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

Efficacy of a Transdiagnostic internet-based treatment for emotional disorders with a specific component to address positive affect: Study protocol for a randomized controlled trial

BACKGROUND

Emotional disorders (ED) are among the most prevalent mental disorders. However, less than 50% of people suffering from ED receive the appropriate treatment. This situation has led to the development of new intervention proposals based on the transdiagnostic perspective, which tries to address the underlying processes common to ED. Most of these programs focus primarily on down-regulating negative affectivity, rather than increasing strengths and up-regulating positive affectivity. The data suggest the existence of disturbances in positive affectivity in these disorders, and so new interventions focusing on these problems are greatly needed. It is also essential to provide assistance to all the people in need. Information and Communication Technologies can be very useful. This study aims to evaluate the efficacy of a transdiagnostic Internet-based treatment for ED in a community sample. The protocol includes traditional CBT components, as well as a specific component to address positive affect. We intend to test this protocol, including this specific component or not, versus a waiting list control group. Moreover, we aim to test the differential effect of this specific component, and study the effectiveness (in terms of patients' acceptance) of using a self-applied Internet-based program. This paper presents the study protocol.

METHODS

The study is a randomized controlled trial. 207 participants will be randomly assigned to: a)Transdiagnostic Internet-based protocol (TIBP), b)Transdiagnostic Internet-based protocol + positive affect component (TIBP + PA), or c)a Waiting List control group (WL). Primary outcomes measures will be the BDI-II, the BAI, and the PANAS. Secondary outcomes will include diagnosis-specific measures of the principal disorder. Participants' treatment acceptance will also be measured. Participants will be assessed at pre-, post-treatment, and 3- and 12- month follow-ups. The data will be analyzed based on the Intention-to-treat principle. Per protocol analyses will also be performed.

DISCUSSION

To the best of our knowledge, this is the first study of a transdiagnostic Internet-based treatment for ED with a specific component to up-regulate positive affectivity. This intervention could contribute to improve the efficiency and effectiveness of current treatment programs for ED, promote the dissemination of EBTs, and help to decrease the high prevalence of ED.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT02578758 . Registered 15 October 2015.

Treating Suicidal Thoughts and Behaviors Within an Emotional Disorders Framework: Acceptability and Feasibility of the Unified Protocol in an Inpatient Setting

We provide a theoretical rationale for applying a transdiagnostic, shared mechanism treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders [UP]) to suicidal thoughts and behaviors. We also present results from a proof of concept study examining the feasibility and acceptability of adding a modified UP to treatment as usual (TAU) in an inpatient setting for individuals reporting a recent suicide attempt or active suicidal ideation. Participants ( N = 12) were randomly assigned to receive UP + TAU or TAU alone. Findings indicate good feasibility and acceptability of the adjunctive intervention. Among participants who were responsive to contact attempts postdischarge ( n = 6), there were no observable differences in suicidal thoughts or behaviors during a 6-month follow-up. This application represents a promising initial extension of a cognitive-behavioral, emotion-focused treatment to suicidal individuals within an inpatient setting. Future studies adequately powered to speak to efficacy of the modified UP intervention are warranted.

Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis

Research evaluating transdiagnostic CBT (tCBT) demonstrates its efficacy. Some evidence suggests equivalence between tCBT and diagnosis-specific CBT (dxCBT), however more investigations are necessary to clarify any difference in efficacy. This meta-analysis was conducted to compare tCBT and dxCBT, and to investigate the differential impact of comorbidity on effect sizes. Pre and post scores from primary anxiety measures in 83 treatment conditions, taken from studies primarily targeting anxiety disorders, were summarised and compared. Meta-regression analyses were then used to test the effects of comorbidity. DxCBT and tCBT meta-effects were found to be large, where g=0.951, 95% CI: 0.874-1.027, and g=1.059, 95% CI: 0.876-1.242, respectively. While statistically different (p=0.008), overlap of confidence intervals indicated a lack of clinical significance. Furthermore, no relationship between comorbidity rate and tCBT outcome was observed. These results were discussed in the context of previous findings in the transdiagnostic CBT literature.

Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention

BACKGROUND

Research suggests that the positive affect system may be an important yet underexplored treatment target in anxiety and depression. Existing interventions primarily target the negative affect system, yielding modest effects on measures of positive emotions and associated outcomes (e.g., psychological well-being). The objective of the present pilot study was to evaluate the efficacy of a new transdiagnostic positive activity intervention (PAI) for anxiety and depression.

METHOD

Twenty-nine treatment-seeking individuals presenting with clinically impairing symptoms of anxiety and/or depression were randomly allocated to a 10-session protocol comprised of PAIs previously shown in nonclinical samples to improve positive thinking, emotions, and behaviors (e.g., gratitude, acts of kindness, optimism; n = 16) or a waitlist (WL) condition (n = 13). Participants were assessed at pre- and posttreatment, as well as 3- and 6-month follow-up, on measures of positive and negative affect, symptoms, and psychological well-being. ClinicalTrials.gov Identifier: NCT02330627 RESULTS: The PAI group displayed significantly larger improvements in positive affect and psychological well-being from pre- to posttreatment compared to WL. Posttreatment and follow-up scores in the PAI group were comparable to general population norms. The PAI regimen also resulted in significantly larger reductions in negative affect, as well as anxiety and depression symptoms, compared to WL. Improvements across all outcomes were large in magnitude and maintained over a 6-month follow-up period.

CONCLUSIONS

Targeting the positive affect system through a multicomponent PAI regimen may be beneficial for generating improvements in positive emotions and well-being, as well as reducing negative affect and symptoms, in individuals with clinically impairing anxiety or depression.

An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents

A substantial proportion of adolescents are non-responders to well-established treatments for anxiety and depression, and many existent approaches do not adequately address comorbidity. There is a need to develop and evaluate unified treatments for adolescents that flexibly address higher order factors shared among internalizing or emotional disorders. The Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A) is a transdiagnostic treatment that targets shared vulnerability and maintenance factors in a flexible format. This study examined initial outcomes of a randomized, waitlist-controlled trial of the UP-A. The UP-A outperformed waitlist at mid-treatment with respect to disorder severity and functional impairment, and there was a significant treatment effect in favor of the UP-A on all outcome measures at post-treatment. Within-subjects analyses collapsing across participants revealed significant improvements on outcome measures over time. Results support further study of the UP-A and its potential efficacy in treating adolescent anxiety and depression.

