Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial

Cognitive behaviour treatment of co-occurring depression and generalised anxiety in routine clinical practice

Background

Anxiety and depression are closely associated. However, they are typically treated separately and there is a dearth of information on tackling them together.

Aims

The study’s purpose was to establish how best to treat co-occurring anxiety and depression in a routine clinical service—specifically, to compare cognitive behaviour therapy (CBT) focusing only on depression (CBT-D) to a broader CBT focusing on both depression and anxiety (CBT-DA).

Method

Case notes of 69 patients with equally severe clinical levels of depression and anxiety seen in a routine clinical service were randomly selected to review from a pool of 990 patients. The mean age was 44.61 years (SD = 12.97). 65% of the sample were female and 88% reported their ethnicity white. The content of electronic records reporting techniques used and scores on a measure of depression (The Patient Health Questionnaire) and anxiety (The Generalized Anxiety Disorder Assessment) were reviewed to categorise therapy as CBT-D or CBT-DA.

Results

Results indicated significant overall improvement with CBT; 70% and 77% of the sample met criteria for reliable improvement on The Patient Health Questionnaire and The Generalized Anxiety Disorder Assessment respectively. Fewer patients who received CBT-DA met The Generalized Anxiety Disorder Assessment recovery criteria at the end of treatment than those who received CBT-D. Mean post treatment PHQ-9 and GAD-7 scores remained above threshold for those receiving CBT_DA but not those receiving CBT-D. There was no evidence suggesting CBT-DA was superior to CBT-D.

Conclusions

In patients with equally severe clinical levels of depression and anxiety, a broader treatment addressing both anxiety and depression does not appear to be associated with improved outcomes compared to treatment focused on depression.

Effects of a Brief Transdiagnostic Cognitive Behavioural Group Therapy on Disorder Specific Symptoms

Background:In recent years, cognitive behavioural group therapies (CBGT) have been increasingly deployed as a strategy to increase the efficiency and cost-effectiveness in treatment of common mental health problems. The vast majority of these therapies are disorder specific, but in the last few years there has been growing interest in transdiagnostic CBGT.Aims:The aim of this study was twofold: to evaluate the treatment effects of transdiagnostic CBGT on disorder specific symptoms and what (if any) differences would be observed in the treatment effects with regard to general as opposed to disorder specific symptoms measured pre- and post-treatment.Method:The participants were 233 adult patients diagnosed with depression and/or anxiety disorders. They underwent a 6-week transdiagnostic CBGT. To compare treatment effects on general and disorder specific symptoms, raw scores on all measures were converted to standardized scores.Results:Pre–post differences were significant and there was no evidence that treatment was differentially effective for general and disorder specific symptoms. Effect sizes ranged from medium to large.Conclusion:The 6-week transdiagnostic CBGT is feasible for a wide range of mood and anxiety disorders. The results indicate that low-intensity transdiagnostic group therapies may have similar effects on both general and disorder specific symptoms.

Outcomes of a Randomized Controlled Trial on the Effectiveness of Depression and Anxiety Prevention for Adolescents with a High Familial Risk

A randomized controlled trail was conducted to examine the effectiveness of a depression and anxiety prevention program ‘Een Sprong Vooruit’ (A Leap Forward) among adolescent girls with a high familial risk (N = 142). The results showed neither effects of the prevention program directly after the intervention, nor at 6 or 12 months follow-up on depression and anxiety symptoms. Further, latent growth curve modeling (LGCM) was used to examine whether the growth functions for the intervention and the control condition were different. The slope representing the change in depression symptoms was not significantly different between the intervention and the control condition. For anxiety symptoms, the difference between slopes was also not significant. Based on these results, we suggested that these high-risk adolescent girls might benefit more from a more intensive prevention program.

Transdiagnostic Approach to Food Avoidance After Bariatric Surgery: A Case Study

This study describes treatment of an adult woman, referred to as “Carla,” who was referred for psychological intervention following bariatric surgery due to recurrent nausea and vomiting along with food avoidance. Carla evinced symptoms including dietary range restriction, failure to progress to recommended caloric intake, fear of vomiting, and body dissatisfaction. She was diagnosed with generalized anxiety disorder, along with comorbidities including dysthymia, body dysmorphia, and subsyndromal specific phobia of vomiting (SPOV). Treatment included 20 weekly sessions utilizing a transdiagnostic approach to treatment, which has been shown to be efficacious in management of multiple comorbidities. The limited body of research and results of this case suggest expansion of the criteria for avoidant restrictive food intake disorder (ARFID) to allow for inclusion of this constellation of symptoms within bariatric patients.

A Preliminary Examination of the Effects of Transdiagnostic Versus Single Diagnosis Protocols on Anger During the Treatment of Anxiety Disorders

Dysregulated anger is often present in the emotional (i.e., anxiety, mood, and related) disorders; however, it is rarely targeted in treatment. Transdiagnostic treatments, which focus on processes that contribute to dysregulated emotions across the range of psychopathology, might represent an efficient way to treat this anger. Using a subset of data from a recently completed equivalency trial comparing the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) to single diagnosis protocols (SDPs) for specific disorders, this study began exploring whether the UP led to great reductions in anger compared with the SDPs. Results indicated that there was a small, nonsignificant, decrease in anger in the UP condition, whereas there was a moderate, nonsignificant increase in anger in the SDP condition. At posttreatment, UP patients had significantly lower anger scores than patients who received an SDP. These preliminary results suggest that transdiagnostic treatments may be well poised to target dyregulated anger in the context of emotional disorders.

