has been consistently linked with PTSD symptom severity, little work has tested whether trait-level AS amplifies the effects of naturalistic trauma reminders on momentary PTSD symptomology. Trauma-exposed adults (N = 82) completed a baseline survey and diary follow-up in which PTSD symptoms were assessed three days/week for two weeks. Multilevel modeling was used to evaluate whether baseline, trait-level AS moderated the association between within-person increases in trauma reminders and PTSD symptoms. Unexpectedly, AS total score did not significantly moderate the relationship between momentary trauma reminders and PTSD symptom clusters. However, AS cognitive and social concerns significantly interacted with trauma reminders to predict greater PTSD avoidance symptoms and AS physical concerns blunted the effect of trauma reminders on negative alterations in cognition and mood (NACM). These findings add to growing literature linking AS with PTSD symptom severity and demonstrated that AS subfactors may differentially amplify the effects of traumatic reminders on PTSD symptom clusters.
Gambling disorder represents a growing global public health challenge, particularly among populations with high symptom severity and psychiatric comorbidity. This proof-of-concept study aimed to develop a guided, internet-delivered cognitive behavioral therapy intervention based on the etiological Pathways Model and to evaluate its feasibility, within-group changes in outcomes, and potential mediators. The sample included twenty-five participants with high symptom severity of gambling disorder and comorbid psychiatric symptoms, primarily depression and anxiety. During treatment, participants completed an average of 19.9 behavioral exercises (standard deviation = 43.7) targeting gambling disorder, emotional vulnerability, and impulsivity. Participants rated the internet-delivered program as acceptable and user-friendly and reported only expected negative effects related to cognitive behavioral therapy. Gambling symptoms, anxiety symptoms, and depression symptoms decreased significantly with large within-group effects, with seventy-two percent classified as responders at post-treatment and fifty-two percent at three-month follow-up. Exploratory mediation analyses indicated that reductions in gambling symptoms were explained by both gambling disorder-specific and pathway-related factors. The findings support the feasibility of theoretically informed internet-delivered cognitive behavioral therapy for gambling disorder with comorbidities and highlight opportunities to optimize interventions for vulnerable subgroups.
Acceptance and commitment therapy (ACT) is a transdiagnostic psychotherapy intervention. We sought to demonstrate the degree to which ACT interventions incrementally reduce depression symptoms when they are primary targets, as well as secondary features of other conditions. We reviewed controlled trials for ACT interventions with depression outcome measures. Studies were identified from the comprehensive repository of ACT controlled trials. Analyses included data from 21,830 participants (k = 263 studies). Overall, ACT interventions resulted in a significant reduction in depression symptoms (g = 0.88). ACT interventions targeting depression against passive controls (waitlists) demonstrated strong incremental effects (g = 1.10). ACT interventions against passive controls where depression was a secondary outcome demonstrated moderate incremental effects (g = 0.61). ACT interventions that targeted depression against active controls demonstrated weak effects (g = 0.35). Publication year did not influence outcomes. ACT was only modestly superior to controls in trials conducted in the United States/Canada, relative to trials from other world regions. Higher quality studies were associated with weaker effects. Altogether, ACT is associated with a significant reduction in depression regardless of whether it is targeted. The degree to which ACT is superior to other interventions is small and likely dependent on contextual factors.
This preregistered study (https://osf.io/pktw4/) aimed to integrate multiple research domains to uncover mechanisms of psychopathology. Relationships between cognitive processing biases-fear learning, interpretation bias (training), and global-local processing-and their prediction of social anxiety (SA) levels measured by the Social Phobia Inventory were examined. Using Bayesian modeling and meta-analytic techniques, task relationships and their association with SA symptoms were evaluated across two datasets (N1 = 209, N2 = 97). Results showed non-significant between-task relationships. Negative interpretation bias was consistently associated with higher SA symptoms, and fear generalization positively predicted SA symptoms in the larger sample. No significant relationship was found between SA symptoms and global-local processing. Crucially, while initial correlations suggested transdiagnostic effects, a post-hoc bifactor analysis revealed that fear generalization was associated with general psychopathology, whereas negative interpretation bias retained a unique, specific association with social anxiety that was not explained by general psychopathology. Limitations include analogue samples and online task administration. These findings emphasize the centrality of interpretation bias as a specific mechanism in social anxiety, distinct from the broader transdiagnostic role of fear generalization.
