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

The Unified Protocol or Dialectical Behaviour Therapy? Considerations for Choosing Between Two Evidence-Based Transdiagnostic Psychotherapies for Complex Patients

The advent of multiple transdiagnostic treatments in recent decades has advanced the field of clinical psychology while also raising questions for clinicians and patients about how to decide between treatments and how to best deliver a chosen treatment. The purpose of this paper is to review two prominent transdiagnostic treatments that target emotion dysregulation: dialectical behaviour therapy and the unified protocol for transdiagnostic treatment for emotional disorders. First, we review the theoretical underpinnings, research support and proposed mechanisms of action for these treatments. Next, we discuss patient and therapist variables that might indicate which treatment is more appropriate for a given patient and discuss decision-making guidelines to help make this determination with an emphasis on complex patients who may present with risk and/or clinical comorbidities. Finally, we discuss areas for future research that can help further ensure we work to match patients to the treatment that is most likely to benefit them.

Study protocol for a randomized controlled trial testing the efficacy of Emotion Detectives In-Out: a blended version of the unified protocol for transdiagnostic treatment of emotional disorders in Portuguese children

BACKGROUND

Childhood emotional disorders (EDs; i.e., anxiety and depressive disorders) are currently a public health concern. Their high prevalence, long-term effects, and profound influence on the lives of children and families highlight the need to identify and treat these disorders as early and effectively as possible. This clinical trial will examine the efficacy of a blended version (i.e., combining face-to-face and online sessions into one treatment protocol) of the Unified Protocol for Children (the "Emotion Detectives In-Out" program). This program is a manualized cognitive-behavioral therapy for the transdiagnostic treatment of EDs in children aged 7 to 12 years that aims to reduce the intensity and frequency of strong and aversive emotional experiences by helping children learn how to confront those emotions and respond to them in more adaptive ways.

METHODS

This study is designed as a multicenter equivalence randomized controlled parallel-group two-arm trial comparing the Emotion Detectives In-Out program with an evidenced-based group intervention for children with anxiety disorders (the Coping Cat program). Participants will be children aged between 7 and 12 years with an anxiety disorder or with clinically significant anxiety symptoms as well as one of their parents or a legal representative. A minimum sample size of 138 children (69 per group) is needed to test whether the efficacy of the proposed intervention is equivalent to that of the well-established Coping Cat intervention.

DISCUSSION

We expect Emotion Detectives In-Out to be a feasible and efficacious alternative intervention for treating children's EDs by allowing for a greater increase in children's access to care. A blended format is expected to overcome common barriers to treatment (e.g., parents´ lack of time to attend regular sessions) and make the intervention more accessible to families.

TRIAL REGISTRATION

The clinical trial is registered at ClinicalTrials.gov (Identifier: NCT05747131, date assigned February 28, 2023).

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.

Transdiagnostic Cognitive Behavioral Psychotherapy: Unified Protocol as an Example

The fact that there are many limitations of the current classification systems led to the emergence of transdiagnostic approaches (TA) that focus on the common psychopathological processes underlying disorders rather than categorical diagnoses. TA focuses on the underlying common psychopathological processes in the emergence and persistence of mental disorders. Thus, even if the disorders are categorically diagnosed differently, it can be determined how they overlap or separate with each other. TA aims to treat mental disorders using these aspects. TA has a flexible and modular structure that can be easily integrated into cognitive behavioral therapies. The rest of this review will focus on the Unified Protocol (UP), one of the most popular TA examples. The main purpose of the UP is to enable patients to recognize their feelings and give more adaptive reactions to their negative emotions. Accordingly, UP consists of eight modules. The modules can usually be completed in a total of 11 - 17 weeks. Each 50 to 60-minute individual session is held once a week. If necessary, changes can be made to the number or the frequency of sessions allocated to modules. The goals of each module of the UP and the treatment approaches towards these goals allow a very clearly defined approach. For this reason, there is a need for a detailed evaluation, conceptualization and treatment plan before the UP is put into practice. We hope that mental health professionals from Turkey will contribute to the developments in the UP.

Internet-based cognitive behavioural therapy combined with attentional bias modification training in generalized anxiety disorder: a randomized, controlled multi-session experiment

BACKGROUND

Although attentional bias modification training (ABM) and cognitive behavioural therapy (CBT) are two effective methods to decrease the symptoms of generalized anxiety disorders (GAD), to date, no randomized controlled trials have yet evaluated the effectiveness of an intervention combining internet-based cognitive behavioural therapy (ICBT) and ABM for adults with GAD.