Comparing the Efficacy of Mindfulness-Based Stress Reduction Therapy with Emotion Regulation Treatment on Quality of Life and Symptoms of Irritable Bowel Syndrome

Objective: Irritable bowel syndrome is a common gastrointestinal disorder. The perception of stress and GI-specific anxiety play a key role in irritable bowel syndrome (IBS). The present study aims at comparing the efficacy of mindfulness-based stress reduction therapy with emotion regulation on the quality of life and severity in patients IBS. Method : This randomized clinical trial was conducted in 3 phases: pretest, posttest, and follow-up. Follow-up was performed 2 months after the last intervention. The study population consisted of 24 IBS patients who were randomly selected according to Rome-IV Criteria and were then divided into 3 eight-member groups: (1) mindfulness-based stress reduction, (2) emotion regulation, and (3) control group. IBS-QOL34 and IBS-SSS were administered as assessment tools to all the 3 groups. The experimental groups were subjected to MBSR and ER psychotherapy, while the control group received no psychological intervention. After the 2-month follow-up, the 3 groups were evaluated again.

RESULTS

The results revealed that MBSR improved the quality of life of IBS patients and dicreased severity of their condition. The findings of between and within subjects design revealed that the difference between MBSR and control groups was significant in IBS at follow-up (p = 0.01). Conclusion: MBSR could be considered as a new, effective, and stable method in psychotherapy, in irritable bowel syndrome.

Stepped care in primary care - guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomized controlled trial

BACKGROUND

Common mental disorders (CMD) cause large suffering and high societal costs. Cognitive behavioural therapy (CBT) can effectively treat CMD, but access to treatment is insufficient. Guided self-help (GSH) CBT, has shown effects comparable with face-to-face CBT. However, not all patients respond to GSH, and stepping up non-responders to face-to-face CBT, could yield larger response rates. The aim was to test a stepped care model for CMD in primary care by first evaluating the effects of GSH-CBT and secondly, for non-responders, evaluating the additional effect of face-to-face CBT.

METHODS

Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia, adjustment or exhaustion disorder were included. In Step I, all patients received GSH-CBT. In Step II, non-responders were randomized to face-to-face CBT or continued GSH. The primary outcome was remission status, defined as a score below a pre-established cutoff on a validated disorder-specific scale.

RESULTS

After GSH-CBT in Step I, 40% of patients were in remission. After Step II, 39% of patients following face-to-face CBT were in remission compared with 19% of patients after continued GSH (p = 0.004). Using this stepped care model required less than six therapy sessions per patient and led to an overall remission rate of 63%.

CONCLUSIONS

Stepped care can be effective and resource-efficient to treat CMD in primary care, leading to high remission rates with limited therapist resources. Face-to-face CBT speeded up recovery compared with continued GSH. At follow-ups after 6 and 12 months, remission rates were similar in the two groups.

Heterogeneity in the Strength of the Relation Between Social Support and Post-Trauma Psychopathology

Potentially traumatic events (PTEs) increase risk for psychopathology, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD). Social support (SS) is associated with reduced symptoms for each disorder. Each disorder, however, is highly heterogeneous such that they are comprised of clusters of different symptoms. It is unclear if SS is associated with all clusters equally. The current study examined the relation between SS and the symptom clusters of each disorder. Participants completed a battery of self-report assessments for PTSD, MDD, GAD, and SS. All participants experienced a Criterion A traumatic event. Although SS was significantly associated with all symptom clusters, the strength of relations varied. The relation between SS and MDD-affective was significantly stronger than its association with all other factors. The relations between SS and GAD, MDD-somatic, PTSD-AAR, and PTSD-NACM did not significantly differ. These relations were stronger than the relations between SS and the remaining PTSD factors. There was no significant difference in the relations between SS and PTSD-intrusions or PTSD-avoidance. These results suggest that SS is more closely aligned to specific aspects of post-trauma psychopathology.

"P" and "DP:" Examining Symptom-Level Bifactor Models of Psychopathology and Dysregulation in Clinically Referred Children and Adolescents

OBJECTIVE

This study examined cross-informant evidence for a general factor of psychopathology ("P") and a narrower, clinically oriented dysregulation general factor based on the Dysregulation Profile ("DP") in a large clinical sample of children and adolescents. We also compared the magnitude of P and DP general factor associations with self-harm and suicidal ideation as an indicator of criterion validity.

METHOD

Itemwise data from the Child Behavior Checklist (N = 2,934; 4-18 years of age) were analyzed using confirmatory bifactor modeling and replicated in a supplementary analysis using Youth Self Report data (N = 2,395).

RESULTS

General P and DP bifactor models fit the data better than single-factor and correlated factor models. Cross-informant criterion analyses on a subset of youth (n = 1,552) suggested that whether modeled as latent P or DP, associations with a brief composite index of self-harm and suicidal ideation are essentially of the same magnitude.

CONCLUSION

Our findings provide novel, large-sample support for the existence of general factors of psychopathology and dysregulation in clinically referred children and adolescents using a standardized rating system of psychopathology symptoms. Moreover, our results provide preliminary evidence that general psychopathology and dysregulation factors are clinically meaningful constructs. In addition, our findings raise the possibility that the DP general factor may serve as an efficient proxy for the general psychopathology factor in future clinical applications. Further efforts are necessary to understand the core empirical meaning of the P factor and to determine how it can be applied to clinical assessment and intervention.

A Naturalistic Comparison of Group Transdiagnostic Behaviour Therapy (TBT) and Disorder-Specific Cognitive Behavioural Therapy Groups for the Affective Disorders

BACKGROUND

Transdiagnostic psychotherapies are designed to apply the same underlying treatment principles across a set of psychiatric disorders, without significant tailoring to specific diagnoses. Several transdiagnostic psychotherapy protocols have been developed recently, each of which has its own strengths and weaknesses. One promising treatment is Transdiagnostic Behaviour Therapy (TBT), in that it is one of the few transdiagnostic treatments to date shown to be effective in patients with depressive and anxiety disorders. However, TBT has only been investigated via individual psychotherapy.

