The utility of completing adjuvant video lessons based on the unified protocol during psychotherapy: A retrospective study using a telehealth platform in routine clinical care

Digital supplements to tele-psychotherapy are increasingly needed. The purpose of this retrospective study was to investigate the association between outcomes and the use of supplemental video lessons based on the Unified Protocol (UP), an empirically supported transdiagnostic treatment.

Participants included 7,326 adults in psychotherapy for depression and/or anxiety. Partial correlations were calculated between number of UP video lessons completed and change in outcomes after 10 weeks, controlling for number of therapy sessions and baseline scores. Then, participants were divided into those who did not complete any UP video lessons (n = 2355) and those who completed at least 7/10 video lessons (n = 549), and propensity-matched on 14 covariates. Repeated measures analysis of variance compared these groups (n = 401 in each group) on outcomes.

Among the entire sample, symptom severity decreased as the number of UP video lessons completed increased, with the exception of lessons on avoidance and exposure. Those watching at least 7 lessons showed significantly greater reduction in both depression and anxiety symptoms than those who did not watch any.

Viewing supplemental UP video lessons in addition to tele-psychotherapy had a positive and significant association with symptom improvement and may provide an additional tool for clinicians to implement UP components virtually.

Are changes in joviality associated with cognitive behavioral treatment outcomes? Examining an emerging treatment target

The present study expands on the growing body of research on the effects of cognitive behavioral therapy (CBT) on positive affect. More specifically, we explore how CBT may promote increases in the Joviality subscale of the Positive and Negative Affect Schedule-Expanded Form (PANAS-X), a measure of self-rated affect that captures positive emotions, including joy and excitement, and how change in joviality may be associated with concurrent symptom change. We utilized data from a randomized equivalence trial comparing the efficacy of the unified protocol (UP) for transdiagnostic treatment of emotional disorders, a transdiagnostic CBT, against various well-established single disorder protocols (SDP) and waitlist control. First, we generated affect profiles for patients receiving CBT (either UP or SDP) or waitlist control, based on their baseline and posttreatment positive affect (PA) and negative affect (NA), compared with a clinical reference sample. We found that the affect profile for most patients receiving CBT shifted from high NA/low PA to low NA/high PA. Further, participants receiving CBT were more likely than individuals in the waitlist control to achieve this outcome. We then examined the PANAS-X Joviality subscale, which has been subject to very limited previous research. Change in joviality was associated with improvement in symptoms of both anxiety (B = -0.81, p = .00) and depression (B = -0.94, p = .00). Joviality increased more rapidly in individuals with more severe anxiety but not severe depression. We discuss the possible clinical implications of these preliminary results, including the role of treatment innovations incorporating a focus on increasing positive affect, particularly the emotions associated with joviality, while simultaneously decreasing negative affect. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effectiveness and mediators of change of an online CBT intervention for students with adjustment disorder-study protocol for a randomized controlled trial

BACKGROUND

Adjustment problems and disorders are highly prevalent among university students worldwide. These problems can cause significant interference in academic and social functioning and increase vulnerability to other mental health disorders. Unfortunately, only half of students in need receive psychological help. Furthermore, few studies have evaluated psychological interventions for adjustment disorders in students. New, more scalable forms of treatment for students with an adjustment disorder need to be developed, evaluated, and implemented. The study aims to determine the effectiveness of an online transdiagnostic cognitive behavioural intervention for students experiencing adjustment disorder and to assess mediators of change.

METHOD/DESIGN

In this three-arm randomized controlled trial, we plan to recruit 214 Polish students diagnosed with an adjustment disorder. Participants who meet initial eligibility criteria will be randomly assigned to one of three 6-week conditions: (1) online cognitive behavioural therapy intervention based on an existing, empirically supported transdiagnostic protocol, the unified protocol; (2) online progressive muscle relaxation training as an active control group; or (3) waiting-list control group. Both interventions are asynchronous, interactive, and include minimal amount of therapist support. Assessments will consist of self-report questionnaires, daily diary measures, and neurocognitive tasks for evaluating cognitive functioning. These will be conducted at baseline, post-treatment, and 1-month follow-up. Daily diary measures will be taken during the first and last week of treatment (or waitlist period). Primary outcome measures will include adjustment disorder severity; secondary outcome measures will consist of other negative (psychopathology: depression, anxiety, and stress) and positive (life satisfaction) indexes of mental health as well as process measures (e.g. mindfulness, experiential avoidance, cognitive fusion).

DISCUSSION

To our knowledge, the current study is the first to evaluate the effectiveness of a psychological intervention for students with adjustment disorder. Therefore, it may have important practical implications for students with this disorder. It can potentially guide the development of a scalable, validated treatment option.

TRIAL REGISTRATION

Clinical Trials, NCT05768308, registered 14 March 2023, https://www.

CLINICALTRIALS

gov/ct2/show/NCT05768308.

Effects of a Contextual Adaptation of the Unified Protocol in Multiple Emotional Disorders in Individuals Exposed to Armed Conflict in Colombia: A Randomized Clinical Trial

Importance

A transdiagnostic treatment, the Unified Protocol, is as effective as single diagnostic protocols in comorbid emotional disorders in clinical populations. However, its effects on posttraumatic stress disorder and other emotional disorders in individuals living in war and armed conflict contexts have not been studied.

Objective

To evaluate the efficacy of a cultural and contextual adaptation of the Unified Protocol (CXA-UP) on posttraumatic stress disorder, anxiety, and depression compared to waitlist control in individuals exposed to armed conflict in Colombia.

