A Pilot Study of the Efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Treating Posttraumatic Psychopathology: A Randomized Controlled Trial

Dimensional approaches to studying, assessing, and treating traumatic stress: Introduction to the Special Section

Dimensional models of psychopathology are gaining empirical support and are, thus, increasingly common in research and clinical practice. This is true for traumatic stress studies, although the movement toward dimensional conceptualizations of traumatic stress may be somewhat slower, perhaps due at least in part to how trauma is diagnosed. The purpose of this special section is to collect and showcase cutting-edge basic, applied, and conceptual work on dimensional models of traumatic stress. Its goal is to highlight the utility of such models and to facilitate greater connection between traumatic stress studies and the broader dimensional movement in psychopathology.

Mapping PTSD, depression, and anxiety: A network analysis of co-occurring symptoms in treatment-seeking first responders

First responders are at high risk for a range of co-occurring mental health conditions due to their repeated exposure to traumatic events. When first responders present for treatment, their complex presentation of symptoms including posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder (GAD) can prove challenging to differentiate for clinical purposes. Network analysis provides a means to identify the nuanced associations between the symptoms of these conditions and to identify groups of related symptoms. In this study, a treatment-seeking sample of first responders (N = 432) completed self-report measures of PTSD, depression, and GAD. Network analysis was used to identify symptom clusters within the sample. Our cross-sectional data yielded six empirically distinct communities: depression symptoms, GAD symptoms, and four communities comprising PTSD symptoms - intrusion and avoidance; irritability and aggression; negative affect; and arousal and sleep. Network associations underscore the heterogeneity of PTSD and also highlight overlapping and diverging symptoms of depression and GAD. These findings are discussed within the context of existing research on first responders, and recommendations for further study and treatment interventions are provided.

Unified Protocol vs Trauma-Focused Cognitive Behavioral Therapy Among Adolescents With PTSD

Harmful consequences of COVID-19, such as prolonged quarantine, lack of social contact, and especially loss of parents or friends, can negatively impact children and adolescents' mental health in diverse ways, including engendering posttraumatic stress symptoms. Our study is the first to compare the transdiagnostic Unified Protocol for the Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017) with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) in terms of outcomes related to PTSD symptoms (COVID-19-related vs. COVID-19 unrelated PTSD) and comorbid symptoms (i.e., anxiety, depression) and other measures (i.e., emotion regulation, self-injury, anger). Individuals diagnosed with PTSD were randomly assigned to the UP-A (n = 46) or TF-CBT group (n = 47), administered the SCID-5 and a battery of measures and followed up posttreatment and then after 3, 6, and 9 months. Ninety-three adolescents with PTSD were enrolled, 45% boys and 61% COVID-19-related PTSD. We adopted an intention-to-treat approach. At the initial post-intervention assessment, except for emotion regulation and unexpressed angry feelings, in which UP-A participants reported greater reductions, no significant differences in other variables were secured between the UP-A and TF-CBT. However, at follow-up assessments, the UP-A evidenced significantly better outcomes than TF-CBT. We found support for the UP-A compared with TF-CBT in treating adolescents with PTSD, regardless of COVID-19-related PTSD status, in maintaining treatment effectiveness over time.

Validation of the PCL-5, PHQ-9, and GAD-7 in a Sample of Veterans

OBJECTIVE

Veterans can present at nongovernment (Department of Defense, Department of Veterans Affairs) mental health agencies with complex symptom constellations that frequently include posttraumatic stress disorder, depression, and generalized anxiety. To date, no veteran study has validated these measures on a treatment-seeking sample of veterans outside the DoD and VA.

METHODS

We used a treatment-seeking sample of veterans ( N = 493) to validate measures that assess these constructs (PTSD Checklist 5, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7).

RESULTS

The seven-factor posttraumatic stress disorder hybrid configuration was the best fit. The best fitting model of the depression measure was a two-factor structure, cognitive-affective, and somatic depression. The measure of generalized anxiety was a unidimensional model.

LIMITATIONS

Follow-up studies should validate these measures on nontreatment-seeking discharged veterans.

CONCLUSIONS

We interpret these findings within the veteran scholarship and explore clinical implications for providers.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

Affective Depression Mediates PTSD to Suicide in a Sample of Treatment-Seeking First Responders

OBJECTIVE

The aim of this study was to examine the associations of comorbid posttraumatic stress disorder (PTSD), affective or somatic depression, and suicide among first responders (FRs).

METHOD

We used baseline data from FRs ( N = 232) who sought services at a nonprofit mental health agency specializing in treating trauma exposed FRs. We conducted two PROCESS simple mediation models with PTSD as the predictor, affective depression and somatic depression as the mediators, and suicidality as the dependent variable.

RESULTS

Affective depression significantly mediated the relationship between PTSD and suicidality, whereas somatic depression did not. The direct effect of PTSD on suicidality was not significant.

LIMITATIONS

These data are cross-sectional and should be followed up with longitudinal analyses across the course of treatment.