AIMS

The present study investigated the effectiveness of a group protocol for TBT, compared with disorder-specific group psychotherapies, in a naturalistic setting.

METHOD

109 participants with various diagnoses of affective disorders completed either group TBT (n = 37) or a disorder-specific group psychotherapy (n = 72). Measures included assessments of psychiatric symptomatology and transdiagnostic impairment at baseline and post-treatment.

RESULTS

Overall, participants in the TBT group demonstrated significant improvements across all measures. When compared with disorder-specific groups, no statistical differences were observed between groups across symptoms; however, participants in the TBT group demonstrated roughly twice the treatment effect sizes in transdiagnostic impairment compared with participants in the disorder-specific groups. In addition, when participants from the most well-represented diagnosis and disorder-specific treatment (social anxiety disorder) were investigated separately, participants in the TBT group demonstrated significantly larger improvements in comorbid depressive symptoms than participants in the disorder-specific treatment.

CONCLUSIONS

Pending replication and additional comparison studies, group TBT may provide an effective group treatment option for patients with affective disorders.

A Web-Based Transdiagnostic Intervention for Affective and Mood Disorders: Randomized Controlled Trial

BACKGROUND

Research increasingly supports a transdiagnostic conceptualization of emotional disorders (ie applying the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses), and many international researchers are currently investigating this issue.

OBJECTIVE

The aim of this study was to evaluate the efficacy and acceptability of a Web-based transdiagnostic program using a sample of Romanian adults diagnosed with anxiety and/or depression.

METHODS

Volunteer participants registered for the study and completed a series of online self-report measures. Participants who fulfilled basic inclusion criteria on these measures were contacted for a telephone diagnostic interview using the Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Axis I Disorders (SCID-I). Enrolled participants were randomized to either the active treatment group (N=69) or the wait-list control group (N=36) using a 2:1 ratio. The transdiagnostic treatment was based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al, 2011) that addresses common underlying mechanisms of anxiety and depression. Participants randomized to the active treatment condition received 10 weeks of Web-based treatment based on the UP. Throughout treatment, graduate students in clinical psychology provided guidance that consisted of asynchronous written communication on a secure Web platform. After the intervention, participants in both study conditions were invited to complete a set of self-report measures and a postintervention SCID-I interview conducted by a different team of graduate students blinded to participants' group and diagnostic status. Six months later, participants in the active treatment group were invited to complete an online follow-up assessment.

RESULTS

During the intervention, active treatment participants completed on average 19 homework assignments (SD 12.10), and we collected data from 79.0% (83/105) at postintervention and 51% (35/69) at follow-up for self-report measures. Postintervention SCID-I interviews were collected from 77.1% (81/105) participants. Relative to the wait-list control group, the transdiagnostic intervention yielded overall medium to large effect sizes for the primary outcome measures (within-group Hedges g=0.52-1.34 and between-group g=0.39-0.86), and also for anxiety sensitivity (g=0.80), symptom interference (g=0.48), and quality of life (g=0.38). Significant within-groups effects only were reported for the active treatment group on Panic Disorder Severity Scale-Self Report (PDSS-SR, g=0.58-0.65) and Yale-Brown Obsessive Compulsive Scale (Y-BOCS, g=0.52-0.58).

CONCLUSIONS

Insignificant between-group differences for the Y-BOCS and PDSS-SR could be explained by the small number of participants with the associated primary diagnostic (eg, only 3 participants with obsessive compulsive disorder) by the choice of outcome measure (PDSS-SR was not rated among the evidence-based measures) and by the fact that these disorders may be more difficult to treat. However, the overall results suggest that the transdiagnostic intervention tested in this study represents an effective treatment option that may prove easier to disseminate through the use of Web-based delivery systems.

TRIAL REGISTRATION

ClinicalTrials.gov CT02739607; https://clinicaltrials.gov/ct2/show/study/NCT02739607 (Archived by WebCite at http://www.webcitation.org/6yY1VeYIZ).

Transdiagnostic Treatment Personalization: The Feasibility of Ordering Unified Protocol Modules According to Patient Strengths and Weaknesses

Most patients in community practice attend significantly fewer sessions than are recommended by treatment protocols that have demonstrated efficacy in addressing emotional disorders. Personalized interventions that target the core processes thought to maintain a wide range of disorders may serve to increase treatment efficiency, addressing this gap. This study sought to evaluate the feasibility and acceptability of the personalized delivery of a mechanistically transdiagnostic intervention, the Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders. Using an AB phase change design in accordance with the single-case reporting guideline for behavioral interventions (SCRIBE), 18 individuals with heterogeneous emotional disorders were randomly assigned to receive UP treatment modules ordered according to either their pretreatment strengths or weaknesses. Results support the feasibility of reordering the treatment modules as the majority of patients presented with marked differences in skill levels, as well as the acceptability of this approach as patients in both conditions reported satisfaction with their assigned treatment order. Furthermore, the majority of patients demonstrated symptom improvement consistent with previously reported effects of the standard-order UP. Finally, there is preliminary evidence to suggest that those in the strengths condition displayed improvements in outcomes earlier in treatment than those in the weaknesses condition. Taken together, these findings offer preliminary support for improving treatment efficiency through the utilization of a personalized, strengths-based, transdiagnostic approach.