A real world dissemination and implementation of Transdiagnostic Behavior Therapy (TBT) for veterans with affective disorders

Dissemination and implementation of evidence-based psychotherapies is challenging in real world clinical settings. Transdiagnostic Behavior Therapy (TBT) for affective disorders was developed with dissemination and implementation in clinical settings in mind. The present study investigated a voluntary local dissemination and implementation effort, involving 28 providers participating in a four-hour training on TBT. Providers completed immediate (n=22) and six-month follow-up (n=12) training assessments and were encouraged to collect data on their TBT patients (delivery fidelity was not investigated). Findings demonstrated that providers endorsed learning of and interest in using TBT after the training. At six-months, 50% of providers reported using TBT with their patients and their perceived effectiveness of TBT to be very good to excellent. Submitted patient outcome data evidenced medium to large effect sizes. Together, these findings provide preliminary support for the effectiveness of a real world dissemination and implementation of TBT.

The new transdiagnostic cognitive behavioral treatments: Commentary for clinicians and clinical researchers

Recognition of the limitations of the current categorical diagnostic system and increased understanding of commonalities across clinical problems associated with negative emotion, including anxiety and depression, has led to the development of transdiagnostic psychological interventions. This new approach holds promise in shifting our emphasis from diagnostic categories to treating core construct that cut across disorders. This paper identifies some of the similarities and differences across various cognitive-behavioral transdiagnostic protocols and key challenges in assessment and case conceptualization for clinicians wishing to use this approach. Some key needs in the research literature that would be particularly helpful to clinicians are also identified.

Applying the Unified Protocol Transdiagnostic Treatment to Nonsuicidal Self-Injury and Co-Occurring Emotional Disorders: A Case Illustration

This article presents the use of a transdiagnostic, emotion-focused treatment with a young woman with nonsuicidal self-injury (NSSI), social anxiety disorder, and generalized anxiety disorder. The patient also presented with subclinical depressive, posttraumatic stress, and eating disorder symptoms. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Barlow et al., 2011), a cognitive-behavioral intervention designed to be applicable across anxiety, depressive, and related disorders with strong emotional components, was used to address the range of Laura's presenting concerns. After 16 individual treatment sessions, Laura experienced significant reductions in NSSI (and urges to engage in NSSI) as well as observable improvements in her self-reported ability to respond more adaptively to intense emotion. She also reported moderate reductions in her anxiety disorder symptoms. This case illustration demonstrates how a short-term, transdiagnostic treatment approach can be flexibly applied to a variety of problems maintained by aversive and avoidant reactions to intense emotion.

A hierarchical causal taxonomy of psychopathology across the life span

We propose a taxonomy of psychopathology based on patterns of shared causal influences identified in a review of multivariate behavior genetic studies that distinguish genetic and environmental influences that are either common to multiple dimensions of psychopathology or unique to each dimension. At the phenotypic level, first-order dimensions are defined by correlations among symptoms; correlations among first-order dimensions similarly define higher-order domains (e.g., internalizing or externalizing psychopathology). We hypothesize that the robust phenotypic correlations among first-order dimensions reflect a hierarchy of increasingly specific etiologic influences. Some nonspecific etiologic factors increase risk for all first-order dimensions of psychopathology to varying degrees through a general factor of psychopathology. Other nonspecific etiologic factors increase risk only for all first-order dimensions within a more specific higher-order domain. Furthermore, each first-order dimension has its own unique causal influences. Genetic and environmental influences common to family members tend to be nonspecific, whereas environmental influences unique to each individual are more dimension-specific. We posit that these causal influences on psychopathology are moderated by sex and developmental processes. This causal taxonomy also provides a novel framework for understanding the heterogeneity of each first-order dimension: Different persons exhibiting similar symptoms may be influenced by different combinations of etiologic influences from each of the 3 levels of the etiologic hierarchy. Furthermore, we relate the proposed causal taxonomy to transdimensional psychobiological processes, which also impact the heterogeneity of each psychopathology dimension. This causal taxonomy implies the need for changes in strategies for studying the etiology, psychobiology, prevention, and treatment of psychopathology. (PsycINFO Database Record

Effectiveness of an Extended Yoga Treatment for Women with Chronic Posttraumatic Stress Disorder

BACKGROUND

Yoga has been found to be an effective posttraumatic stress disorder (PTSD) treatment for a variety of trauma survivors, including females with chronic PTSD. Aim/Purpose: The current study builds on extant research by examining an extended trauma-sensitive yoga treatment for women with chronic PTSD. The study sought to optimize the results of a treatment protocol examined in a recent randomized controlled trial with a shorter duration and without assignment or monitoring of home practice.

MATERIALS AND METHODS

The authors examined a 20-week trauma-sensitive yoga treatment in a non-randomized single-group treatment feasibility study for women with chronic treatment-resistant PTSD (N = 9). The authors examined PTSD and dissociation symptom reduction over several assessment periods.

RESULTS

The results indicate that participants experienced significant reductions in PTSD and dissociative symptomatology above and beyond similar treatments of a shorter duration.

CONCLUSIONS

The findings suggest that more intensive trauma-sensitive yoga treatment characterized by longer duration and intentional assignment and monitoring of home practice may be more advantageous for individuals with severe and chronic PTSD. The implications of the findings for the potentially more substantial role of yoga as an intervention for a subset of adults with chronic treatment-resistant PTSD are discussed.