AIMS

This study aimed to investigate the effectiveness of an intervention combining ICBT and ABM for adults with GAD.

METHOD

Sixty-three participants diagnosed with GAD were randomly assigned to the treatment group (ICBT with ABM; 31 participants) or the control group (ICBT with ABM placebo; 32 participants), and received 8 weeks of treatment and three evaluations. The CBT, ABM and ABM-placebo training were conducted via the internet. The evaluations were conducted at baseline, 8 weeks later, and 1 month later, respectively.

RESULTS

Both the treatment and control groups reported significantly reduced anxiety symptoms and attentional bias, with no clear superiority of either intervention. However, the treatment group showed a greater reduction in negative automatic thoughts than the control group after treatment and at 1-month follow-up (η² = 0.123).

CONCLUSION

The results suggest that although not differing in therapeutic efficacy, the intervention combining ICBT and ABM is superior to the intervention combining ICBT and ABM-placebo in the reduction of negative automatic thoughts. ABM may be a useful augmentation of ICBT on reducing anxiety symptoms.

Is there evidence that emotional reasoning processing underlies emotional disorders in adults? A systematic review

The prevalence of emotional disorders has increased in recent times. Emotional Reasoning (ER), which is a transdiagnostic process, occurs when feelings, rather than objective evidence, are used as a source of information to make judgements about the valence of a situation. Differences in ER may explain the existence and maintenance of emotional disorders. The objective is to systematically review the role of ER in the occurrence and severity of emotional disorders. Following PRISMA guidelines, we searched through: PubMed, PsycInfo, Scopus and The Cochrane Library. Search terms were "Emotional Reasoning", "ex-consequentia reasoning", "Affect-as-information"; and "emotional disorders", "anxiety", "depression", "depressive". Nine articles were included. An association was demonstrated between ER and a greater degree of anxious symptomatological severity. In depressive symptomatology, no significant differences were found. One study reported the effect of Cognitive Behavioural Therapy on ER bias, finding no changes after the intervention. Finally, another study evaluated the efficacy of computerised experiential training in reducing ER bias, showing significant differences. There are few studies on ER and its evolution in research has not been uniform over time. Encouragingly, though, research to date suggests that ER is a transdiagnostic process involved in several anxiety disorders. More investigation is needed to dilucidate whether ER also underlies the onset and maintenance of depressive disorders.

Application of the unified protocol for the transdiagnostic treatment of comorbid emotional disorders in patients with ultra-high risk of developing psychosis: A randomized trial study protocol

Background

Cognitive Behavioral Therapy is delivered in most of the early intervention services for psychosis in different countries around the world. This approach has been demonstrated to be effective in decreasing or at least delaying the onset of psychosis. However, none of them directly affect the comorbidity of these types of patients that is often the main cause of distress and dysfunctionality. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) is a psychological intervention that combines cognitive-behavioral and third-generation techniques that address emotional dysregulation as an underlying mechanism that these disorders have in common. The application of this intervention could improve the comorbid emotional symptoms of these patients.

Materials and methods

The study is a randomized controlled trial in which one group receives immediate UP plus standard intervention and the other is placed on a waiting list to receive UP 7 months later, in addition to standard care in one of our early psychosis programs. The sample will be 42 patients with UHR for psychosis with comorbid emotional symptoms. The assessment is performed at baseline, at the end of treatment, and at 3-months’ follow-up, and includes: general psychopathology, anxiety and depression, positive and negative emotions, emotional dysregulation, personality, functionality, quality of life, cognitive distortions, insight, and satisfaction with the UP intervention.

Discussion

This will be the first study of the efficacy, acceptability, and viability of the UP in a sample of young adults with UHR. The results of this study may have clinical implications, contributing to improving the model of care for young people who consult for underlying psychotic, anxiety, and/or depressive symptoms that can lead to high distress and dysfunctionality.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT04929938].