Towards an evidence-based unified psychodynamic protocol for emotional disorders

BACKGROUND

In psychotherapy research unified, transdiagnostic and modular treatments have emerged. This is true for both cognitive-behavioral therapy and psychodynamic therapy. Recently, two unified psychodynamic protocols were presented, one for anxiety disorders, another for depressive disorders. Integrating the treatment principles for these two highly prevalent disorder groups into one protocol for "emotional disorders" may be useful for both clinical practice and training in psychotherapy.

METHODS

After updating the evidence for psychodynamic therapy in anxiety and depressive disorders in terms of randomized controlled trials (RCTs) by a systematic search, the treatment elements applied in those RCTs providing evidence for the efficacy of psychodynamic therapy in depressive or anxiety disorders were reviewed and compared.

RESULTS

Twenty-seven RCTs for anxiety or depressive disorders were identified. A review revealed a high overlap between the principles used for the psychodynamic treatment of anxiety and depressive disorders, reflecting the transdiagnostic nature of psychodynamic therapy. The overlap suggested to integrate the identified treatment principles into one unified psychodynamic protocol for "emotional disorders" (UPP-EMO). As a result, seven treatment principles or modules were distilled which can be flexibly applied depending on the patient´s symptoms and needs. In addition, a separate module addresses diagnostic assessment. Across modules, a focus on resources has been included.

LIMITATIONS

Despite being based on RCTs, UPP-EMO has not yet been examined in an RCT - which is planned as a next step.

CONCLUSIONS

As psychodynamic therapy is transdiagnostic in origin focusing on core underlying processes of mental disorders, acceptability of UPP-EMO among psychodynamic psychotherapists is likely to be high.

Understanding the Etiology of Chronic Pain From a Psychological Perspective

The etiology of chronic pain-related disability is not fully understood, particularly from a clinical perspective. Investigations to date have identified risk factors and elucidated some important processes driving the development of persistent pain problems. Yet this knowledge and its application are not always accessible to practicing physical therapists or other clinicians. This article aims to summarize the main psychological processes involved in the development of chronic pain disability and to derive some guidelines for treatment and future research. To this end, the focus is on the paradox of why coping strategies that are helpful in the short term continue to be used even when-ironically-they maintain the problem in the long term. To aid in summarizing current knowledge, 4 tenets that elucidate the etiology of chronic pain are described. These tenets emphasize that chronic pain disability is a developmental process over time, contextual factors set the stage for this development, underlying transdiagnostic psychological factors fuel this development, and the principles of learning steer the development of pain behaviors. With these tenets, an explanation of how a chronic problem develops for one person but not another is provided. Finally, hypotheses that can be empirically tested to guide clinical application as well as basic research are generated. In conclusion, understanding the psychological processes underlying the etiology of chronic pain provides testable ideas and a path forward for improving treatment interventions.

Efficacy of the unified protocol for the treatment of emotional disorders in the Spanish public mental health system using a group format: study protocol for a multicenter, randomized, non-inferiority controlled trial

Background

Emotional disorders, which include both anxiety and depressive disorders, are the most prevalent psychological disorders according to recent epidemiological studies. Consequently, public costs associated with their treatment have become a matter of concern for public health systems, which face long waiting lists. Because of their high prevalence in the population, finding an effective treatment for emotional disorders has become a key goal of today’s clinical psychology. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders might serve the aforementioned purpose, as it can be applied to a variety of disorders simultaneously and it can be easily performed in a group format.

Methods

The study is a multicenter, randomized, non-inferiority controlled clinical trial. Participants will be 220 individuals with emotional disorders, who are randomized to either a treatment as usual (individual cognitive behavioral therapy) or to a Unified Protocol condition in group format. Depression, anxiety, and diagnostic criteria are the primary outcome measures. Secondary measures include the assessment of positive and negative affect, anxiety control, personality traits, overall adjustment, and quality of life. An analysis of treatment satisfaction is also conducted. Assessment points include baseline, post-treatment, and three follow-ups at 3, 6, and 12 months. To control for missing data and possible biases, intention-to-treat and per-protocol analyses will be performed.

Discussion

This is the first randomized, controlled clinical trial to test the effectiveness of a transdiagnostic intervention in a group format for the treatment of emotional disorders in public settings in Spain. Results obtained from this study may have important clinical, social, and economic implications for public mental health settings in Spain.

Trial registration

Retrospectively registered at https://clinicaltrials.gov/. Trial NCT03064477 (March 10, 2017). The trial is active and recruitment is ongoing. Recruitment is expected to finish by January 2020.

Unified protocol for the discontinuation of long-term serotonin reuptake inhibitors in obsessive compulsive disorder: Study protocol and methods

Obsessive-compulsive disorder (OCD) is chronic psychiatric disorder associated with high rates of functional impairment and decreased quality of life. Although serotonin reuptake inhibitors have demonstrated efficacy in the treatment of OCD, little data is available to guide clinicians on how to manage these medications long-term. Cognitive-behavioral approaches provide a promising avenue for helping OCD patients discontinue maintenance SRIs while minimizing the potential for symptom worsening. This manuscript describes the rationale and methods for pilot feasibility study designed to a unified, cognitive-behavioral strategy for discontinuing long-term SRIs in OCD. The aims of the study are (1) to evaluate the feasibility and acceptability of research procedures and interventions, (2) to test the efficacy of this treatment relative to an enhanced control condition and (3) to investigate the role of distress tolerance in both taper completion and clinical outcome. Our central aim is to investigate whether this approach improves discontinue outcomes relative to an enhanced control condition. Identifying optimal long-term treatment strategies for this population is needed to guide clinicians managing this often-chronic disorder.