Design, Setting, and Participants

From April 2017 to March 2020, 200 participants 18 years and older were randomly assigned to the CXA-UP or to a waitlist condition. CXA-UP consisted of 12 to 14 twice-a-week or weekly individual 90-minute face-to-face sessions. Outcomes were assessed at baseline, posttreatment, and 3 months following treatment. Analyses were performed and compared for all randomly allocated participants (intent-to-treat [ITT]) and for participants who completed all sessions and posttreatment measures (per protocol [PP]). The study took place at an outpatient university center and included individuals who were registered in the Colombian Victims Unit meeting DSM-5 diagnostic criteria for posttraumatic stress disorder, anxiety, or depression or were severely impaired by anxiety or depression. Individuals who were receiving psychological therapy, were dependent on alcohol or drugs, were actively suicidal or had attempted suicide in the previous 2 months, had psychosis or bipolar disorder, or were cognitively impaired were excluded.

Intervention

CXA-UP or waitlist.

Main Outcomes and Measures

Primary outcomes were changes in anxiety, depression, and somatic scores on the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist for DSM-5.

Results

Among the 200 participants (160 women [80.0%]; 40 men [20.0%]; mean [SD] age, 43.1 [11.9] years), 120 were randomized to treatment and 80 to waitlist. Results for primary outcomes in the ITT analysis showed a significant pretreatment-to-posttreatment reduction when comparing treatment and waitlist on the posttraumatic stress disorder checklist for DSM-5 scores (slope [SE], -31.12 [3.00]; P < .001; Cohen d, 0.90; 90% CI, 0.63-1.19), 9-item Patient Health Questionnaire (PHQ-9) (slope [SE],-11.94 [1.30]; P < .001; Cohen d, 0.77; 90% CI, 0.52-1.06), PHQ-anxiety (slope [SE], -6.52 [0.67]; P < .001; Cohen d, 0.82; 90% CI, 0.49-1.15), and PHQ-somatic (slope [SE], -8.31 [0.92]; P < .001; Cohen d, 0.75; 90% CI, 0.47-1.04).

Conclusions and Relevance

In this study, significant reductions and large effect sizes in all measures of different emotional disorders showed efficacy of a single transdiagnostic intervention in individuals exposed to armed conflicts.

Trial Registration

ClinicalTrials.gov Identifier: NCT03127982.

Outcomes of People of Color in an Efficacy Trial of Cognitive-Behavioral Treatments for Anxiety, Depression, and Related Disorders: Preliminary Evidence

ABSTRACT

Although evidence-based psychological treatments such as cognitive behavioral therapy (CBT) have strong empirical support for reducing anxiety and depression symptoms, CBT outcome research often does not report race and ethnicity variables, or assess how well CBT works for people from historically excluded racial and ethnic groups. This study presents post hoc analyses comparing treatment retention and symptom outcomes for participants of color ( n = 43) and White participants ( n = 136) from a randomized controlled efficacy trial of CBT. χ 2 tests and one-way ANCOVA showed no observable differences between the two samples on attrition or on clinician-rated measures of anxiety and depression at posttreatment and follow-up. Moderate to large within-group effect sizes on anxiety and depression were found for Black, Latinx, and Asian American participants at almost all time points. These preliminary findings suggest that CBT for anxiety and comorbid depression may be efficacious for Black, Asian American, and Latinx individuals.

Understanding the role of COVID-19-related workplace stress and institutional betrayal on mental health in nurses: Some heroes wear scrubs

This study examined the association of three specific COVID-19-related workplace stressors (percentage of nursing work with COVID-positive [COVID+] patients, number of COVID-19-related patient deaths witnessed, and living separately from family for safety) and their associations with posttraumatic stress symptoms (PTSS) and symptoms of major depressive disorder (MDD) and generalized anxiety disorder (GAD) among 391 nurses (93.6% White, 93.4% utilize she/her pronouns). Cross-sectional data were collected via an online survey. Institutional betrayal (i.e., the perception that an institution failed to protect a member who depends on and trusts it) was examined as a moderator of these associations. Although institutional betrayal was not a significant moderator in the three individual models, it held small-to-medium-sized positive main effects with PTSS and symptoms of GAD and MDD in both the individual and combined models. In the individual models, the percentage of nursing work with COVID+ patients was significantly positively associated with all three mental health conditions, f² = .019-.195, whereas it only showed a significant effect with PTSS in the combined model, f² = .138. Living separately from family was significantly positively associated with PTSS and MDD symptoms in both the individual, f² = .037 and .015, respectively, and combined models, f² = .025 and .013, respectively. Number of patient deaths held a significant positive association with PTSS alone, f² = .022, in the individual model only. The findings are discussed in light of ways in which health care settings can better support and prioritize mental health among nursing staff.

Telehealth Transdiagnostic Cognitive Behavioral Therapy for Depression in Parkinson's Disease: A Pilot Randomized Controlled Trial

Background

Cognitive behavioral therapy (CBT) is an effective treatment for depression in persons with Parkinson's disease (PwPD), but there are significant barriers preventing PwPD from receiving care in person. Telehealth CBT circumvents many of these barriers.

Objectives

We conducted a pilot randomized controlled trial evaluating the efficacy, feasibility, and acceptability of telehealth transdiagnostic CBT intervention for depression in PwPD.

Methods

Twelve PwPD with Major Depressive Disorder were enrolled, half randomly assigned to the treatment-immediate condition (TI) and half to the waitlist control condition (WLC). TI and WLC participants received 12 CBT sessions and assessments before treatment, immediately after treatment, and at the 6-week follow-up.