Efficacy of a transdiagnostic guided internet-delivered intervention for emotional, trauma and stress-related disorders in Mexican population: study protocol for a randomized controlled trial

BACKGROUND

Emotional and stress-related disorders show high incidence, prevalence, morbidity, and comorbidity rates in Mexico. In recent decades, research findings indicate that cognitive behavioral interventions, from a disorder-specific perspective, are the effective front-line treatment for anxiety and depression care. However, these treatments are not often used. Reasons include limited access and low availability to effective interventions and comorbidity between mental disorders. Emotional deregulation of negative affectivity has been found to be a mediating factor in addressing emotional disorders from a transdiagnostic perspective, aimed at two or more specific disorders. In addition, technological advancement has created alternatives for psychological assistance, highlighting the possibilities offered by technologies since Internet-supported intervention programs have been empirically tested for effectiveness, efficiency and efficacy and can be key to ensuring access to those who are inaccessible. The aim of the study is to evaluate the efficacy, moderators of clinical change and acceptability of a transdiagnostic guided Internet-delivered intervention versus a transdiagnostic self-guided Internet-delivered intervention for emotional, trauma and stress-related disorders, and waiting list in community sample.

METHODS

A three-armed, parallel group, superiority randomized controlled clinical trial with repeated measurements at four times: pretest, posttest, follow-up at 3, 6 and 12 months. Outcomes assessor, participant, care provider and investigator will be blinded. Participants aged 18 to 70 years will be randomly allocated 1:1:1 to one of three study arms: a) Transdiagnostic guided internet-delivered intervention with synchronous assistance, b) Transdiagnostic self-guided internet-delivered intervention, c) Waiting list group. Based on sample size estimation, a minimum of 207 participants (69 in each intervention group) will be included.

DISCUSSION

The study could contribute to improving the efficacy of transdiagnostic internet-delivered interventions to promote the dissemination of evidence-based treatments and eventually, to decrease the high prevalence of emotional and trauma-related disorders in the Mexican population.

TRIAL REGISTRATION

ClinicalTrial.gov: NCT05225701 . Registered February 4, 2022.

The Royal Canadian Mounted Police (RCMP) Study: protocol for a prospective investigation of mental health risk and resilience factors

The Royal Canadian Mounted Police (RCMP), like all public safety personnel (PSP), are frequently exposed to potentially psychologically traumatic events that contribute to posttraumatic stress injuries (PTSI). Addressing PTSI is impeded by the limited available research. In this protocol paper, we describe the RCMP Study, part of the concerted efforts by the RCMP to reduce PTSI by improving access to evidence-based assessments, treatments and training as well as participant recruitment and RCMP Study developments to date. The RCMP Study has been designed to (1) develop, deploy and assess the impact of a system for ongoing annual, monthly and daily evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; (4) augment the RCMP Cadet Training Program with skills to proactively mitigate PTSI; and (5) assess the impact of the augmented training condition (ATC) versus the standard training condition (STC). Participants in the STC (n = 480) and ATC (n = 480) are assessed before and after training and annually for 5 years on their deployment date; they also complete brief monthly and daily surveys. The RCMP Study results are expected to benefit the mental health of all participants, RCMP and PSP by reducing PTSI among all who serve.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Innovative moments in recovered cases treated with the unified protocol for transdiagnostic treatment of emotional disorders

OBJECTIVE

Innovative moments (IMs) are moments in which the previous problematic pattern of meaning is challenged. Studies have shown that IMs are associated with good psychotherapy outcomes. A three-level hierarchy of IMs was observed in recent studies, with level 1 IMs being more elementary and levels 2 and 3 being more complex and associated with treatment success. However, studies with manualized protocol treatments are thus far lacking. This study analyzed the longitudinal progression of IMs in the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) and explored its associations with changes in psychological distress.

METHODS

Data were collected from a Portuguese university-based outpatient clinic and included 18 cases with positive outcomes. Nine sessions of each case were coded with the IM coding system (N=162).

RESULTS

Multilevel analyses showed a significant increase in all IM levels across treatments. The decrease in psychological distress predicted an increase in level 2 IMs in the same session.

CONCLUSION

The evolution of IMs is similar to what was found previously in other studies. Contrary to what was found in previous studies, IMs did not predict outcomes in the following session, whereas the reduction in psychological distress predicted the emergence of level 2 IMs.