A Randomized Controlled Pilot Trial of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C) is an intervention for children aged 7 to 13 targeting high negative emotion, emotional reactivity, and emotion regulation deficits common across emotional disorders. Our objective was to collect pilot randomized controlled trial (RCT) data on the efficacy of the UP-C, comparing UP-C with an active, anxiety-focused intervention. Participants were 47 children with at least one primary anxiety disorder; approximately one half had elevated depression symptoms. Participants received either UP-C or the anxiety-focused control treatment. No condition-related differences were found with respect to diagnostic remission and anxiety symptoms. However, differences in favor of UP-C were observed with respect to treatment response at follow-up, depression symptoms, sadness dysregulation, and cognitive reappraisal. Results provide preliminary evidence that the UP-C may be at least as efficacious in treating anxiety as well-supported anxiety-specific treatment protocols and may produce greater gains in certain emotion reactivity and regulation variables.

Targeting Comorbid Anxiety and Depression Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

This article presents the use of an emotion-focused, transdiagnostic therapy approach designed for adolescents with a range of anxiety, obsessive-compulsive, depressive, and related disorders, referred to here as emotional disorders. Preliminary work suggests that emotional disorders share underlying temperament factors, such as high neuroticism and low extroversion in adults and adolescents, possibly influencing the development and maintenance of emotional disorders across the life span. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and similar core dysfunction-focused, transdiagnostic therapy approaches may lead to successful treatment by targeting higher order factors that cut across an array of emotional disorders The utility of UP-A for adolescents experiencing a variety of emotional disorder symptoms is demonstrated here through the case illustration of Tony, a 15-year-old adolescent male with severe social and generalized anxiety and mild levels of depression. After 16 individual treatment sessions, Tony demonstrated significant reductions in anxiety and depressive symptoms, as well as an ability to respond more adaptively to a range of emotional experiences. This case study illustrates how short-term, transdiagnostic treatment using the UP-A can effectively ameliorate a wide range of emotional disorder symptoms in adolescents and may also lead to changes in core features of neuroticism, potentially preventing development of further emotional difficulties over time.

Transdiagnostic Therapy

Transdiagnostic cognitive-behavioral (CBT) therapy is a modified form of CBT designed to be applicable with patients across the range of anxiety and related emotional disorders. Based on emerging genetic, neurologic, developmental, cognitive, and behavioral science, transdiagnostic CBT may alleviate barriers to dissemination and accessibility by providing a single treatment approach across diagnoses. Data from clinical trials and metaanalyses suggest treatment efficacy that is comparable with traditional CBT approaches, with possibly superior efficacy among patients with multiple comorbid anxiety and emotional diagnoses. Limitations in the evidence base and remaining areas for future research are discussed.

Dropping out of a transdiagnostic online intervention: A qualitative analysis of client's experiences

INTRODUCTION

An important concern in Internet-based treatments (IBTs) for emotional disorders is the high dropout rate from these protocols. Although dropout rates are usually reported in research studies, very few studies qualitatively explore the experiences of patients who drop out of IBTs. Examining the experiences of these clients may help to find ways to tackle this problem.

METHOD

A Consensual Qualitative Research study was applied in 10 intentionally-selected patients who dropped out of a transdiagnostic IBT.

RESULTS

22 categories were identified within 6 domains. Among the clients an undeniable pattern arose regarding the insufficient support due to the absence of a therapist and the lack of specificity of the contents to their own problems.

CONCLUSIONS

The analyzed content has direct impact on the clinical application of IBTs. A more tailored manage of expectations as well as strategies to enhance the therapeutic relationship in certain clients are identified as the two key elements in order to improve the dropout in IBTs. Going further, in the mid and long run, ideographic interventions would be vital. The present study permits to better grasp the phenomenon of dropout in IBTs and delineate specific implications both in terms of research, training and practice.

Internet delivered transdiagnostic treatment with telephone support for pain patients with emotional comorbidity: a replicated single case study

In pain patients, comorbid emotional problems have been linked to negative outcomes, including suboptimal treatment gains. Developing parsimonious and accessible treatment options is therefore important. The overarching aim of this study was to test an internet delivered therapist guided transdiagnostic treatment with telephone support. An adapted version of the Unified Protocol for Transdiagnostic Treatments of Emotional Disorders was used as an intervention for pain patients with residual pain problems and comorbid emotional problems after having received a multimodal pain rehabilitation. The study used a replicated AB single case experimental design (N = 5; 3 females). Outcome measures were depressive and general anxiety symptoms, pain intensity, pain coping problems, and diagnostic status. Feasibility measures (completion and compliance) and patient satisfaction were also assessed. Scores on Nonoverlap of All Pairs (NAP) indicate a decrease of anxiety for three participants and a decrease of depression for four participants. Decreases were small and did not always reach statistical significance. Also, Tau-U scores could only confirm a reliable trend for one participant. Two out of four patients who were diagnosed with psychiatric disorders before treatment did no longer fulfill diagnostic criteria posttreatment. No improvements could be seen on pain problems. The treatment was feasible and patient satisfaction was high. Hence, while an internet delivered transdiagnostic treatment with telephone support may be a feasible and accepted secondary intervention for pain patients with comorbid emotional problems, the effects are unclear. The gap between high patient satisfaction and small changes in symptomatology should be explored further.

Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled Trial

BACKGROUND

Mental disorders have become a major health issue, and a substantial number of afflicted individuals do not get appropriate treatment. Web-based interventions are promising supplementary tools for improving health care for patients with mental disorders, as they can be delivered at low costs and used independently of time and location. Although psychodynamic treatments are used frequently in the face-to-face setting, there has been a paucity of studies on psychodynamic Web-based self-help interventions.