CONCLUSIONS

To reduce suicide risk, it is recommended that clinicians target affective depression instead of PTSD symptoms.

Network analysis of distress, suicidality, and resilience in a treatment seeking sample of first responders

INTRODUCTION

First responders are routinely and regularly exposed to traumatic events that can clinically manifest with a symptom constellation of posttraumatic stress disorder (PTSD), generalized anxiety, depression, and suicidality.

METHODS

We used network analysis to examine baseline data from treatment seeking first responders (n = 308) to examine the interrelatedness of those constructs, including a measure of resilience. We estimated two models: a regularized partial correlation network and a Bayesian Directed Acyclic Graph (DAG).

RESULTS

The models reveal converging evidence highlighting the central role of negative alterations in cognitions and mood PTSD cluster along with affective depression. These nodes did not significantly differ, though they were among the strongest in the partial correlation network and shared the most variance with the other nodes. The DAG results suggested that the negative alterations in cognitions and mood PTSD cluster predicted downstream constructs of affective depression; intrusion, hyperarousal, and avoidance PTSD clusters; and resilience. Only resilience and affective depression exhibited direct effects on suicidality. Both somatic depression and suicidality were endogenous endpoints in the DAG. Resilience exhibited an inverse path to suicide. However, resilience was relatively independent of the other constructs in the models and the DAG suggested that it was a consequence of PTSD related distress.

LIMITATIONS

The data is cross-sectional in nature that should be followed up in longitudinal studies.

CONCLUSION

Findings are discussed in respect to the role of distress and emotional dysregulation as common factors underlying a broad range of internalizing problems.

Thinking hierarchically about posttraumatic response: Commentary on Lehinger et al. (2022)

Lehinger et al.'s (2022) study on the associations between posttraumatic stress symptoms, posttraumatic cognitions, and alcohol use in sexual assault survivors extends previous research on posttraumatic response to sexual trauma. The study is useful for these purposes but it also raises other interesting questions about the nature of posttraumatic response and the structure of psychopathology more generally. In this commentary, we describe Lehinger et al.'s (2022) study and its findings and discuss their potential relevance for emerging transdiagnostic, hierarchical models of psychopathology.

Primary Outcomes for Adults Receiving the Unified Protocol after Hurricane Harvey in an Integrated Healthcare Setting

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated efficacy for treating anxiety and depression. However, there are limited effectiveness data when conducted in real-world settings with diverse populations, including those with trauma. We evaluated treatment outcomes in a naturalistic, community setting among 279 adults who received UP following Hurricane Harvey. We examined change in overall clinical severity, depression and anxiety symptoms, functional impairment, and baseline outcome predictors (i.e., demographic characteristics, impact from Hurricane Harvey, co-occurrence of depression and anxiety symptoms). Global clinical severity, depression and anxiety symptoms, and functional impairment decreased by end-of-treatment. Participants experienced global symptom improvement to a lesser degree than demonstrated in efficacy trials. Participants who experienced greater storm impact reported larger reductions in anxiety symptoms than those less impacted by Harvey. Further studies evaluating the effectiveness of the UP post-disaster and with diverse samples are needed.

Neuromodulation as an Augmenting Strategy for Behavioral Therapies for Anxiety and PTSD: a Narrative Review

PURPOSE OF REVIEW

Post-traumatic stress disorder (PTSD) is a prevalent problem. Despite current treatments, symptoms may persist, and neuromodulation therapies show great potential. A growing body of research suggests that transcranial magnetic stimulation (TMS) is effective as a standalone treatment for PTSD, with recent research demonstrating promising use when combined synergistically with behavioral treatments. In this review, we survey this literature including data suggesting mechanisms involved in anxiety and PTSD that may be targeted by neurostimulation.

RECENT FINDINGS

Evidence suggests the mechanism of action for TMS that contributes to behavioral change may be enhanced neural plasticity via increased functionality of prefrontal and subcortical/limbic structures and associated networks. Some research has demonstrated a behavioral change in PTSD and anxiety due to enhanced extinction learning or improved ability to think flexibly and reduce ruminative tendencies. Growing evidence suggests TMS may be best used as a therapeutic adjunct, at least acutely, for extinction-based exposure therapies in patients by accelerating therapy response.

SUMMARY

While TMS has shown promise as a standalone intervention, augmentation with psychotherapy is one avenue of interest. Non-responders to current EBPs might particularly benefit from this sort of targeted approach, and it may shorten treatment length, which would help the successful completion of a course of therapy.