Premature termination of the unified protocol for the transdiagnostic treatment of emotional disorders: The role of ambivalence towards change

Ambivalence towards change is an expected, recurrent process in psychological change. However, the prolonged experience of ambivalence in psychotherapy contributes to client disengagement, which could result in treatment dropout. Considering the negative effects of premature termination of therapy and the convenience of the identification of clients who are at risk of dropping out before achieving good-outcome, the current study explored the predictive power of ambivalence for premature therapy termination using a multilevel time-backwards model (i.e., considering the session of the dropout as session zero and then modelling what occurred from the dropout until session 1). Participants included a total of 96 psychotherapy clients (38 dropouts) treated in a university-based clinic following the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Multilevel modelling using a time-backwards model to analyse dropout data provided evidence of the predictive power of ambivalence evolution throughout treatment on the decision to prematurely discontinue treatment (p < .0001; R² _adj  = .29). Specifically, good-outcome dropouts presented a decreasing ambivalence trend throughout treatment, whereas poor-outcome dropouts tended to experience the same levels of ambivalence before deciding to drop out (time × dropout; β₁₁  = .64, p = .014). Additionally, poor-outcome dropouts presented higher levels of ambivalence (β₀₁  = 9.92, p < .0001) in the last session. The results suggest that the pattern of client ambivalence towards change is a predictor of premature termination of therapy. Implications for clinical and research contexts are discussed.

Delivering Transdiagnostic Treatment Over Telehealth During the COVID-19 Pandemic: Application of the Unified Protocol

The COVID-19 pandemic has necessitated an abrupt transition to remote delivery of psychology services at a time when patients and practicing clinicians are experiencing an increase in life stressors (e.g., job loss, social isolation, need to adapt to telehealth practice), which can exacerbate mental health concerns and contribute to clinician burnout. Because the COVID-19 pandemic is affecting diverse individuals in myriad ways, these circumstances can elicit a wide range of emotions and emotional responses. Thus, treatment during this time must be able to address heterogeneous presenting problems while placing minimal burden on clinicians who are adjusting to continuously changing circumstances. Transdiagnostic, emotion-focused, cognitive behavioral treatments (CBT), such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), may be particularly well suited to address the challenges faced by practicing psychologists, and their patients, in the current COVID-19 pandemic. This paper discusses the applicability and adaptability of transdiagnostic treatments to telehealth, focusing primarily on the UP in the context of the COVID-19 pandemic. Further, while many CBT skills (e.g., mindfulness) can be easily translated to tele-delivery, other skills, such as exposure, can be more difficult to implement remotely, especially in the midst of a pandemic. Thus, this paper also provides practical suggestions for clinicians with regard to implementing the UP remotely.

Negative and Positive Affect Regulation in a Transdiagnostic Internet-Based Protocol for Emotional Disorders: Randomized Controlled Trial

BACKGROUND

Emotional disorders (EDs) are among the most prevalent mental disorders. Existing evidence-based psychological treatments are not sufficient to reduce the disease burden of mental disorders. It is therefore essential to implement innovative solutions to achieve a successful dissemination of psychological treatment protocols, and in this regard, the use of information and communication technologies such as the internet can be very useful. Furthermore, the literature suggests that not everyone with an ED receives the appropriate treatment. This situation has led to the development of new intervention proposals based on the transdiagnostic perspective, which attempts to address the underlying processes common to EDs. Most of these transdiagnostic interventions focus primarily on downregulating negative affectivity (NA), and less attention has been paid to strengths and the upregulation of positive affectivity, despite its importance for well-being and mental health.

OBJECTIVE

This study aims to evaluate the efficacy of a transdiagnostic internet-based treatment for EDs in a community sample.

METHODS

A 3-armed randomized controlled trial was conducted. A total of 216 participants were randomly assigned to a transdiagnostic internet-based protocol (TIBP), a TIBP+ positive affect (PA) component, or a waiting list (WL) control group. The treatment protocol contained core components mainly addressed to downregulate NA (ie, present-focused emotional awareness and acceptance, cognitive flexibility, behavioral and emotional avoidance patterns, and interoceptive and situational exposure) as well as a PA regulation component to promote psychological strengths and enhance well-being. Data on depression, anxiety, quality of life, neuroticism and extraversion, and PA/NA before and after treatment were analyzed. Expectations and opinions of treatment were also analyzed.

RESULTS

Within-group comparisons indicated significant pre-post reductions in the two experimental conditions. In the TIBP+PA condition, the effect sizes were large for all primary outcomes (d=1.42, Beck Depression Inventory [BDI-II]; d=0.91, Beck Anxiety Inventory [BAI]; d=1.27, Positive and Negative Affect Schedule-Positive [PANAS-P]; d=1.26, Positive and Negative Affect Schedule-Negative [PANAS-N]), whereas the TIBP condition yielded large effect sizes for BDI-II (d=1.19) and PANAS-N (d=1.28) and medium effect sizes for BAI (d=0.63) and PANAS-P (d=0.69). Between-group comparisons revealed that participants who received one of the two active treatments scored better at posttreatment than WL participants. Although there were no statistically significant differences between the two intervention groups on the PA measure, effect sizes were consistently larger in the TIBP+PA condition than in the standard transdiagnostic protocol.