OBJECTIVE

The objective of this study was to determine the feasibility and preliminary efficacy of a transdiagnostic affect-focused psychodynamic Web-based self-help intervention designed to increase emotional competence of patients with mental disorders.

METHODS

A total of 82 psychotherapy inpatients with mixed diagnoses were randomized into two groups. Following discharge, the intervention group (IG) got access to a guided version of the intervention for 10 weeks. After a waiting period of 10 weeks, the wait-list control group (WLCG) got access to an unguided version of the intervention. We reported the assessments at the beginning (T0) and at the end of the intervention, resp. the waiting period (T1). The primary outcome was satisfaction with the treatment at T1. Secondary outcome measures included emotional competence, depression, anxiety, and quality of life. Statistical analyses were performed with descriptive statistics (primary outcome) and analysis of covariance; a repeated measurement analysis of variance was used for the secondary outcomes. Effect sizes were calculated using Cohen d and data were analyzed as per protocol, as well as intention-to-treat (ITT).

RESULTS

Patients were chronically ill, diagnosed with multiple diagnoses, most frequently with depression (84%, 58/69), anxiety (68%, 47/69), personality disorder (38%, 26/69), and depersonalization-derealization disorder (22%, 15/69). A majority of the patients (86%, 36/42) logged into the program, of which 86% (31/36) completed the first unit. Satisfaction with the units mastered was rated as good (52%, 16/31) and very good (26%, 9/31). However, there was a steady decline of participation over the course of the program; only 36% of the participants (13/36) participated throughout the trial completing at least 50% of the sessions. According to the ITT analysis, participants improved statistically significantly and with moderate effect sizes (Cohen d) compared with the WLCG regarding depression (d=0.60), quality of life (d=0.53), and emotional competence (d=0.49). Effects were considerably stronger for the completers with respect to depression (d=1.33), quality of life (d=0.83), emotional competence (d=0.68), and general anxiety (d=0.62).

CONCLUSIONS

Although overall program satisfaction and benefit of the program were favorable with respect to the indicators of emotional disorders, the rate of completion was low. Our findings point to the need to target the intervention more specifically to the needs and capabilities of participants and to the context of the intervention.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02671929; https://clinicaltrials.gov/ct2/show/NCT02671929 (Archived by WebCite at http://www.webcitation.org/6ntWg1yWb).

Development of a Single-Session, Transdiagnostic Preventive Intervention for Young Adults at Risk for Emotional Disorders

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.

Transdiagnostische expositionsbasierte Behandlung von Angststörungen

Zusammenfassung. Hintergrund: Neben störungsspezifischen Behandlungskonzepten werden in den letzten Jahren vermehrt transdiagnostische Behandlungsmanuale in der expositionsbasierten Behandlung von Ängsten und komorbiden Störungen eingesetzt. Die vorliegende narrative systematische Übersichtsarbeit beschreibt den Stand der Forschung zu transdiagnostischen Behandlungskonzepten in Hinsicht auf Angst- und komorbide Störungen. Methode: Die Literaturrecherche und die Datenanalyse wurden angelehnt an die PRISMA Guidelines vorgenommen. Die Ergebnisse von 17 Untersuchungen zu expositionsbasierten transdiagnostischen Behandlungskonzepten der letzten fünfzehn Jahre werden beschrieben. Ergebnisse: Die Resultate der referierten Studien zeigen, dass expositionsbasierte transdiagnostische Behandlungen die Symptome, sowohl der primären als auch der komorbiden Störungen, signifikant reduzieren. Expositionsbasierte transdiagnostische Konzepte sind effektiv zur Behandlungen von Angststörungen und komorbider Störungen. Sie stellen eine geeignete Alternative zu störungsspezifischen Behandlungen dar. Diskussion: Die Implikationen transdiagnostischer Konzepte für das praktische Vorgehen bei der individualisierten Diagnostik, der Vorbereitung und Durchführung von Expositionen werden erörtert. Schließlich werden Vorschläge für die Konzeptualisierung einer störungsübergreifenden Behandlung von Angststörungen, insbesondere solcher mit komorbider Symptomatik, vorgestellt.

The general relationship between internalizing psychopathology and chronic physical health conditions: a population-based study

Studies have consistently demonstrated a reciprocal relationship between internalizing disorders and several chronic physical health conditions. Yet, much of the extant literature fails to take into account the role of comorbidity among internalizing disorders when examining the relationship with poor physical health. The current study applied latent variable modelling to investigate the shared and specific relationships between internalizing (fear and distress factors) and a range of physical health conditions. Data comprised 8841 respondents aged 16-85 years who took part in the 2007 Australian National Survey of Mental Health and Wellbeing. Multiple indicator, multiple causes models were used to parse the shared and specific relationships between internalizing disorders and variables associated with poor physical health. The study found that several physical conditions were significantly related to mean levels of fear and distress. The results were broadly similar but minor differences emerged depending on whether lifetime or past 12 months indicators of mental disorders and physical conditions were utilized in the model. Finally, the results demonstrated that the association between individual mental disorders and physical health conditions are better accounted for by indirect relationships with broad transdiagnostic dimensions rather than including additional disorder-specific relationships. The results indicate that researchers should focus on common mechanisms across multiple internalizing disorders and poor physical health when developing prevention and treatment initiatives.

Challenging assumptions from emotion dysregulation psychological treatments

BACKGROUND

Contemporary treatments assume that the inability to downregulate negative emotional arousal is a key problem in the development and maintenance of psychopathology and that lack of effective regulation efforts and a preference to use maladaptive regulation strategies is a primary mechanism. Though ubiquitous, there is limited empirical evidence to support this assumption. Therefore, the aim of the current study was to examine whether self-reported emotion dysregulation equated to difficulties reducing emotional arousal during a behavioral task and to primary use of maladaptive strategies to manage negative emotions.

