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Objective: Interpersonal problems have been identified as a plausible mechanism underlying the onset and maintenance of eating disorders. The Interpersonal Relationships in Eating Disorders (IR‐ED) scale is the first eating disorders‐specific measure of interpersonal problems, which was developed in a nonclinical sample. The aims of the current study were to (a) confirm the factor structure of the IR‐ED within a large clinical sample, (b) investigate measurement invariance of the IR‐ED across nonclinical and clinical samples, (c) examine the convergent validity of the IR‐ED using a generic measure of interpersonal problems, and (d) investigate the incremental clinical utility of the IR‐ED in uniquely predicting eating disorder symptomatology. Method: Treatment‐seeking individuals (N = 437) completed the IR‐ED at their initial assessment appointment at a specialist eating disorder outpatient service. Results: A multiple‐group confirmatory factor analysis supported an invariant bifactor structure comprising a general interpersonal problems factor and two group factors—Avoidance of Body Evaluation and Food‐Related Interpersonal Tension. Convergent validity was demonstrated by a large, statistically significant correlation with a generic measure of interpersonal problems (r = 0.62, p < 0.001). A series of structural equation models further revealed unique incremental predictive utility of the IR‐ED for eating disorder symptomatology. Discussion: The IR‐ED has strong psychometric properties and may prove beneficial in the assessment, formulation, and treatment of eating‐specific interpersonal problems among patients with eating disorders. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. (Contains 1 table.)

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 ( d s = 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. [ABSTRACT FROM AUTHOR]

The most common strategy for comparing two independent groups is in terms of some measure of location intended to reflect the typical observation. However, it can be informative and important to compare the lower and upper quantiles as well, but when there are tied values, extant techniques suffer from practical concerns reviewed in the paper. For the special case where the goal is to compare the medians, a slight generalization of the percentile bootstrap method performs well in terms of controlling Type I errors when there are tied values [Wilcox RR. Comparing medians. Comput. Statist. Data Anal. 2006;51:1934–1943]. But our results indicate that when the goal is to compare the quartiles, or quantiles close to zero or one, this approach is highly unsatisfactory when the quantiles are estimated using a single order statistic or a weighted average of two order statistics. The main result in this paper is that when using the Harrell–Davis estimator, which uses all of the order statistics to estimate a quantile, control over the Type I error probability can be achieved in simulations, even when there are tied values, provided the sample sizes are not too small. It is demonstrated that this method can also have substantially higher power than the distribution free method derived by Doksum and Sievers [Plotting with confidence: graphical comparisons of two populations. Biometrika 1976;63:421–434]. Data from two studies are used to illustrate the practical advantages of the method studied here. [ABSTRACT FROM AUTHOR]

Researchers disagree as to whether cigarette warnings elicit psychological reactance in smokers. We used an experimental design to investigate whether (a) cigarette warnings elicit state reactance; and (b) the degree of reactance elicited by graphic cigarette warnings exceeds that elicited by text-only cigarette warnings. Smokers were exposed to graphic or text-only warnings and then completed reactance measures. Text-only warnings elicited little reactance, whereas over 80% of smokers who were exposed to graphic warnings experienced some reactance. Smokers who were exposed to graphic warnings were more likely to experience elevated and extreme levels of reactance. Our findings are consistent with recent studies indicating that graphic anti-smoking warnings can elicit maladaptive psychological responses. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]