The efficacy of transdiagnostic cognitive behavioural therapy on reducing negative affect, anxiety sensitivity and improving perceived control in children with emotional disorders - a randomized controlled trial

In response to the high rate of comorbidity among different types of emotional disorders in children, Transdiagnostic Unified Protocol of Emotional disorder in children (UP-C) was developed to address common underlying mechanisms in the development and maintenance of emotional disorders using empirically supported cognitive and behavioural strategies. Although, studies supported the effectiveness of this protocol in the treatment of wide range of emotional disorders, further studies are needed to examine its effect on transdiagnostic factors. The present study aimed to investigate the efficacy of the UP-C on negative affect, anxiety sensitivity and perceived control in children with emotional disorders. During this randomized controlled trial, 34 children aged 7 to 13 with emotional disorders were randomly assigned to treatment (n=18) and control (n=16) groups. The treatment group and their parents received 15 sessions of UP-C. Negative Affect Schedule for Children (PANASNA- C), Children’s Anxiety Sensitivity Index (CASI), Anxiety Control Questionnaire-Children (ACQ-C) were carried out in all phases (pre-treatment, post-treatment, 3 and 8 months follow- up). The results showed that following UP-C, negative affect (hedges’g=2.01) and anxiety sensitivity (hedges’g=1.05) were significantly reduced, and perceived control (hedges’g= –2.36) was significantly improved. The results remained relatively constant during the follow-ups. Findings provide evidence that the UP-C has significant effect on negative affect, anxiety sensitivity and perceived control as roots of emotional disorders.

A Preliminary Evaluation of the Unified Protocol among Trauma-Exposed Adults with and without PTSD

The purpose of this study was to evaluate whether the Unified Protocol (UP)-a mechanistically transdiagnostic psychological treatment-provides benefit to individuals with a range of trauma histories, psychological difficulties, and diagnostic comorbidity. Using data from a sequential multiple-assignment randomized trial (SMART), this exploratory analysis included a sample of 69 community-recruited adults seeking outpatient mental health treatment. We examined reductions in anxiety and depressive symptoms and changes in aversive and avoidant reactions to intense emotions-the UP's putative mechanism-first by comparing individuals with and without trauma histories and then specifically among participants with PTSD. Findings suggest that the UP may lead to similar improvements in clinical diagnostic severity, anxiety, and depression among patients with trauma exposure as those without trauma exposure. Roughly half of participants with PTSD demonstrated reductions in PTSD clinical severity, anxiety, depression, and distress aversion, suggesting the UP may be an efficacious treatment for people with PTSD and comorbid conditions.

Application of the Unified Protocol for a Japanese Patient with Post-Traumatic Stress Disorder and Multiple Comorbidities: A Single-Case Study

(1) Background: The efficacy of the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy, with trauma-focused exposure has not been sufficiently demonstrated for post-traumatic stress disorder (PTSD) with multiple comorbidities. This study examined the effects of UP treatment with trauma-focused exposure on symptoms of PTSD and comorbidities in a client who was hesitant about exposure. (2) Methods: The client, who had comorbid dysthymia, social anxiety disorder, agoraphobia, and bulimia nervosa, participated in the UP for 20 sessions over 6 months. The principal diagnosis and symptoms of the comorbid disorders were assessed at baseline, post-intervention, and at the 3-month follow-up. This treatment was conducted as part of a clinical study (UMIN000008322). (3) Results: The client showed improvement in the principal diagnosis and symptoms of the comorbid disorders post-intervention compared with baseline and no longer met the diagnostic criteria for any of the disorders. Considerable symptom improvement was observed with imaginal exposure to trauma memories. (4) Conclusions: The UP was an effective alternative treatment for PTSD and symptoms of comorbidities in this client who was hesitant about exposure to traumatic memories, and that the inclusion of trauma-focused exposure provided sufficient therapeutic effects. Further research is needed to examine the generalizability of our findings.

A nine-month study on the course of COVID-19 related perceived post-traumatic stress disorder among Italian community-dwelling adults

The present study aimed to evaluate base rate estimates, course of, and psychopathology and personality risk factors for COVID-19-related post-traumatic stress disorder (PTSD) in community-dwelling adults during the pandemic. 203 participants from a sample of 811 Italian community-dwelling adults agreed to participate in a nine-month, three-wave (Wave 1: March 2020; Wave 2: June 2020; Wave 3: December 2020) longitudinal study. Participants in the longitudinal study did not differ from the cross-sectional original sample on age, gender, civil status, educational level, occupation, and Italian area of residence. At each wave, participants were administered the PTSD scale of the International Trauma Questionnaire (ITQ), DSM-5 measures of acute stress, dissociation, depression and anxiety, as well as a maladaptive personality domain measure at Wave 1. Participants were instructed to answer to the ITQ items based only on COVID-19 pandemic and related containment measures. The point prevalence estimates of COVID-19 related PTSD at each wave ranged from 11% to 13%; however, up to roughly 23% of our participants experienced clinically relevant PTSD features during nine months of the COVID-19 pandemic in Italy. Multiple logistic regression results showed that experiencing internalizing symptoms (i.e., mostly acute stress) and selected personality features (i.e., Negative Affectivity and Psychoticism) at Wave 1 represent risk factors for PTSD symptoms at later waves. These findings extend previous knowledge on COVID-19 related PTSD and support the need for preventive and treatment interventions for PTSD during the COVID-19 pandemic.