Transdiagnostic group CBT vs. standard group CBT for depression, social anxiety disorder and agoraphobia/panic disorder: Study protocol for a pragmatic, multicenter non-inferiority randomized controlled trial

BACKGROUND

Transdiagnostic Cognitive Behavior Therapy (TCBT) manuals delivered in individual format have been reported to be just as effective as traditional diagnosis specific CBT manuals. We have translated and modified the "The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders" (UP-CBT) for group delivery in Mental Health Service (MHS), and shown effects comparable to traditional CBT in a naturalistic study. As the use of one manual instead of several diagnosis-specific manuals could simplify logistics, reduce waiting time, and increase therapist expertise compared to diagnosis specific CBT, we aim to test the relative efficacy of group UP-CBT and diagnosis specific group CBT.

METHODS/DESIGN

The study is a partially blinded, pragmatic, non-inferiority, parallel, multi-center randomized controlled trial (RCT) of UP-CBT vs diagnosis specific CBT for Unipolar Depression, Social Anxiety Disorder and Agoraphobia/Panic Disorder. In total, 248 patients are recruited from three regional MHS centers across Denmark and included in two intervention arms. The primary outcome is patient-ratings of well-being (WHO Well-being Index, WHO-5), secondary outcomes include level of depressive and anxious symptoms, personality variables, emotion regulation, reflective functioning, and social adjustment. Assessments are conducted before and after therapy and at 6 months follow-up. Weekly patient-rated outcomes and group evaluations are collected for every session. Outcome assessors, blind to treatment allocation, will perform the observer-based symptom ratings, and fidelity assessors will monitor manual adherence.

DISCUSSION

The current study will be the first RCT investigating the dissemination of the UP in a MHS setting, the UP delivered in groups, and with depressive patients included. Hence the results are expected to add substantially to the evidence base for rational group psychotherapy in MHS. The planned moderator and mediator analyses could spur new hypotheses about mechanisms of change in psychotherapy and the association between patient characteristics and treatment effect.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02954731 . Registered 25 October 2016.

Testing the effectiveness of a transdiagnostic treatment approach in reducing violence and alcohol abuse among families in Zambia: study protocol of the Violence and Alcohol Treatment (VATU) trial

BACKGROUND

Violence against women and girls (VAWG) is an urgent global health problem. Root causes for VAWG include the individual- and family-level factors of alcohol abuse, mental health problems, violence exposure, and related adverse experiences. Few studies in low- and middle-income countries (LMIC) have assessed the effectiveness of psychological interventions for reducing VAWG. This randomized controlled trial, part of the What Works to Prevent Violence Against Women and Girls consortium, examines the effectiveness of a common elements treatment approach (CETA) for reducing VAWG and comorbid alcohol abuse among families in Zambia.

METHODS/DESIGN

Study participants are families consisting of three persons: an adult woman, her male husband or partner, and one of her children aged 8-17 (if available). Eligibility criteria include experience of moderate-to-severe intimate partner violence by the woman and hazardous alcohol use by her male partner. Family units are randomized to receive CETA or treatment as usual. The primary outcome is VAWG as measured by the Severity of Violence Against Women Scale, assessed along with secondary outcomes at 24 months post-baseline. Interim assessments are also conducted at 4-5 months (following CETA completion) and 12 months post-baseline.

CONCLUSIONS

This ongoing trial is one of the first in sub-Saharan Africa to evaluate the use of an evidence-based common elements approach for reducing VAWG by targeting a range of individual- and family-level factors, including alcohol abuse. Results of this trial will inform policy on what interventions work to prevent VAWG in LMIC with local perspectives on scale up and wider implementation.

Current Definitions of "Transdiagnostic" in Treatment Development: A Search for Consensus

Research in psychopathology has identified psychological processes that are relevant across a range of Diagnostic and Statistical Manual (DSM) mental disorders, and these efforts have begun to produce treatment principles and protocols that can be applied transdiagnostically. However, review of recent work suggests that there has been great variability in conceptions of the term "transdiagnostic" in the treatment development literature. We believe that there is value in arriving at a common understanding of the term "transdiagnostic." The purpose of the current paper is to outline three principal ways in which the term "transdiagnostic" is currently used, to delineate treatment approaches that fall into these three categories, and to consider potential advantages and disadvantages of each approach.

The direct and indirect effects of the negative affectivity trait on self reported physical function among patients with upper extremity conditions

Negative affectivity is a personality trait that predisposes people to psychological distress and low life satisfaction. Negative affectivity may also affect pain intensity and physical function in patients with musculoskeletal conditions. We explored the association of negative affectivity to pain intensity and self-reported physical function, and tested whether pain intensity mediates the effect of negative affectivity on physical function. In a cross-sectional study, 102 patients with upper extremity musculoskeletal conditions presenting to an orthopedic surgeon completed self-report measures of negative affectivity, pain intensity, and physical function in addition to demographic and injury information. We used the Preacher and Hayes' bootstrapping approach to quantify the indirect effect of negative affectivity on physical function through pain intensity. Negative affectivity correlated with greater pain intensity and lower self-reported physical function significantly. Also, pain intensity mediated the association of negative affectivity with physical function. The indirect effect accounted for one-third of the total effect. To conclude, negative affectivity is associated with decreased engagement in daily life activities both directly, but also indirectly through increased pain intensity. Treatments targeting negative affectivity may be more economical and efficient for alleviation of pain and limitations associated with musculoskeletal illness than those addressing coping strategies or psychological distress.

Transdiagnostic mechanisms of change and cognitive-behavioral treatments for PTSD

This paper reviews the current status of transdiagnostic mechanisms of change targeted in cognitive-behavioral interventions, with a focus on mechanisms that are also relevant to emotional disorders that frequently co-occur with PTSD. First, an overview of the rationale for and key features of identifying mechanisms of change is presented, with a discussion of why it is crucial to examine mechanisms that are relevant across diagnostic boundaries. A review of the current evidence for five promising transdiagnostic mechanisms (hope, neuroticism, emotion regulation, cognitive reappraisal, and anxiety sensitivity) is then provided. Finally, the implications of the increasing evidence of transdiagnostic mechanisms of change are discussed in relation to recently developed transdiagnostic treatment protocols that provide an alternative treatment approach for PTSD.

Emotion dysregulation as a cross-cutting target for inpatient psychiatric intervention

BACKGROUND

This prospective, open effectiveness trial examined trajectories of change in a cross-cutting measure of emotion dysregulation in an intensive multimodal inpatient treatment for adults experiencing serious mental illness (SMI).