CONCLUSIONS

Overall, the findings indicate that EDs can be effectively treated with a transdiagnostic intervention via the internet, as significant improvements in depression, anxiety, and quality of life measures were observed. Regarding PA measures, promising effects were found, but more research is needed to study the role of PA as a therapeutic component.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02578758; https://clinicaltrials.gov/ct2/show/NCT02578758.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-017-1297-z.

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.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial

BACKGROUND

Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care.

METHODS

In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis.

RESULTS

A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79].

CONCLUSIONS

Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

Changes in Risk Factors During the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

This study aimed to assess whether changes in potentially modifiable risk factors associated with the construct of neuroticism and common to emotional disorders (i.e., poor distress tolerance and heightened avoidance) occur in concordance with the administration of different treatment components of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and with reductions in emotional disorder symptoms (i.e., anxiety and depressive symptoms) overall. Using single-case analytic strategies, including multiple-baseline design and modeling techniques, the authors treated 8 adolescents with emotional disorder diagnoses and evaluated trajectories of change in distress tolerance and experiential avoidance as well as in the sequencing of such change in regard to change in anxiety and depressive symptoms. Clinical outcomes were favorable based on parent, adolescent, and clinician-rated measures. Treatment-based change was demonstrated, at both group and individual levels, and at expected points in treatment, in regard to facets of neuroticism. Overall, self-reported change in experiential avoidance and distress tolerance tended to occur simultaneously to reductions in emotional disorder symptoms. This study helps to clarify the course of expected change in variables believed to be common among a range of emotional disorders during a transdiagnostic treatment and provides initial information regarding tailoring the UP-A for individuals with different clinical profiles.

Exploring the Effects of the Mindfulness and Countering Emotional Behaviors Modules From the Unified Protocol on Dysregulated Anger in the Context of Emotional Disorders

Dysregulated anger in the context of emotional (e.g., mood, anxiety, related) disorders is associated with treatment attrition and a lower likelihood of responding to extant treatments. Therefore, there is a need to identify the most effective skills for targeting this anger and prioritize their delivery in treatment with the hope of producing more potent interventions. The current study explored the specific effects of two treatment skills (mindfulness and countering emotional behaviors) in isolation and combination as interventions for dysregulated anger using single-case experimental design. Patients were randomized to a 2- or 4-week baseline with no intervention applied and then to the first treatment skill received. All patients subsequently completed the alternate treatment skill and 1 month of follow-up. Results suggested the first module had clinically meaningful effects for five patients and the second module produced incremental improvement for five patients. Visual inspection and effect sizes indicated mindfulness produced greater reductions in anger when delivered in isolation compared to countering emotional behaviors (d = 0.96, 0.33, for mindfulness and countering emotional behaviors, respectively). With regard to the second module, more patients (n = 4) experienced a reduction in anger in response to mindfulness than to countering emotional behaviors (n = 1); effect sizes indicated significant improvements in response to both modules (d = 0.83, 0.72, for mindfulness and countering emotional behaviors, respectively). Taken together, results suggest mindfulness may be a more efficacious intervention for anger than countering emotional behaviors. Implications of these results for addressing dysregulated anger in treatment are discussed.

Treating a Cluster of Internalizing Disorders With the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: A Case Study

Psychotherapy outcome research rarely focuses on the ideographic application of treatment manuals, though some modules might prove markedly more important for a client than others. Clients in need of psychoeducation, emotion regulation skills, and changes in maladaptive patterns of thinking might balk at portions of the Unified Protocol for the Treatment of Emotional Disorders that seem irrelevant to their concerns. The current case study focused on emotion dysregulation and perfectionism given their role in anxiety, depression, obsessions, and compulsions. The Overall Anxiety Severity and Impairment Scale (OASIS), Overall Depression Severity and Impairment Scale (ODSIS), and Yale-Brown Obsessive Compulsive Scale (Y-BOCS) confirmed qualitative reports and therapist observations of improvement. Additional sessions focused on fostering self-compassion and processing the termination of a romantic relationship rather than completing every section of the manual. This case demonstrates that flexible adaptation of a transdiagnostic treatment manual, in conjunction with a strong working alliance and other non-specifics of therapy, can produce beneficial outcomes even when other modules are not applied. These results might support ideographic application of select modules from treatment manuals and support a symptoms approach to psychotherapy.