Results

The intervention was efficacious for treating depression in PwPD, with secondary benefits to anxiety, apathy, learning, memory, and quality of life. Improvements were largely maintained at follow-up. The intervention was highly feasible and acceptable.

Conclusions

Telehealth transdiagnostic CBT was an effective intervention for PwPD with depression.

Effectiveness of the internet-based Unified Protocol transdiagnostic intervention for the treatment of depression, anxiety and related disorders in a primary care setting: a randomized controlled trial

Background

Research has shown that internet-based cognitive behavioural therapy (iCBT) can be a very promising solution to increase access to and the dissemination of evidence-based treatments to all of the population in need. However, iCBT is still underutilized in clinical contexts, such as primary care. In order to achieve the effective implementation of these protocols, more studies in ecological settings are needed. The Unified Protocol (UP) is a transdiagnostic CBT protocol for the treatment of emotional disorders, which includes depression, anxiety and related disorders, that has shown its efficacy across different contexts and populations. An internet-based UP (iUP) programme has recently been developed as an emerging internet-based treatment for emotional disorders. However, the internet-delivered version of the UP (iUP) has not yet been examined empirically. The current project seeks to analyse the effectiveness of the iUP as a treatment for depression, anxiety and related emotional disorders in a primary care public health setting.

Methods

The current study will employ a parallel-group, randomized controlled trial design. Participants will be randomly assigned to (a) the internet-based Unified Protocol (iUP), or (b) enhanced waiting list control (eWLC). Randomization will follow a 2:1 allocation ratio, with sample size calculations suggesting a required sample of 120 (iUP=80; eWLC=40). The Mini-International Neuropsychiatric Interview (M.I.N.I.) will be used for assessing potential participants. The Overall Anxiety Severity and Impairment Scale (OASIS) and the Overall Depression Severity and Impairment Scale (ODSIS) as well as other standardized questionnaires will be used for assessments at baseline, 4 weeks, 8 weeks and 12 weeks from baseline and for the iUP condition during the follow-up.

Discussion

Combining the advantages of a transdiagnostic treatment with an online delivery format may have the potential to significantly lower the burden of emotional disorders in public health primary care setting. Anxiety and depression, often comorbid, are the most prevalent psychological disorders in primary care. Because the iUP allows for the treatment of different disorders and comorbidity, this treatment could represent an adequate choice for patients that demand mental health care in a primary care setting.

Trial registration

ISRCTN18056450 10.1186/ISRCTN18056450.

Skill Acquisition During Transdiagnostic Treatment With the Unified Protocol

The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is an emotion-focused, cognitive-behavioral intervention developed to address the full range of anxiety, depressive, and related disorders. The UP consists of core therapeutic skills that, though unique in focus, are each designed to promote an approach-oriented stance toward emotional experiences. The goal of the present investigation was to characterize changes in these skills for patients that received a course of treatment with the UP, as well as to examine associations between skills and symptoms changes. Patients with principal anxiety disorders, assigned to receive treatment with the UP (N = 88) as part of a randomized controlled trial, were included in this study. They completed validated self-report measures of UP skills (Understanding Emotions, Mindful Emotion Awareness, Cognitive Flexibility, Countering Emotional Behaviors, and Interoceptive Awareness and Tolerance), as well as clinician-rated measures of psychological symptoms. Skill measures improved significantly over the course of 12 to 16 UP treatment sessions and changes in these skills measures were associated with improvements in anxiety symptoms. Determining whether improvement on all the skills learned during a course of treatment with UP is associated with symptom remission is critical to establishing the most streamlined and efficient interventions that may ultimately be best suited to widespread dissemination.

Does the unified protocol really change neuroticism? Results from a randomized trial

BACKGROUND

Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition.

METHOD

Patients with principal anxiety disorders (N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms.

RESULTS

At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT (t(218) = -2.17, p = 0.03, d = -0.32) and WL conditions(t(207) = -2.33, p = 0.02, d = -0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms.

CONCLUSIONS

Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.

A pilot trial of a transdiagnostic treatment for emotional disorders-a locally adapted variant of group Unified Protocol (UP) for Chinese adults

There has been increasing interest in transdiagnostic cognitive-behavioral therapy (CBT), which is more cost efficient yet yields similar effect sizes when compared to disorder-specific CBT. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders was adapted for Hong Kong Chinese adults with common mental disorders, such as depression and anxiety. It was piloted in community settings and delivered in a group format. Thirty-one Chinese adults (female = 93.5%, mean age = 44 years) with heterogeneous anxiety and depressive disorders were recruited from a number of public-funded community mental health centers in Hong Kong to participate in a pilot trial of a locally adapted variant of UP. Treatment consisted of 14 group sessions plus one individual session. Each group included six to nine participants. The diagnostic and outcome measures included Anxiety Disorders Interview Schedule for DSM-IV, The Chinese versions of Beck Depression Inventory-Revised (C-BDI-II), Beck Anxiety Inventory (C-BAI), Positive Affect subscale of Positive and Negative Affect Scale, and Work and Social Adjustment Scale. Results indicate significant improvement across a number of outcome measures, with moderate-to-large effect sizes for measures of depression (d = 1.11), anxiety (d = 0.67), positive affect (d = 0.54), and work and social functioning (d = 0.49). Furthermore, 45.2% and 29.0% of the participants scored within the normal range of C-BDI-II and C-BAI at posttreatment, respectively, compared to 3.2% and 6.5% at pretreatment. This pilot, uncontrolled trial demonstrated potential effectiveness of a locally adapted variant of group UP for Chinese adults with common mental disorders. It achieved comparable effect sizes to those observed in western populations.