METHODS

Adult inpatients with SMI (N=994) completed an average of 38.6 days of inpatient treatment. Latent growth curve (LGC) methods were used to model emotion dysregulation trajectories, estimating expected remission based on individual patterns of change.

RESULTS

Absolute reductions in experiential avoidance (d=1.03, CI_95% [.94, 1.10]) and emotional dysregulation were substantial with large effect size improvements (d=.98, CI_95% [.90, 1.05]). Initial scores for experiential avoidance and emotion dysregulation were higher for patients with diagnoses of bipolar, depressive, anxiety, and personality disorders; whereas, male gender was associated with lower initial scores. Substance use diagnoses were associated with rapid improvement in experiential avoidance and specific emotion dysregulation involving goal-directed behavior and impulse control. Presence of a personality disorder predicted rapid improvement in overall emotion dysregulation and clarity of emotional experiences.

CONCLUSIONS

Adults with SMI demonstrated substantial improvement in experiential avoidance and emotion dysregulation over the course of intensive inpatient treatment, with significant variability in patterns of change. Substance use and personality disorders were associated with rapid improvements in specific aspects of emotion dysregulation.

Toward a Unified Treatment for Emotional Disorders: Update on the Science and Practice

Mental health professionals have long been concerned with describing and proscribing a structure around the myriad variations of psychological and emotional distress that are deemed to be disordered. This has frequently been characterized as a conflict between so-called "lumpers" and "splitters"-those who advocate broad categorizations based on overarching commonalities versus those who endeavor toward a highly refined structure emphasizing unique characteristics. Many would argue that with the era of the modern Diagnostic and Statistical Manual of Mental Disorders (DSM-III to DSM-5), a splitting ideology has been dominant despite re-emerging concerns that some groups of diagnoses, particularly disorders of anxiety and other emotions, may be more similar than different. As a result of such concerns, transdiagnostic or unified models of psychopathology have burgeoned. In this review, we describe the work of Barlow, Allen, and Choate (2004), whose invited paper "Toward a Unified Treatment for Emotional Disorders" reignited transdiagnostic perspectives of emotional disorders. We provide an update on the scientific models and evidence-based treatments that have followed in the wake of this 2004 publication, including key areas for future study in the advancement of transdiagnostic and unified treatment of emotional disorders.

Anxiety and Depression in Children of Depressed Parents: Dynamics of Change in a Preventive Intervention

The current study examined effects of a preventive intervention on patterns of change in symptoms of anxiety and depression in a sample of children of depressed parents. Parents with a history of depression (N = 180) and their children (N = 242; 50% female; M_age = 11.38; 74% Euro-American) enrolled in an intervention to prevent psychopathology in youth. Families were randomized to a family group cognitive behavioral intervention (FGCB) or a written information (WI) control condition. Parents and youth completed the Child Behavior Checklist and Youth Self Report at baseline, 6-, 12-, 18-, and 24-month follow up. Youth in the FGCB intervention reported significantly greater declines in symptoms of both anxiety and depression at 6, 12, and 18 months compared to youth in the WI condition. Youth with higher baseline levels of each symptom (e.g., anxiety) reported greater declines in the other symptom (e.g., depression) from 0 to 6 months in the FGCB intervention only. Changes in anxiety symptoms from 0 to 6 months predicted different patterns of subsequent changes in depressive symptoms from 6 to 12 months for the two conditions, such that declines in anxiety preceded and predicted greater declines in depression for FGCB youth but lesser increases in depression for WI youth. Findings inform transdiagnostic approaches to preventive interventions for at-risk youth, suggesting that both initial symptom levels and initial magnitude of change in symptoms are important to understand subsequent patterns of change in response to intervention.

Isolating the Unique Effects of the Unified Protocol Treatment Modules Using Single Case Experimental Design

The Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders is a cognitive-behavioral intervention designed to treat the range of anxiety, depressive, and related disorders. Thus far, the UP treatment modules have only been studied when they are delivered in their entirety and presented in a standard sequence. To personalize the presentation of the UP modules for a given patient's presentation (e.g., providing the modules in a varied order, dropping irrelevant modules), it is first necessary to establish that each module leads to change in the skill it is designed to promote, and that these changes can occur in the absence of the other modules. Using a multiple baseline design in accordance with the single-case reporting guidelines in behavioral interventions (SCRIBE), eight patients with heterogeneous emotional disorders were randomly assigned to a 1- or 3-week baseline assessment phase followed by four sessions of one of four UP modules (psychoeducation, emotional awareness, cognitive flexibility, and countering emotional behaviors). Results provide preliminary support for the notion that each UP module under study leads to change in its associated skill in the absence of the other modules (five of eight patients demonstrated reliable change in the module-specific skill). In addition, exploratory analyses suggest that the emotion awareness training and cognitive flexibility modules appeared to exhibit change specific to their associated skills, psychoeducation, and countering emotional behaviors demonstrated somewhat more broad-based change across skills.

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.

Emergence of Transdiagnostic Treatments for PTSD and Posttraumatic Distress

Both theoretical and empirical findings have demonstrated similarities across diagnoses, leading to a growing interest in transdiagnostic interventions. Most of the evidence supporting transdiagnostic treatment has accumulated for depression, anxiety, and eating disorders, with minimal attention given to posttraumatic stress disorder and other reactions to traumatic stressors. Although single-diagnosis protocols are effective for posttraumatic stress disorder (PTSD) and other trauma-related disorders, in principle, transdiagnostic approaches may have beneficial applications within a traumatized population. This paper defines different types of transdiagnostic treatments, reviews transdiagnostic approaches used in related disorders, and discusses their applicability to PTSD. Examples are drawn from existing transdiagnostic treatments in order to provide a framework for the application of such interventions to the field of traumatic stress. Implications for implementation and dissemination are also discussed.