Better Safe Than Sorry: A Common Signature of General Vulnerability for Psychopathology

Several labels, such as neuroticism, negative emotionality, and dispositional negativity, indicate a broad dimension of psychopathology. However, largely separate, often disorder-specific research lines have developed that focus on different cognitive and affective characteristics that are associated with this dimension, such as perseverative cognition (worry, rumination), reduced autobiographical memory specificity, compromised fear learning, and enhanced somatic-symptom reporting. In this article, we present a theoretical perspective within a predictive-processing framework in which we trace these phenotypically different characteristics back to a common underlying “better-safe-than-sorry” processing strategy. This implies information processing that tends to be low in sensory-perceptual detail, which allows threat-related categorical priors to dominate conscious experience and for chronic uncertainty/surprise because of a stagnated error-reduction process. This common information-processing strategy has beneficial effects in the short term but important costs in the long term. From this perspective, we suggest that the phenomenally distinct cognitive and affective psychopathological characteristics mentioned above represent the same basic processing heuristic of the brain and are only different in relation to the particular type of information involved (e.g., in working memory, in autobiographical memory, in the external and internal world). Clinical implications of this view are discussed.

Puberty and Transdiagnostic Risks for Mental Health

Puberty in girls represents a notable period of vulnerability for different psychological disorders. The research literature has primarily considered external and contextual factors that might explain these rises in symptomatology. In the present study, we investigate relations of pubertal status and timing with individual cognitive, emotional, and behavioral tendencies, commonly identified as transdiagnostic processes, in a sample of N = 228 girls (M_age  = 11.75 years). We also test whether these transdiagnostic processes mediate associations of pubertal status and pubertal timing with depressive symptoms. Results support greater endorsement of rumination, co-rumination, negative urgency, and both anxious and angry rejection sensitivity in girls with more advanced pubertal status, as well as in girls with early pubertal timing. Higher levels of transdiagnostic processes fully mediated associations of pubertal status and timing with depressive symptoms at significant and marginally significant levels, respectively. Although the data are cross-sectional, these findings offer promising preliminary evidence that transdiagnostic processes represent an important mental health risk in early adolescent girls.

Treating perfectionism using internet-based cognitive behavior therapy: A study protocol for a randomized controlled trial comparing two types of treatment

Perfectionism is characterized by setting high standards and striving for achievement, sometimes at the expense of social relationships and wellbeing. Despite sometimes being viewed as a positive feature by others, people with perfectionism tend to be overly concerned about their performance and how they are being perceived by people around them. This tends to create inflexible standards, cognitive biases, and performance-related behaviors that maintain a belief that self-worth is linked to accomplishments. Cognitive behavior therapy has been shown to be a viable treatment for perfectionism, both in terms of reducing levels of perfectionism and improving psychiatric symptoms. Furthermore, a number of recent studies indicate that it can be successfully delivered via the Internet, both with regular support and guidance on demand from a therapist. In the present study protocol, a clinical trial for perfectionism is described and outlined. In total, 128 participants will be recruited and randomized to either a treatment that has already been demonstrated to have many benefits, Internet-based Cognitive Behavior Therapy for perfectionism (iCBT-P), or an active comparison condition, Internet-based Unified Protocol (iUP), targeting the emotions underlying depression and anxiety disorders. The results will be investigated with regard to self-reported outcomes of perfectionism, psychiatric symptoms, self-compassion, and quality of life, at post-treatment and at six- and 12-month follow-up. Both iCBT-P and iUP are expected to have a positive impact, but the difference between the two conditions in terms of their specific effects and adherence are currently unknown and will be explored. The clinical trial is believed to lead to a better understanding of how perfectionism can be treated and the specificity of different treatments.

Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial

Background

Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT.

Objective

This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings.

Methods

A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up.

Results

The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants.

Conclusions

EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed.

Trial Registration

ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668

Lay-therapist-delivered, low-intensity, psychosocial intervention for refugees and asylum seekers (PROSPER): protocol for a pilot randomised controlled trial

Background

Asylum seekers and refugees (AS&Rs) experience impaired mental health and wellbeing, related to stresses in their country of origin, experiences in transit and reception on arrival, including significant barriers to accessing mainstream services. Their contact with health care is often crisis-driven and mediated through non-governmental organisations (NGOs).