Homework Compliance and Quality in Cognitive Behavioral Therapies for Anxiety Disorders and Obsessive-Compulsive Disorder

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.

Telehealth cognitive behavioral therapy for depression in Parkinson's disease: A case study

Parkinson's disease (PD) is characterized as a motor disorder, but the majority of individuals with PD also suffer from nonmotor symptoms, including mental health difficulties, such as depression, anxiety, and apathy, as well as decreased cognitive function, daily function, sleep quality, and quality of life. Cognitive behavioral therapy (CBT) is an effective treatment for depression in PD, but motor disability, work schedule, transportation issues, and care partner burden may cause difficulty in attending weekly face-to-face therapy sessions. A promising avenue in the delivery of CBT is telehealth. CBT administered live via videoconference technology may circumvent many of the barriers that prevent those with PD from receiving treatment. This case study evaluates the preliminary efficacy, feasibility, and acceptability of 12-week telehealth CBT for depression in PD. CBT administered via telehealth was feasible, acceptable, and efficacious for a study participant with PD and major depressive disorder. In addition to effectively treating depression, the telehealth intervention improved quality of life and aspects of cognitive functioning, as well as symptoms of anxiety, apathy, and subjective cognitive impairment, all of which are prevalent nonmotor symptoms of PD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effectiveness of the Unified Protocol for transdiagnostic treatment of emotional disorders in group format in Spain: Results from a randomized controlled trial with 6-months follow-up

BACKGROUND

The present study aims to investigate the effectiveness of the Unified Protocol (UP), a transdiagnostic treatment of emotional disorders (EDs), when applied in a group format in the public mental health system in Spain.

METHODS

488 participants with a primary diagnosis of ED were randomized to the UP group or to the treatment as usual (TAU; individual, disorder-specific cognitive behavioral therapy). Personality, depression and anxiety symptoms, affect, and quality of life were assessed at pre-treatment, 3 months after treatment onset (coinciding with the end of the UP treatment), and 6 and 9 months after treatment onset (follow-ups). The moderating effect of the treatment condition and the number of sessions received in the evolution of study outcomes was investigated with a linear mixed model analysis.

RESULTS

A significant improvement in outcomes occurred in both conditions, except for extraversion in the TAU. Improvements in depression, anxiety and quality of life were larger in the UP condition. After the treatment, improvements were maintained at follow-ups in all study outcomes. An interaction between Time*Condition*Sessions was found for depression.

CONCLUSION

The results add to the existing evidence on the effectiveness of the UP and may be important for implementation purposes in the Spanish or other similar public mental health systems. Trial registration number NCT03064477 (March 10, 2017).

Initial Effectiveness Evaluation of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Homeless Women

The purpose of this study is to evaluate the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders adapted for homeless women (UPHW). Eighty-one homeless women participated in this single-blinded quasi-experimental clinical trial, involving up to 12 sessions of group treatment, and 3-and 6-month follow-ups. The participants received either immediate treatment with the UPHW (n = 46) or delayed treatment, following a 12-week wait-list control period (WLC; n = 35). Primary outcomes included depression and anxiety. Secondary measures comprised positive and negative affect, psychological well-being, health perception, and social support. The UPHW resulted in significant improvement on measures of anxiety, depression and negative affect. Improvements in anxiety and depression were maintained over a 3-month follow-up period, but not at 6-month. The reliability of the clinical changes showed significant differences between UPHW and WLC for depression. Moreover, the inter-session assessment in the UPHW group showed a linear trend reduction for depression and anxiety scores along the 12 sessions. The clinical implications on the UPHW in social settings are also discussed.

Isolating the Effects of Mindfulness Training Across Anxiety Disorder Diagnoses in the Unified Protocol

The Unified Protocol for Transdiagnostic Treatment (UP; Barlow et al., 2011) has recently demonstrated statistically equivalent therapeutic effects compared to leading cognitive behavioral therapy (CBT) protocols for anxiety disorders designed to address disorder-specific symptoms (i.e., single-disorder protocols [SDP]); Barlow et al., 2017). Although all treatment protocols included similar evidence-based CBT elements, investigation of those related to symptom improvement in the UP is warranted. Because the UP is unique from the SDPs for its inclusion of mindfulness, the present study evaluated mindfulness as a primary treatment element. We explored whether UP participants, compared to SDP, demonstrated greater improvements in mindfulness from pre- to posttreatment, and whether these improvements predicted posttreatment severity across anxiety disorder diagnoses. Participants were individuals with a principle anxiety disorder (N = 179) randomized to receive either the UP or SDP. Results indicated significant improvements pre- to posttreatment in mindfulness for participants receiving either the UP or SDP. However, at posttreatment, mindfulness scores were significantly greater for the UP condition. At the diagnosis level, posttreatment scores in mindfulness were significantly greater in the UP condition than the respective SDP conditions for principal Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SOC). Moreover, results suggest that change in mindfulness is related to posttreatment severity, when moderated by treatment condition, but only for participants with principal GAD. Taken together, the UP is effective in improving mindfulness in a sample with heterogeneous anxiety disorders, but this change seems particularly relevant for reduction in symptom severity for individuals with principal GAD.