METHODS

44 anxious and depressed adults with high emotion dysregulation induced negative distress using autobiographic memory recall. After induction, participants were instructed to downregulate but were not provided any specific instructions in strategies to use. Self-reported emotional arousal was assessed before and after induction and after regulation. Qualitative descriptions of regulation efforts were collected and codedinto effective and maladaptive strategies.

RESULTS

The task was successful in inducing emotional arousal and participants were successful in their efforts to down regulate negative emotions. Additionally, effective regulation strategies were used more frequently than maladaptive strategies.

LIMITATIONS

Data collected was exclusively self-report and the sample size was small.

CONCLUSION

Adults who report high emotion dysregulation may still have effective emotion regulation strategies in their behavioral repertoire and are more likely to engage in these effective strategies when given an unspecific prompt to regulate negative emotional arousal. Despite reporting problems with emotion regulation, adults with anxiety and depression can successfully downregulate distress when prompted to do so.

Transdiagnostic treatment of bipolar disorder and comorbid anxiety using the Unified Protocol for Emotional Disorders: A pilot feasibility and acceptability trial

BACKGROUND

Comorbid anxiety in bipolar disorder (BD) is associated with greater illness severity, reduced treatment response, and greater impairment. Treating anxiety in the context of BD is crucial for improving illness course and outcomes. The current study examined the feasibility, acceptability and preliminary efficacy of the Unified Protocol (UP), a transdiagnostic cognitive behavioral therapy, as an adjunctive treatment to pharmacotherapy for BD and comorbid anxiety disorders.

METHODS

Twenty-nine patients with BD and at least one comorbid anxiety disorder were randomized to pharmacotherapy treatment-as-usual (TAU) or TAU with 18 sessions of the UP (UP+TAU). All patients completed assessments every four weeks to track symptoms, functioning, emotion regulation and temperament. Linear mixed-model regressions were conducted to track symptom changes over time and to examine the relationship between emotion-related variables and treatment response.

RESULTS

Satisfaction ratings were equivalent for both treatment groups. Patients in the UP+TAU group evidenced significantly greater reductions over time in anxiety and depression symptoms (Cohen's d's>0.80). Baseline levels of neuroticism, perceived affective control, and emotion regulation ability predicted magnitude of symptom change for the UP+TAU group only. Greater change in perceived control of emotions and emotion regulation skills predicted greater change in anxiety related symptoms.

LIMITATIONS

This was a pilot feasibility and acceptability trial; results should be interpreted with caution.

CONCLUSIONS

Treatment with the UP+TAU was rated high in patient satisfaction, and resulted in significantly greater improvement on indices of anxiety and depression relative to TAU. This suggests that the UP may be a feasible treatment approach for BD with comorbid anxiety.

Development of an integrated cognitive behavioral therapy for anxiety and opioid use disorder: Study protocol and methods

Opioid use disorder is a highly disabling psychiatric disorder, and is associated with both significant functional disruption and risk for negative health outcomes such as infectious disease and fatal overdose. Even among those who receive evidence-based pharmacotherapy for opioid use disorder, many drop out of treatment or relapse, highlighting the importance of novel treatment strategies for this population. Over 60% of those with opioid use disorder also meet diagnostic criteria for an anxiety disorder; however, efficacious treatments for this common co-occurrence have not be established. This manuscript describes the rationale and methods for a behavioral treatment development study designed to develop and test an integrated cognitive-behavioral therapy for those with co-occurring opioid use disorder and anxiety disorders. The aims of the study are (1) to develop and pilot test a new manualized cognitive behavioral therapy for co-occurring opioid use disorder and anxiety disorders, (2) to test the efficacy of this treatment relative to an active comparison treatment that targets opioid use disorder alone, and (3) to investigate the role of stress reactivity in both prognosis and recovery from opioid use disorder and anxiety disorders. Our overarching aim is to investigate whether this new treatment improves both anxiety and opioid use disorder outcomes relative to standard treatment. Identifying optimal treatment strategies for this population are needed to improve outcomes among those with this highly disabling and life-threatening disorder.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial

Importance

Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments.

Objective

To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders.

Design, Setting, and Participants

From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat.

Interventions

The UP or SDPs.

Main Outcomes and Measures

Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs.

Results

Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, -0.93; 95% CI, -1.29 to -0.57) and SDPs (Cohen d, -1.08; 95% CI, -1.43 to -0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, -0.26 to 0.75) and from baseline to the 6-month follow-up (β, 0.16; 95% CI, -0.39 to 0.70) indicated statistical equivalence between the UP and SDPs.

Conclusions and Relevance

The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders.

Trial Registration

clinicaltrials.gov Identifier: NCT01243606.

Effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Among Veterans With Posttraumatic Stress Disorder: A Pilot Study

Effective treatment options are needed for veterans who do not participate in trauma-focused psychotherapy. Research has yet to examine the effectiveness of transdiagnostic psychotherapy in veterans with posttraumatic stress disorder (PTSD) and co-occurring psychological disorders. This pilot study examined the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) delivered in a 16-week group format. We examined treatment outcomes in male and female veterans ( n = 52) in an outpatient specialty PTSD clinic at a large Veterans Affairs (VA) medical center. We hypothesized significant decreases in emotion regulation difficulty (Difficulties in Emotion Regulation Scale), PTSD symptom severity (PTSD Checklist for DSM-5), and depressive symptom severity (Patient Health Questionnaire-9). In addition, we hypothesized that reductions in emotion regulation difficulty across treatment would negatively predict PTSD and depressive symptoms at posttreatment. PTSD symptoms, depressive symptoms, and emotion regulation difficulty all evidenced significant improvements at the end of treatment relative to baseline ( ps < .001). In addition, reductions in emotion regulation across treatment were associated with lower PTSD and depressive symptoms at posttreatment ( ps < .001). This pilot study provides preliminary evidence supporting use of UP among veterans with PTSD and co-occurring disorders. Well-designed clinical trials evaluating efficacy of UP among veterans are needed.