Problem Management Plus (PM+) is a psychosocial intervention recommended by the World Health Organisation to address distress experienced by adults affected by humanitarian crises. We are investigating its application for the first time in a high-income country.

Methods

In a pilot randomised controlled trial (RCT), PM+ will be delivered to AS&Rs in contact with NGOs in Liverpool City Region, UK by lay therapists who have lived experience of forced migration. Following systematic review and stakeholder engagement, PM+ has been adapted to the local context, and lay therapists have been trained in its delivery.

We will assess the feasibility of conducting a three-arm RCT of five 90-min sessions of PM+, delivered individually or in groups by lay therapists to AS&Rs experiencing emotional distress and functional impairment, compared with each other and with usual support offered by local NGOs. Distress and impairment at baseline will be measured by the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule (WHO-DAS). We aim to recruit 105 participants, 35 per arm.

Primary health outcomes are anxiety and depressive symptoms at 3 months, measured by HADS. Secondary outcomes include subjective wellbeing, functional status, progress on identified problems, presence of post-traumatic stress disorder and depressive disorder and service usage. Longer-term impact will be assessed at 6 months post baseline, on the same parameters.

We will assess the feasibility of conducting a full RCT in relation to the following elements: recruitment and retention of lay therapists and study participants; fidelity of delivery of PM+; and suitability of the study measures, including any linguistic or cultural barriers.

Discussion

We will use these findings to specify the parameters for a full RCT to test the effectiveness and cost-effectiveness of PM+ in reducing emotional distress and health inequalities, and improving functional ability and wellbeing, amongst asylum seekers and refugees.

Trial registration

ISRCTN, ID: ISRCTN15214107. Registered on 10 September 2019.

Augmenting the unified protocol for transdiagnostic treatment of emotional disorders with transcranial direct current stimulation in individuals with generalized anxiety disorder and comorbid depression: A randomized controlled trial

BACKGROUND

The aim of the current study was to compare the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) with and without transcranial direct current stimulation (tDCS) in individuals suffering from generalized anxiety disorder (GAD) and comorbid depression.

METHODS

A total of 43 individuals diagnosed with GAD and comorbid depression enrolled in a randomized controlled trial (IRCT20140929019334N1). Participants were randomly assigned to three groups including UP with tDCS (UP+tDCS; n = 15), UP alone (UP; n = 13) or wait-list control (n = 15). GAD and depression symptoms, worry severity, anxiety sensitivity, and intolerance of uncertainty were assessed at baseline, post-treatment and 3-month follow-up.

RESULTS

Treatment with both UP+tDCS and UP alone resulted in significant lower ratings across all measures relative to wait-list controls at post-treatment and 3-month follow-up (all p-values <0.001). UP+tDCS showed significantly greater reductions in anxiety (p = 0.001 post-treatment; p = 0.003 follow-up), worry (p = 0.001 post-treatment; p = 0.002 follow-up), and anxiety sensitivity (p = 0.003 post-treatment; p = 0.002 follow-up) relative to UP alone.

LIMITATIONS

The present study had some limitations. First, the sample size was low. Another limitation was the use of a short-term follow-up.

CONCLUSIONS

These results suggest augmenting UP treatment with tDCS may be an efficacious strategy to improve treatment outcomes in GAD with comorbid depression. Trial registration reference is IRCT20140929019334N1 (see https://irct.ir/trial/27988).

The Unified Protocol compared with diagnosis-specific protocols for anxiety disorders: 12-month follow-up from a randomized clinical trial

OBJECTIVE

To examine whether the Unified Protocol (UP) remains equivalent to single-disorder protocols (SDPs) in the treatment of anxiety disorders at 12-month follow-up.

METHOD

We report results from the 12-month follow-up of a recent randomized equivalence trial [1]. Data are from 179 participants (55.31% female sex, 83.24% White, average age 30.66) who met criteria for a principal anxiety disorder and were randomized to either the UP or SDP conditions. Consistent with the parent trial, the primary outcome was principal diagnosis clinician severity rating (CSR) from the Anxiety Disorder Interview Schedule (ADIS). Secondary outcomes included anxiety, depression, and impairment. Missing data were accommodated using multiple imputation (10,000 imputed data sets) under a missing at random assumption. Equivalence between the UP and SDPs was tested using slope difference scores from latent growth models and 95% confidence interval of between-condition effect sizes.