Trajectories of change in well-being during cognitive behavioral therapies for anxiety disorders: Quantifying the impact and covariation with improvements in anxiety

Cognitive behavioral therapy (CBT) has been found to be very effective in reducing many forms of mental illness, but much less is known about whether CBT also promotes mental health or well-being. The goals of the present study were to (a) quantify the magnitude and timing of changes in overall well-being and specific facets of well-being during different CBTs for anxiety disorders, (b) determine whether these effects vary across transdiagnostic and disorder-specific CBT, and (c) examine how changes in well-being during treatment relate to changes in anxiety. A total of 223 adults (55.6% female, Mage = 31.1 years) were randomized to 1 of 5 CBT protocols for anxiety disorders at an outpatient clinic. Analyses included standardized mean gain effect sizes (ESsg) and latent growth curve modeling. Moderate-to-large increases in overall well-being and the 3 components of subjective, psychological, and social well-being were observed, mainly during the second half of CBT, and these increases were maintained at a 6-month follow-up. The magnitude of effects was comparable for transdiagnostic and disorder-specific CBT protocols and greater than in the waitlist condition. Parallel process latent growth curve models indicated that trajectories of change in well-being across treatment were strongly correlated with trajectories of change in clinician-rated and self-reported anxiety. Together, these findings suggest that different CBT protocols for anxiety consistently produce robust and lasting changes in well-being, and these changes are strongly linked to changes in anxiety during treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mindful Emotion Awareness Facilitates Engagement with Exposure Therapy: An Idiographic Exploration Using Single Case Experimental Design

Exposure therapy works through inhibitory learning, whereby patients are exposed to stimuli that elicit anxiety in order to establish safety associations. Mindful emotion awareness, or nonjudgmental and present-focused attention toward emotions, may facilitate engagement in exposures, which may in turn enhance therapeutic outcome. This study utilizes a single-case experimental design (n = 6) to investigate the effect of mindful emotion awareness training on the use of avoidant strategies during exposures, distress during exposures, overall mindfulness, experiential avoidance, and symptom reduction in a sample of participants with social anxiety disorder. Data were analyzed using a combination of visual inspection and quantitative effect size metrics commonly applied in single-case experimental designs. To further investigate the relationship between distress and avoidant strategy use, contemporaneous and cross-lagged correlations were run. Results highlight individual differences in responses to mindful emotion awareness training and exposure exercises. Given these individual differences, repeated assessment and monitoring over the course of treatment may help clinicians most effectively identify treatment skills that will be most helpful for individual patients.

Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.

Cleansing the Attentional Palate: A Preliminary Test of a Novel Approach to Facilitate Disengagement From Rumination

Resource allocation theory suggests that rumination depletes cognitive resources that could be directed toward task-relevant processes. We propose a new approach to the treatment of rumination that specifically targets this misappropriation of cognitive resources, wherein individuals engage in an attentionally demanding task in order to interrupt the ruminative cycle. We argue that this strategy would serve to free cognitive resources from rumination and facilitate performance on other tasks. Thus, the present study served as an initial test of this novel approach. This study employed a within-subjects design, in which participants were 30 college students who completed self-report measures of baseline mood state, anxiety, depression, and trait rumination. Subsequently, they underwent sad mood and rumination inductions followed by random assignment to either a low attentional demand disengagement strategy (DS) followed by a high attentional demand DS or vice versa. Reading comprehension was assessed at baseline and following each of the two DSs. The high attentional demand DS condition was associated with better performance on the reading comprehension task compared to the low attentional demand DS condition. These results provide initial support for our novel approach to targeting rumination and demonstrate that attentionally demanding DSs may successfully free cognitive resources that might otherwise be consumed by rumination. Thus, future research into attentionally demanding DSs that interrupt ruminative cycles is warranted. This approach could be a useful adjunct for interventions targeting disorders driven by rumination, such as depression.

Fostering engagement in early sessions of transdiagnostic cognitive-behavioral therapy

This article describes the early sessions of a transdiagnostic cognitive-behavioral treatment for emotional disorders that is designed to target temperamental characteristics, particularly neuroticism and resulting emotion dysregulation, underlying all anxiety, depressive, and related disorders. These sessions facilitate clinical improvement by setting realistic expectations, fostering a collaborative therapeutic alliance, and improving motivation for change. Addressing these common factors in early sessions strengthens patient engagement, which is necessary for patients to benefit most greatly from subsequent treatment elements. We begin with a brief description of the treatment protocol and theoretical model. Next, we describe how the early sessions, specifically, are used to help facilitate application of later treatment skills that target specific psychopathological mechanisms. Finally, we present a clinical case example and utilize clinical vignettes from the early sessions to illustrate the therapy process. Specific clinical exchanges are highlighted to offer advice on how therapists can most effectively implement these procedures. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Quality of Life in Heterogeneous Anxiety Disorders: Changes Across Cognitive-Behavioral Treatments

Quality of life is lower among individuals with anxiety disorders; however, this construct is rarely a focus in treatment research. This study explores changes in quality of life in a randomized, controlled trial of several cognitive-behavioral treatments (CBTs) for anxiety disorders. Adults with heterogeneous anxiety disorders (N = 223) were randomly assigned to (a) unified protocol for transdiagnostic treatment of emotional disorders, (c) a single-disorder protocol targeting their principal diagnosis, or (c) a waitlist control condition, and assessed at baseline, posttreatment, and 6-month follow-up. At baseline, the sample evidenced deficits in quality of life, with no significant differences in quality of life across diagnoses or condition. Results suggest improved quality of life among participants in treatment, at similar rates across treatment condition and diagnostic category, and at levels significantly higher than the waitlist. Improvements were maintained through 6-month follow-up. This study supports CBT as effective in promoting quality of life.