Interactive effect of negative affectivity and anxiety sensitivity in terms of mental health among Latinos in primary care

From a public health perspective, primary care medical settings represent a strategic location to address mental health disapirty among Latinos. Yet, there is little empirical work that addresses affective vulnerability processes for mental health problems in such settings. To help address this gap in knowledge, the present investigation examined an interactive model of negative affectivity (tendency to experience negative mood states) and anxiety sensitivity (fear of the negative consequences of aversive sensations) among a Latino sample in primary care in terms of a relatively wide range of anxiety/depression indices. Participants included 390 Latino adults (Mage=38.7, SD=11.3; 86.9% female; 95.6% reported Spanish as first language) from a primary care health clinic. Primary dependent measures included depressive, suicidal, social anxiety, and anxious arousal symptoms, number of mood and anxiety disorders, and disability. Consistent with prediction, the interaction between negative affectivity and anxiety sensitivity was significantly related to suicidal, social anxiety, and anxious arousal symptoms, as well as number of mood/anxiety diagnoses and disability among the primary care Latino sample. The form of the interactions indicated a synergistic effect, such that the greatest levels of each outcome were found among those with high negative affectivity and high anxiety sensitivity. There was a trending interaction for depressive symptoms. Overall, these data provide novel empirical evidence suggesting that there is a clinically-relevant interplay between anxiety sensitivity and negative affectivity in regard to the expression of anxiety and depressive symptoms among a Latino primary care sample.

Using Movement to Regulate Emotion: Neurophysiological Findings and Their Application in Psychotherapy

Emotion regulation is a person’s active attempt to manage their emotional state by enhancing or decreasing specific feelings. Peripheral theories of emotion argue that the origins of emotions stem from bodily responses. This notion has been reformulated in neurophysiological terms by Damasio, who claimed that emotions are generated by conveying the current state of the body to the brain through interoceptive and proprioceptive afferent input. The resulting brain activation patterns represent unconscious emotions and correlate with conscious feelings. This proposition implies that through deliberate control of motor behavior and its consequent proprioception and interoception, one could regulate his emotions and affect his feelings. This concept is used in dance/movement (psycho)therapy where, by guiding to move in a certain way, the therapist helps the client to evoke, process, and regulate specific emotions. Exploration and practice of new and unfamiliar motor patterns can help the client to experience new unaccustomed feelings. The idea that certain motor qualities enhance specific emotions is utilized by the therapist also when she mirrors the client’s movements or motor qualities in order to feel what the client feels, and empathize with them. Because of the mirror neurons, feeling what the client feels is enabled also through observation and imagination of their movements and posture. This principle can be used by verbal therapists as well, who should be aware of its bi-directionality: clients seeing the therapist’s motor behavior are unconsciously affected by the therapist’s bodily expressions. Additional implications for psychotherapy, of findings regarding mirror neurons activation, are discussed.

Unified Protocol Transdiagnostic Treatment in Group Format

Barlow et al. published the unified protocol (UP) for transdiagnostic treatment of emotional disorders, focusing on common pathological factors across a variety of diagnoses. The limited UP research to date suggests that this treatment may be particularly useful for anxiety disorders. However, it has largely been evaluated only in individual treatment format. The current study examined the effectiveness of the UP treatment in a group format, with individuals with comorbid anxiety disorder symptoms. Twenty-six individuals with clinically significant anxiety symptoms in at least two of the following areas, social anxiety, worry, or panic, participated in a 14-week manualized group treatment using the UP. Significant decreases were found on general anxiety, worry, social anxiety, panic, depression, and negative affect, and increases on positive affect. The UP may hold promise for a transdiagnostic group treatment of comorbid anxiety symptoms, but further examination of this treatment is warranted.

Updating Watson & Marks (1971): How Has Our Understanding of the Mechanisms of Extinction Learning Evolved and Where Is Our Field Going Next?

J. P. Watson and I. M. Marks published a seminal article in Behavior Therapy entitled "Relevant and Irrelevant Fear in Flooding-A Crossover Study of Phobic Patients" in 1971 that paved the way for important theoretical developments and empirical studies that examined the mechanisms underlying extinction learning. Indeed, in the 44 years since their article was published, our knowledge about how exposure therapy works has increased considerably. In this review, we explore the progress our field has made in understanding extinction learning and how Watson and Marks' important work has influenced this progress. We provide a brief summary of the design and major findings of the Watson and Marks (1971) study, followed by a brief description of several theoretical conceptualizations of fear extinction that were developed following the article's publication. We also review empirical studies that illustrate the "state of the science" with regard to the following key issues that were explored in Watson and Marks' paper: (a) the effect of specificity of exposure stimuli content in exposure therapy on outcome; (b) fear activation as a mechanism of exposure; and (c) the associations between within- and between-session extinction learning and treatment outcome. The major findings of these three issues over the past 4 decades are summarized and discussed.

Spontaneous Thought and Vulnerability to Mood Disorders: The Dark Side of the Wandering Mind

There is increasing interest in spontaneous thought, namely task-unrelated or rest-related mental activity. Spontaneous thought is an umbrella term for processes like mindwandering, involuntary autobiographical memory, and daydreaming, with evidence elucidating adaptive and maladaptive consequences. In this theoretical framework, we propose that, apart from its positive functions, spontaneous thought is a precursor for cognitive vulnerability in individuals who are at-risk for mood disorders. Importantly, spontaneous thought mostly focuses on unattained goals and evaluates the discrepancy between current and desired status (Klinger, 1971, 2013a). In individuals who stably (i.e., trait negative affectivity) or transitorily (i.e., stress) experience negative emotions in reaction to goal-discrepancy, spontaneous thought fosters major cognitive vulnerabilities (e.g., rumination, hopelessness, low self-esteem, and cognitive reactivity) which, in turn, enhance depression. Furthermore, we also highlight preliminary links between spontaneous thought and bipolar disorder. The evidence for this framework is reviewed and we discuss theoretical and clinical implications of our proposal.