Understanding comorbidity among internalizing problems: Integrating latent structural models of psychopathology and risk mechanisms

It is well known that comorbidity is the rule, not the exception, for categorically defined psychiatric disorders, and this is also the case for internalizing disorders of depression and anxiety. This theoretical review paper addresses the ubiquity of comorbidity among internalizing disorders. Our central thesis is that progress in understanding this co-occurrence can be made by employing latent dimensional structural models that organize psychopathology as well as vulnerabilities and risk mechanisms and by connecting the multiple levels of risk and psychopathology outcomes together. Different vulnerabilities and risk mechanisms are hypothesized to predict different levels of the structural model of psychopathology. We review the present state of knowledge based on concurrent and developmental sequential comorbidity patterns among common discrete psychiatric disorders in youth, and then we advocate for the use of more recent bifactor dimensional models of psychopathology (e.g., p factor; Caspi et al., 2014) that can help to explain the co-occurrence among internalizing symptoms. In support of this relatively novel conceptual perspective, we review six exemplar vulnerabilities and risk mechanisms, including executive function, information processing biases, cognitive vulnerabilities, positive and negative affectivity aspects of temperament, and autonomic dysregulation, along with the developmental occurrence of stressors in different domains, to show how these vulnerabilities can predict the general latent psychopathology factor, a unique latent internalizing dimension, as well as specific symptom syndrome manifestations.

Animal-assisted psychotherapy for young people with behavioural problems in residential care

The aim of this study was to evaluate the impact of an animal-assisted psychotherapy (AAP) programme on clinical symptoms, personal adjustment, and adaptive skills in a group of adolescents in residential care who had experienced childhood trauma and who presented mental health problems and difficulties adapting to the care home environment. The 87 participants (M_age  = 15.17, SD = 1.53) were divided into two groups: a treatment group (25 girls and 27 boys; M_age  = 15.00, SD = 1.55) and a control group (9 girls and 26 boys; M_age  = 15.42, SD = 1.50). The programme consisted of 34 sessions involving both group (23 sessions) and individual (11 sessions) AAP. The Behaviour Assessment System for Children was used to evaluate clinical and adaptive dimensions of behaviour and personality. The results indicated that, in comparison with controls, the young people who took part in the AAP programme reported a significant improvement on two measures of internalizing symptoms, namely, depression and sense of inadequacy. Although no significant differences were observed in relation to externalizing symptoms, the adolescents who received the AAP programme showed improved social skills in terms of their ability to interact satisfactorily with peers and adults in the care home environment, as well as a more positive attitude towards teachers at school. These results suggest that AAP may be a promising treatment for young people who have experienced childhood trauma and who subsequently find it difficult to adapt to the residential care setting.

Training Psychiatry Residents in Psychotherapy: The Role of Manualized Treatments

Evidence-based treatment and manualized psychotherapy have a recent but rich history. As interest and research have progressed, defining the role of treatment manuals in resident training and clinical practice has become more important. Although there is not a universal definition of treatment manual, most clinicians and researchers agree that treatment manuals are an essential piece of evidence-based therapy, and that despite several limitations, they offer advantages in training residents in psychotherapy. Requirements for resident training in psychotherapy have changed over the years, and treatment manuals offer a simple and straightforward way to meet training requirements. In a search limited to only depression, two treatment manuals emerged with the support of research regarding both clinical practice and resident training. In looking toward the future, it will be important for clinicians to remain updated on further advances in evidence based manualized treatment as a tool for training residents in psychotherapy, including recent developments in online and smartphone based treatments.

Chronic Stress Exposure and Generation Are Related to the P-Factor and Externalizing Specific Psychopathology in Youth

Psychopathology is posited to be transdiagnostically linked to chronic stress. Yet efforts to understand the specificity and directionality of these links have been sparse, and the ubiquitous comorbidity of psychopathology has made the seemingly nonspecific links between psychological disorders and chronic stress difficult to interpret. The current study used a latent dimensional bifactor model of psychopathology to account for comorbidity and a multiwave prospective design to disentangle temporal associations between psychopathology and chronic stress longitudinally during the critical adolescent period for psychopathology risk and stress reactivity. A community sample of 567 youth (55.5% female, age M = 11.8 at baseline, M = 15.1 at end of study) were followed prospectively for 3 years, with chronic stress assessed with the Youth Life Stress Interview and psychopathology symptoms assessed via both self and parent report. Exposure to chronic stress predicted what is common across forms of psychopathology (the p factor), which in turn predicted generation of chronic stress over time. After accounting for comorbidity via the p factor, externalizing behaviors also had specific transactional links to chronic stress, whereas links between internalizing psychopathology and chronic stress were completely accounted for by common psychopathology. The results provide the first direct evidence that chronic stress is transdiagnostically and reciprocally linked to psychopathology, during a critical youth period for psychopathology onset and stress reactivity.

Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: An investigation of mediation

Patients' outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., 2011a; Barlow, Sauer-Zavala, et al., in press) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP versus SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance (B = .037, SE = .05, 95% CI [.005, .096]). Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.