Efficacy of the Unified Protocol for transdiagnostic treatment of comorbid psychopathology accompanying emotional disorders compared to treatments targeting single disorders

OBJECTIVE

This study aimed to examine whether the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy for emotional disorders (i.e., anxiety, mood, and related disorders), is efficacious in the treatment of co-occurring emotional disorders compared to established single disorder protocols (SDPs) that target specific disorders (e.g., panic disorder).

METHOD

Participants included 179 adults seeking outpatient psychotherapy. Participant age ranged from 18 to 66 years, with an average of 30.66 years (SD = 10.77). The sample was 55% female and mostly Caucasian (83%). Diagnostic assessments were completed with the Anxiety Disorder Interview Schedule (ADIS), and disorder-specific, clinician-rated measures for the comorbid diagnoses of interest.

RESULTS

In both treatment conditions, participants' mean number of diagnoses dropped significantly from baseline to posttreatment, and baseline to 12-month follow-up. Additionally, large effects were observed for changes in comorbid generalized anxiety (ESSG: UP = -1.72; SDP = -1.98), social anxiety (ESSG: UP = -1.33, -0.86; SDP = -1.60, -1.54), and depression (ESSG: UP = -0.83; SDP = -0.84). Significant differences were not observed in between-group comparisons.

CONCLUSIONS

Results suggest that both the UP and SDPs are efficacious in reducing symptoms of comorbid emotional disorders. The clinical, practical, and cost-effective advantages of transdiagnostic CBT are discussed.

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.

Behavioral activation strategies for major depression in transdiagnostic cognitive-behavioral therapy: An evidence-based case study

Behavioral activation (BA) is a treatment approach that uses functional analysis and context-dependent strategies to enhance environmental positive reinforcement for adaptive, healthy behavior, and decrease behavioral avoidance. BA has gained considerable support for the treatment of depression and can be broadly applied across a wide range of settings and clinical populations. In this article, we provide a brief description of BA as a therapeutic behavioral strategy for depression and present a clinical case example illustrating the integration of BA with other components of a transdiagnostic cognitive-behavioral treatment for emotional disorders. Implications for clinical practice and avenues for future research will be discussed. (PsycINFO Database Record

Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders

Considerable work and attention has supported the use of behavioral activation (BA) strategies in the treatment of depressive disorders. Although not often recognized, BA, both implicitly and explicitly, appears to be conceptually and empirically relevant to the treatment of diverse problem areas, including the anxiety disorders. This article addresses the role of BA strategies in transdiagnostic cognitive-behavioral therapy (CBT) for anxiety and related disorders, including in cases without comorbid depression. Following a brief introduction to a transdiagnostic CBT model of anxiety and related disorders, this article will: (a) provide a rationale for the integration of BA strategies as a potentially potent facilitator of therapeutic change; (b) identify relevant treatment targets of BA in anxiety disorders; and (c) illustrate the implementation and impacts of these strategies using a clinical case example. Finally, suggestions for future research and implications for training and practice will be noted. (PsycINFO Database Record

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).

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.

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.

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.

SECOND-STAGE TREATMENTS FOR RELATIVE NONRESPONDERS TO COGNITIVE BEHAVIORAL THERAPY (CBT) FOR PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA-CONTINUED CBT VERSUS SSRI: A RANDOMIZED CONTROLLED TRIAL

BACKGROUND

Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT.

METHOD

The current trial is a second-step stratified randomized design comparing two treatment conditions-selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively.

RESULTS

Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms.

CONCLUSIONS

These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368.

Mindfulness-Based Exposure Strategies as a Transdiagnostic Mechanism of Change: An Exploratory Alternating Treatment Design

The present study explored whether distress reduction in response to strong negative emotions, a putative transdiagnostic mechanism of action, is facilitated by mindfulness strategies. Seven patients (mean age=31.14years, SD=12.28, range 19-48 years, 43% female, 86% Caucasian) with heterogeneous anxiety disorders (i.e., panic disorder with or without agoraphobia, social anxiety, generalized anxiety) were assigned a randomized order of weeklong blocks utilizing either mindfulness- or avoidance-based strategies while ascending a 6-week emotion exposure hierarchy. Participants completed three exposures per block and provided distress and avoidance use ratings following each exposure. Anxiety severity, distress aversion, and distraction/suppression tendencies were also assessed at baseline and the conclusion of each block. Visual, descriptive, and effect size results showing exposures utilizing mindfulness were associated with higher overall distress levels, compared with those utilizing avoidance. Within blocks, the majority of participants exhibited declining distress levels when employing mindfulness strategies, as opposed to more static distress levels in the avoidance condition. Systematic changes in anxiety severity, distress aversion, and distraction/suppression were not observed. These results suggest mindfulness strategies may be effective in facilitating emotion exposure; however, a minimum dosage may be necessary to overcome initial distress elevation. Potential transdiagnostic change mechanisms and clinical implications are discussed.