Reconciling RDoC and DSM approaches in clinical psychophysiology and neuroscience

The Research Domain Criteria (RDoC) initiative endeavors to foster a science of psychopathology based around dimensions of brain-behavior relationships as opposed to subjectively based diagnostic categories. A rapidly accumulating array of transdiagnostic commonalities, across multiple objective and subjective measures, underscores the clear potential of this initiative. At the same time, a road map for guiding future RDoC research efforts is needed that draws upon the wealth of extant disorder-specific findings. In this issue, Hamm and colleagues provide an example of conceptualizing within-disorder processes in terms of dimensional brain-behavior relationships that advances the understanding of panic disorder with agoraphobia beyond the conventional nosological framework. Their findings and conceptual model are reviewed and discussed in terms of broader transdiagnostic implications.

Personality and trajectories of posttraumatic psychopathology: A latent change modelling approach

BACKGROUND

Survivors of traumatic events may develop a range of psychopathology, across the internalizing and externalizing dimensions of disorder and associated personality traits. However, research into personality-based internalizing and externalizing trauma responses has been limited to cross-sectional investigations of PTSD comorbidity. Personality typologies may present an opportunity to identify and selectively intervene with survivors at risk of posttraumatic disorder. Therefore this study examined whether personality prospectively influences the trajectory of disorder in a broader trauma-exposed sample.

METHODS

During hospitalization for a physical injury, 323 Australian adults completed the Multidimensional Personality Questionnaire-Brief Form and Structured Clinical Interview for DSM-IV, with the latter readministered 3 and 12 months later. Latent profile analysis conducted on baseline personality scores identified subgroups of participants, while latent change modelling examined differences in disorder trajectories.

RESULTS

Three classes (internalizing, externalizing, and normal personality) were identified. The internalizing class showed a high risk of developing all disorders. Unexpectedly, however, the normal personality class was not always at lowest risk of disorder. Rather, the externalizing class, while more likely than the normal personality class to develop substance use disorders, were less likely to develop PTSD and depression.

CONCLUSIONS

Results suggest that personality is an important mechanism in influencing the development and form of psychopathology after trauma, with internalizing and externalizing subtypes identifiable in the early aftermath of injury. These findings suggest that early intervention using a personality-based transdiagnostic approach may be an effective method of predicting and ultimately preventing much of the burden of posttraumatic disorder.

Movement towards transdiagnostic psychotherapeutic practices for the affective disorders

Evidence-based cognitive behavioural therapy (CBT) practices were first developed in the 1960s. Over the decades, refinements and alternative symptom foci resulted in the development of several CBT protocols/manuals for each of the many disorders, especially in the affective disorders. Although shown to be effective in highly trained providers, the proliferation of CBT protocols also has shown to demonstrate challenges in dissemination and implementation efforts due to the sheer number of CBT protocols and their related training requirements (eg, 6 months per protocol) and their related cost (eg, over US$2000 each; lost days/hours at work). To address these concerns, newer transdiagnostic CBT protocols have been developed to reduce the number of disorder-specific CBT protocols needed to treat patients with affective disorders. Transdiagnostic treatments are based on the notion that various disorder-specific CBT protocols contain important but overlapping treatment components that can be distilled into a single treatment and therefore address the symptoms and comorbidities across all of the disorders at once. 3 examples of transdiagnostic treatments include group CBT of anxiety, unified protocol for transdiagnostic treatment for emotional disorders and transdiagnostic behaviour therapy. Each transdiagnostic protocol is designed for a different set of disorders, contains a varied amount of CBT treatment components and is tested in different types of samples. However, together, these 3 transdiagnostic psychotherapies represent the future of CBT practice.

Emotional acceptance, inflammation, and sickness symptoms across the first two years following breast cancer diagnosis

PURPOSE

Breast cancer diagnosis and treatment are associated with increased inflammatory activity, which can induce sickness symptoms. We examined whether emotional acceptance moderates the association between proinflammatory cytokines and self-reported sickness symptoms in women recently diagnosed with breast cancer.

METHODS

Women (N=136) diagnosed with stage 0-III breast cancer within the previous 6months provided plasma samples and completed the FACT: Physical Well-Being Scale, as well as the Acceptance of Emotion Scale every 3months for 2years. At each time point, we quantified interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α using a high sensitivity multiplex assay.

RESULTS

Higher within-subject mean TNF-α across all time-points predicted higher mean sickness symptoms. At individual time-points, higher IL-6 and IL-8 levels were associated with higher sickness symptoms. Mean emotional acceptance across all time-points moderated the relationship between mean IL-8 and sickness symptoms, with sickness symptoms remaining persistently high in women with low emotional acceptance even when IL-8 levels were low. At individual time-points, emotional acceptance positively moderated the correlations of IL-8 and TNF-α with sickness symptoms, such that the associations between higher levels of these proinflammatory cytokines and higher sickness symptoms were attenuated when emotional acceptance was high.

CONCLUSION

Emotional acceptance was shown for the first time to moderate the associations of cytokines with sickness symptoms in breast cancer patients over time following diagnosis and treatment. The association between emotional acceptance and sickness symptoms was significantly different from zero but relatively small in comparison to the range of sickness symptoms. Results suggest that targeting emotion regulation may help to break the cycle between inflammation and sickness symptoms in women with breast cancer.

Using a transdiagnostic, psychodynamic online self-help intervention to maintain inpatient psychosomatic treatment effects: Study protocol of a feasibility study

BACKGROUND

Online self-help interventions have proven to be effective in treating various specific mental disorders, mainly depression and anxiety. Knowledge regarding their acceptance, efficacy, and usefulness in addition to inpatient or outpatient psychotherapy is limited. Therefore, we plan to evaluate an affect-focused, transdiagnostic, psychodynamic online self-help intervention following inpatient psychotherapy for mixed diagnoses in a feasibility study to determine acceptance, satisfaction, and preliminary estimates of efficacy.