Relationships among adaptive and maladaptive emotion regulation strategies and psychopathology during the treatment of comorbid anxiety and alcohol use disorders

Both maladaptive and adaptive emotion regulation strategies have been linked with psychopathology. However, previous studies have largely examined them separately, and little research has examined the interplay of these strategies cross-sectionally or longitudinally in patients undergoing psychological treatment. This study examined the use and interplay of adaptive and maladaptive emotion regulation strategies in 81 patients receiving cognitive-behavioral interventions for comorbid alcohol use and anxiety disorders. Patients completed measures of emotion regulation strategy use and symptoms of psychopathology pre- and post-treatment. Cross-sectionally, higher use of maladaptive strategies (e.g., denial) was significantly related to higher psychopathology pre- and post-treatment, whereas higher use of adaptive strategies (e.g., acceptance) only significantly related to lower psychopathology post-treatment. Prospectively, changes in maladaptive strategies, but not changes in adaptive strategies, were significantly associated with post-treatment psychopathology. However, for patients with higher pre-treatment maladaptive strategy use, gains in adaptive strategies were significantly associated with lower post-treatment psychopathology. These findings suggest that psychological treatments may maximize efficacy by considering patient skill use at treatment outset. By better understanding a patient's initial emotion regulation skills, clinicians may be better able to optimize treatment outcomes by emphasizing maladaptive strategy use reduction predominately, or in conjunction with increasing adaptive skill use.

A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

OBJECTIVE

The aim of this study is to conduct a preliminary examination of long-term outcomes on a broad range of affective disorder symptoms treated with a newly developed intervention: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP).

METHOD

Maintenance of treatment gains at long-term follow-up (LTFU) were explored in patients (N=15, mean age=32.27; 60% female) who completed a clinical trial of the UP.

RESULTS

Treatment gains observed at 6-month follow-up (6MFU) on measures of clinical severity, general symptoms of depression and anxiety, and a measure of symptom interference in daily functioning were largely maintained 12months later (at an average of 18months posttreatment), and any significant changes from 6MFU to LTFU reflected small increases in symptoms that remained, on average, in the subclinical range.

CONCLUSIONS

These findings provide the first initial support for the durability of broad treatment gains following transdiagnostic treatment.

Anxiety sensitivity and interoceptive exposure: a transdiagnostic construct and change strategy

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

The relationship between decision-making and perfectionism in obsessive-compulsive disorder and eating disorders

BACKGROUND AND OBJECTIVES

Obsessive-compulsive disorder (OCD) and eating disorders (EDs) show phenotypic similarities and have been independently associated with deficits in decision-making and maladaptive perfectionism. However, research directly comparing the two disorders is sparse and the significance of observed similarities remains in question. Therefore, the present study compared decision-making in OCD and EDs in relationship to perfectionistic personality traits.

METHODS

Sixty-one women were enrolled in the study comprising 3 mutually exclusive groups: 19 with OCD, 17 with EDs, and 21 healthy controls. Decision-making performance on the Iowa Gambling Task under two conditions, ambiguity and risk, was examined in relationship to perfectionistic traits.

RESULTS

Behavioral results indicated that EDs participants, relative to both OCD and control participants, were impaired in decision-making under conditions of risk. Heightened perfectionism was associated with less risky decision-making in OCD, but more risky decision-making in EDs.

LIMITATIONS

Sample size was small and all participants were women, which may limit generalizability.

CONCLUSION

Results support decision-making deficits in EDs, which may be related to a dysfunctional determination of risk versus reward. This study is the first to suggest that the relationship between perfectionism and risk taking may manifest differently in these phenotypically similar disorders.

Intolerance of uncertainty: a common factor in the treatment of emotional disorders

Intolerance of uncertainty (IU) is a characteristic predominantly associated with generalized anxiety disorder (GAD); however, emerging evidence indicates that IU may be a shared element of emotional disorders.

AIMS

This study aimed to examine IU across diagnostic categories, change in IU during transdiagnostic treatment, and the relationship between change in IU and treatment outcome.

METHOD

Patients diagnosed with heterogeneous anxiety and depressive disorders received up to 18 weeks of a transdiagnostic cognitive-behavioral therapy intervention. Patient self-reported IU and self-report and clinician-rated symptom/functioning measures were administered at pretreatment and posttreatment.

RESULTS

When controlling for negative affectivity, IU correlated with measures of depressive symptoms and worry severity at pretreatment. Patients with GAD and panic disorder exhibited the highest pretreatment IU scores, yet IU scores did not differ significantly based on the presence or absence of a specific diagnosis. A significant decrease in IU was observed, and change in IU was related to reduced anxiety and depressive symptom levels at posttreatment across diagnostic categories.

DISCUSSION

Change in IU can be observed across problem areas in transdiagnostic treatment and such change is correlated with treatment outcome.

Thought-action fusion across anxiety disorder diagnoses: specificity and treatment effects

Thought-action fusion (TAF) is a cognitive error that has been frequently investigated within the context of obsessive-compulsive disorder (OCD). However, evidence suggests that this error may also be present in disorders other than OCD, indicating that TAF is related to higher order factors rather than a specific diagnosis. We explored TAF in a sample of patients with mixed diagnoses undergoing treatment with a transdiagnostic CBT protocol. Elevated TAF levels at baseline were not specific to patients with OCD. However, the presence of any generalized anxiety disorder (GAD) diagnosis was unexpectedly the strongest predictor of likelihood TAF. Likelihood TAF, a particular component of TAF, was reduced after transdiagnostic treatment, and this reduction was not affected by the presence of a GAD diagnosis. Results indicate that TAF is responsive to treatment and should be assessed and, perhaps, treated in disorders beyond OCD.

The Impact of the Unified Protocol for Emotional Disorders on Quality of Life

It has become increasingly clear that mental health is more than just the absence of psychopathology and that there is clinical utility in examining positive aspects of mental health. The present study examined the effects of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders on quality of life in a randomized controlled trial that included individuals with a diverse range of emotional disorders. Results indicated that the Unified Protocol produced significant increases in quality of life when examining both within-individual effect sizes and between-conditions effect sizes compared to a waitlist condition. Furthermore, results indicated that post-treatment levels of quality of life predicted levels of functional impairment independently of diagnostic severity. These results provide further evidence of the importance of examining indicators of mental health in conjunction with markers of psychopathology and provide promising evidence that the Unified Protocol may promote improved mental health in addition to treating psychopathology.

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

This study further evaluates the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). A diagnostically heterogeneous clinical sample of 37 patients with a principal anxiety disorder diagnosis was enrolled in a randomized controlled trial (RCT) involving up to 18 sessions of treatment and a 6-month follow-up period. Patients were randomly assigned to receive either immediate treatment with the UP (n=26) or delayed treatment, following a 16-week wait-list control period (WLC; n=11). The UP resulted in significant improvement on measures of clinical severity, general symptoms of depression and anxiety, levels of negative and positive affect, and a measure of symptom interference in daily functioning across diagnoses. In comparison, participants in the WLC condition exhibited little to no change following the 16-week wait-list period. The effects of UP treatment were maintained over the 6-month follow-up period. Results from this RCT provide additional evidence for the efficacy of the UP in the treatment of anxiety and comorbid depressive disorders, and provide additional support for a transdiagnostic approach to the treatment of emotional disorders.

Transdiagnostic processes in emotional disorders and insomnia: results from a sample of adult outpatients with anxiety and mood disorders

Conceptual similarities between recent models of insomnia and emotional disorders suggest there may be common factors that underlie or maintain these difficulties. Maladaptive cognitive and behavioral processes similar to those described in connection with emotional disorders have been cited as key mechanisms in the maintenance of primary insomnia. Unfortunately, research on this potential overlap is lacking. The present study examined the relationship among anxiety sensitivity (AS), dysfunctional beliefs, fatigue, safety behaviors, and insomnia severity in 59 outpatients with anxiety and mood disorders. Key insomnia processes (dysfunctional beliefs, fatigue, safety behaviors) were all related to insomnia severity in the comorbid sample, although AS was not. However, as hypothesized, AS did moderate the relationship of both dysfunctional beliefs and fatigue with insomnia severity. The relationships between key insomnia processes and insomnia severity was strongest among individuals high in AS. Results support the hypothesis that common mechanisms are involved for insomnia and emotional disorders. AS might function as a mechanism for the maintenance of sleep disturbance in the context of anxiety and mood disorders, suggesting a promising avenue for future research.

Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders

Anxiety and mood disorders are common, chronic, costly, and characterized by high comorbidity. The development of cognitive behavioral approaches to treating anxiety and mood disorders has left us with highly efficacious treatments that are increasingly widely accepted. The proliferation of treatment manuals targeting single disorders, sometimes with trivial differences among them, leaves the mental health professional with no clear way to choose one manual over another and little chance of ever becoming familiar with most of them, let alone trained to competence in their delivery. Deepening understanding of the nature of emotional disorders reveals that commonalities in etiology and latent structures among these disorders supersedes differences. Based on empirical evidence from the domains of learning, emotional development and regulation, and cognitive science, we have distilled a set of psychological procedures that comprise a unified intervention for emotional disorders. The Unified Protocol (UP) is a transdiagnostic, emotion-focused cognitive behavioral treatment, which emphasizes the adaptive, functional nature of emotions, and seeks to identify and correct maladaptive attempts to regulate emotional experiences, thereby facilitating appropriate processing and extinction of excessive emotional responding to both internal (somatic) and external cues. The treatment components of the UP are briefly outlined. Theory and rationale supporting this new approach are described along with some preliminary evidence supporting its efficacy. Implications for the treatment of emotional disorders using the UP are discussed.

Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data

Two studies present preliminary support for the Unified Protocol (UP), a transdiagnostic, emotion-focused cognitive-behavioral treatment developed to be applicable across the emotional disorders. Study 1 presents data from an open clinical trial of the initial version of the UP in a heterogeneous clinical sample, yielding large pre- to post-treatment effect sizes across disorders on measures of DSM-IV diagnostic category severity, and medium to large effect sizes on general measures of depression and anxiety, social adjustment, and levels of negative and positive affect. Following a period of further manual development resulting in specific modifications and enhancements to core treatment components, Study 2 presents data from an additional pilot study of this revised version of the UP. Results from Study 2 demonstrated more robust treatment effect sizes and greater changes across measures of depression, anxiety, positive and negative affect, social adjustment, and quality of life. Relatively similar treatment effects were again demonstrated across a full range of anxiety and mood disorders, suggesting roughly equivalent transdiagnostic efficacy. Implications for the treatment of emotional disorders, clinical practice, and dimensional conceptualizations of psychopathology are discussed.

The Development of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: A Case Study

A detailed description of treatment utilizing the Unified Protocol (UP), a transdiagnostic emotion-focused cognitive-behavioral treatment, is presented using a clinical case example treated during the most current phase of an ongoing randomized controlled trial of the UP. The implementation of the UP in its current, modular version is illustrated. A working case conceptualization is presented from the perspective of the UP drawing from theory and research that underlies current transdiagnostic approaches to treatment and consistent with recent dimensional classification proposals (Brown & Barlow, in press). Treatment is illustrated module-by-module describing how the principles of the UP were applied in the presented case.