METHODS

The intervention is based on the book "Living Like You Mean It" by Ronald J. Frederick (2009) and the Swedish adaption by Johansson and colleagues (2013). The book was translated into German and thoroughly revised using parts of the Swedish adaption and additional tasks from their intervention. In a pilot phase, corrections concerning comprehensibility of the content and exercises were made based on patient's feedback. In the second step, we developed a website presenting the German adaption in eight units. In the third step, at least N = 66 patients from the Department of Psychosomatic Medicine and Psychotherapy will be recruited for a feasibility study. Patients are randomized into two groups. The intervention group (IG) will receive ten weeks of access to the online self-help intervention together with weekly therapeutic feedback on their progress. The wait-list control group (WLC) will receive access to the intervention for ten weeks as well, but without therapeutic feedback and with a ten-week delay. We will conduct assessments at the beginning of the intervention of the IG (T0), the end of the intervention of the IG (T1), two months later (only IG, T2), and at the end of the intervention of the WLC (T3). The primary outcome is satisfaction with the treatment as measured by the ZUF-8 at T1 and T3 respectively. Secondary outcome measures include emotional competence, depression, anxiety, and quality of life.

CONCLUSION

We expect insight into the usefulness and acceptance of an online self-help intervention used to maintain inpatient treatment effects. Furthermore, we await both groups to benefit from the participation in the intervention. Pre- post and between subject differences will be used as estimate effect sizes to calculate the necessary sample size for a larger efficacy trial.

How valid is your case formulation? Empirically testing your cognitive behavioural case formulation for tailored treatment

Although clinicians have used cognitive behavioural case formulations (CBCFs) to guide treatment for many years, the validity of the case formulation (CF) is rarely evaluated. Given the central role of the formulation in treatment planning, particularly for complex or comorbid cases, a straightforward method to empirically evaluate the validity of the CBCF could increase the effectiveness of a treatment plan tailored for a particular client. This article describes a step-by-step, person-specific approach to evaluating a CBCF that can be used for appropriate cases in a clinical practice or especially a clinical training setting. The evaluation focuses on discriminant validity of person-specific scales and constructs and patterns of predicted functional relationships between idiosyncratic cognitions and distress. The approach is illustrated with an adult seen in a training clinic who was diagnosed with generalized anxiety and recurrent major depressive disorders and who completed 28 brief end-of-day, individualized questionnaires. The clinician's CBCF hypotheses were empirically evaluated using mostly simple statistical analyses available in readily accessible worksheets. Intervention implications of the CF evaluation are discussed.

Rethinking the service delivery system of psychological interventions in low and middle income countries

BACKGROUND

Global mental health is a growing field intricately connected to broader health, violence and economic issues. Despite the high prevalence and cost of mental health disorders, an estimated 75 % of those with need in lower resource settings do not receive intervention. Most studies to date have examined the effectiveness of single-disorder mental health treatments - an approach that may be a significant challenge to scale-up and sustainability in lower resource settings.

MAIN BODY

This paper presents a brief overview of the scientific progress in global mental health, and suggests consideration of an internal stepped care delivery approach. An internal stepped care model is one idea of a delivery system, utilizing a common elements approach, where the same provider could navigate between different elements based on severity and type of problems of the client. It is distinct from traditional stepped care models in that clients remain with the same provider, rather than relying on referral systems.

CONCLUSION

An internal stepped care delivery system based on a simplified common elements approach could be more efficient, scalable, sustainable, and reduce the loss of clients to referrals in lower resource settings.

Effectiveness of Transdiagnostic Cognitive Behaviour Therapy for Anxiety and Depression in Adults: A Systematic Review and Meta-analysis

Background: Transdiagnostic Cognitive Behaviour Therapy (CBT) seeks to identify core cognitive-behavioural processes hypothesized to be important across a range of disorders and to develop a treatment that targets these. This contrasts with standard CBT approaches that are disorder-specific. Proponents of transdiagnostic CBT suggest that it may offer advantages over disorder-specific CBT, but little is known about the effectiveness of this approach. Aims: The review aimed to summarize trial-based clinical and cost-effectiveness data on transdiagnostic CBT for anxiety and depression. Method: A systematic review of electronic databases, including peer-reviewed and grey literature sources, was conducted (n = 1167 unique citations). Results: Eight trials were eligible for inclusion in the review. There was evidence of an effect for transdiagnostic CBT when compared to a control condition. There were no differences between transdiagnostic CBT and active treatments in two studies. We found no evidence of cost-effectiveness data. Conclusions: Quality assessment of the primary studies indicated a number of methodological concerns that may serve to inflate the observed effects of transdiagnostic approaches. Although there are positive signs of the value of transdiagnostic CBT, there is as yet insufficient evidence to recommend its use in place of disorder-specific CBT.

Failure Rate of Spine Surgeons in Preoperative Clinical Screening of Severe Psychological Disorders

BACKGROUND

The surgeon's attention to the patient's underlying psychological state is essential to attaining desired outcomes. We aimed to investigate the prevalence and severity of psychological disorders in patients undergoing elective spine surgery.

METHODS

In this case-control study, associated psychological disorders were assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire at a single academic spine surgery center from August 2013 to June 2015. The case group consisted of 68 adult patients (mean age, 38.2 ± 9.6 years; male:female = 41:27) undergoing elective spine surgery and the control group included 69 healthy visitors of the orthopedic patients (mean age, 37.1 ± 6.9 years; male:female = 40:29) who voluntarily participated in the study. The 2 groups were compared for statistical analysis and a p-value < 5% was considered significance.

RESULTS

There was no statistically significant intergroup difference with regard to gender and age. The incidences of abnormal anxiety and depression were the same in the case group (14 patients, 20.6%). The values were 3 (4.3%) and 5 (7.2%), respectively, in the control group, showing statistically significant difference. Any association between the severity of depression and age or sex could not be identified.

CONCLUSIONS

In spite of spine surgeons' attempts to screen severe psychological disorders preoperatively, up to 21% of which cannot be diagnosed prior to elective spine surgery. Therefore, we believe the use of a questionnaire would be helpful in assessing patients' underlying psychological state before elective spine surgery.

Fear of the unknown: One fear to rule them all?

The current review and synthesis was designed to provocatively develop and evaluate the proposition that "fear of the unknown may be a, or possibly the, fundamental fear" (Carleton, 2016) underlying anxiety and therein neuroticism. Identifying fundamental transdiagnostic elements is a priority for clinical theory and practice. Historical criteria for identifying fundamental components of anxiety are described and revised criteria are offered. The revised criteria are based on logical rhetorical arguments using a constituent reductionist postpositivist approach supported by the available empirical data. The revised criteria are then used to assess several fears posited as fundamental, including fear of the unknown. The review and synthesis concludes with brief recommendations for future theoretical discourse as well as clinical and non-clinical research.

Problem Management Plus (PM+) in the treatment of common mental disorders in women affected by gender-based violence and urban adversity in Kenya; study protocol for a randomized controlled trial

Background

Women affected by adversity, including gender-based violence, are at increased risk for developing common mental disorders such as depression, anxiety and posttraumatic stress disorder (PTSD). The World Health Organization (WHO) has developed Problem Management Plus (PM+), a 5-session, individual psychological intervention program, that can be delivered by non-specialist counsellors that addresses common mental disorders in people affected by adversity. The objectives of this study are to evaluate effectiveness of PM+ among women who have been affected by adversity, including gender-based violence, and to perform a process evaluation.

Methods

Informed by community consultations, the PM+ manual has been translated and adapted to the local context. A randomized controlled trial will be carried out in the catchment areas of three local health care facilities in Dagoretti Sub County, Nairobi. After informed consent, females with high psychological distress (General Health Questionnaire-12 (score >2) and functional impairment (WHO Disability Assessment Schedule 2.0 score >16) will be randomised to PM+ (n = 247) or enhanced treatment as usual (n = 247). Post-treatment and 3-months post-treatment follow-up assessments include psychological distress, functional disability, PTSD symptoms, perceived problems for which the person seeks help, health care use and health costs. For evaluating the process of implementing PM+ within local communities in Nairobi 20 key informant interviews will be carried out in participants, PM+ providers, decision makers, clinical staff.

Discussion

If PM+ is proven effective, it will be rolled out to other low and middle income areas and other populations for further adaptation and testing.

Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12616000032459. Registered prospectively on January 18, 2016

Transdiagnostic and Transcultural: Pilot Study of Unified Protocol for Depressive and Anxiety Disorders in Japan

Unified protocol (UP) is a transdiagnostic cognitive behavior therapy for emotional disorders. It remains unknown whether UP is applicable for use in non-Western countries and for depressive disorders. We therefore examined its feasibility for a Japanese clinical population using this clinical trial design, which is multicentered, open-labeled, and single-armed (Clinical registry: UMIN000008322). The primary outcome was severity of anxiety symptoms, as assessed using Structured Interview Guide for the Hamilton Anxiety Rating Scale. Secondary outcomes were depressive symptoms, clinical global impression, functioning, quality of life, affectivity, emotion regulation, and adverse events. Of the 28 prospective participants, 17 were eligible and enrolled (depressive disorders=9, anxiety disorders=8). Severity of anxiety symptoms, which decreased significantly after the intervention, remained low for 3months (Hedges' g=1.29, 95% CI=0.56-2.06). Similar tendencies were observed for secondary outcome measures. No severe adverse event occurred. Two participants dropped out of the intervention. High treatment adherence and interrater reliability were confirmed. Results suggest the feasibility of UP in the Japanese context sufficient to warrant a larger clinical trial.

Maximizing the Impact of e-Therapy and Serious Gaming: Time for a Paradigm Shift

Internet interventions for mental health, including serious games, online programs, and apps, hold promise for increasing access to evidence-based treatments and prevention. Many such interventions have been shown to be effective and acceptable in trials; however, uptake and adherence outside of trials is seldom reported, and where it is, adherence at least, generally appears to be underwhelming. In response, an international Collaboration On Maximizing the impact of E-Therapy and Serious Gaming (COMETS) was formed. In this perspectives' paper, we call for a paradigm shift to increase the impact of internet interventions toward the ultimate goal of improved population mental health. We propose four pillars for change: (1) increased focus on user-centered approaches, including both user-centered design of programs and greater individualization within programs, with the latter perhaps utilizing increased modularization; (2) Increased emphasis on engagement utilizing processes such as gaming, gamification, telepresence, and persuasive technology; (3) Increased collaboration in program development, testing, and data sharing, across both sectors and regions, in order to achieve higher quality, more sustainable outcomes with greater reach; and (4) Rapid testing and implementation, including the measurement of reach, engagement, and effectiveness, and timely implementation. We suggest it is time for researchers, clinicians, developers, and end-users to collaborate on these aspects in order to maximize the impact of e-therapies and serious gaming.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: A randomized controlled trial

Transdiagnostic cognitive behaviour therapy (TD-CBT) aims to target the symptoms of multiple disorders whereas disorder-specific CBT (DS-CBT) targets the symptoms of principal disorders. This study compared the relative benefits of internet-delivered TD-CBT and DS-CBT when provided in clinician-guided (CG-CBT) and self-guided (SG-CBT) formats for people with a principal diagnosis of Panic Disorder (PD). Participants (n=145) were randomly allocated to receive TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of PD (Cohen's d ≥ 0.71; avg. reduction ≥ 36%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d ≥ 0.71; avg. reduction ≥ 33%), generalised anxiety disorder (Cohen's d ≥ 0.91; avg. reduction ≥ 34%) and social anxiety disorder (Cohen's d ≥ 0.50; avg. reduction ≥ 15%) were found over the 24-month follow-up period. Highlighting their efficacy and acceptability, no marked and consistent differences were observed between TD-CBT and DS-CBT or CG-CBT and DS-CBT.

Into the unknown: A review and synthesis of contemporary models involving uncertainty

The current review and synthesis serves to define and contextualize fear of the unknown relative to related constructs, such as intolerance of uncertainty, and contemporary models of emotion, attachment, and neuroticism. The contemporary models appear to share a common core in underscoring the importance of responses to unknowns. A recent surge in published research has explored the transdiagnostic impact of not knowing on anxiety and related pathologies; as such, there appears to be mounting evidence for fear of the unknown as an important core transdiagnostic construct. The result is a robust foundation for transdiagnostic theoretical and empirical explorations into fearing the unknown and intolerance of uncertainty.