RESULTS

The results indicated that the UP and SDP conditions remained equivalent with regard to principal diagnosis clinician severity rating at 12-month follow-up. In addition, there were no significant differences between conditions on secondary outcomes at 12-month follow-up.

CONCLUSIONS

The UP continues to yield outcomes comparable to SDPs at 12-month follow-up, and therefore provides a single intervention that can be used to treat the most commonly occurring psychiatric disorders with durable effects.

Affect regulation training reduces symptom severity in depression - A randomized controlled trial

Deficits in general emotion regulation skills have been shown to be associated with various mental disorders. Thus, general affect-regulation training has been proposed as promising transdiagnostic approach to the treatment of psychopathology. In the present study, we aimed to evaluate the efficacy of a general affect-regulation as a stand-alone, group-based treatment for depression. For this purpose, we randomly assigned 218 individuals who met criteria for major depressive disorder (MDD) to the Affect Regulation Training (ART), to a waitlist control condition (WLC), or to a condition controlling for common factors (CFC). The primary outcome was the course of depressive symptom severity as assessed with the Hamilton Rating Scale for Depression and the Beck Depression Inventory. Multi-level analyses indicated that participation in ART was associated with a greater reduction of depressive symptom severity than was participation in WLC (d = 0.56), whereas the slight superiority of ART over CFC (d = 0.25) was not statistically significant. Mediation analyses indicated that changes in emotion regulation skills mediated the differences between ART/CFC and WLC. Thus, the findings provide evidence for enhancing emotion regulation skills as a common mechanism of change in psychological treatments for depression. The study was registered with ClinicalTrials.gov (NCT01330485) and was supported by grants from the German Research Association (DFG; BE 4510/3-1; HI 456/6-2). Future research should compare the (cost-) efficacy of ART with that of disorder-specific interventions.

An Affirmative Coping Skills Intervention to Improve the Mental and Sexual Health of Sexual and Gender Minority Youth (Project Youth AFFIRM): Protocol for an Implementation Study

BACKGROUND

Sexual and gender minority youth (SGMY, aged 14-29 years) face increased risks to their well-being, including rejection by family, exclusion from society, depression, substance use, elevated suicidality, and harassment, when compared with their cisgender, heterosexual peers. These perils and a lack of targeted programs for SGMY exacerbate their risk for HIV and other sexually transmitted infections. Cognitive behavioral therapy (CBT) interventions support clients by generating alternative ways of interpreting their problems and beliefs about themselves. CBT, tailored to the experiences of SGMY, may help SGMY improve their mood and coping skills by teaching them how to identify, challenge, and change maladaptive thoughts, beliefs, and behaviors. Based on the promising results of a pilot study, a CBT-informed group intervention, AFFIRM, is being tested in a pragmatic trial to assess its implementation potential.

OBJECTIVE

The aim of this study is to scale-up implementation and delivery of AFFIRM, an 8-session manualized group coping skills intervention focused on reducing sexual risk behaviors and psychosocial distress among SGMY. Our secondary aim is to decrease sexual risk taking, poor mental health, and internalized homophobia and to increase levels of sexual self-efficacy and proactive coping among SGMY.

METHODS

SGMY are recruited via flyers at community agencies and organizations, as well as through Web-based advertising. Potential participants are assessed for suitability for the group intervention via Web-based screening and are allocated in a 2:1 fashion to the AFFIRM intervention or a wait-listed control in a stepped wedge wait-list crossover design. The intervention groups are hosted by collaborating community agency sites (CCASs; eg, community health centers and family health teams) across Ontario, Canada. Participants are assessed at prewait (if applicable), preintervention, postintervention, 6-month follow-up, and 12-month follow-up for sexual health self-efficacy and capacity, mental health indicators, internalized homophobia, stress appraisal, proactive and active coping, and hope. Web-based data collection occurs either independently or at CCASs using tablets. Participants in crisis are assessed using an established distress protocol.

RESULTS

Data collection is ongoing; the target sample is 300 participants. It is anticipated that data analyses will use effect size estimates, paired sample t tests, and repeated measures linear mixed modeling in SPSS to test for differences pre- and postintervention. Descriptive analyses will summarize data and profile all variables, including internal consistency estimates. Distributional assumptions and univariate and multivariate normality of variables will be assessed.

CONCLUSIONS

AFFIRM is a potentially scalable intervention. Many existing community programs provide safe spaces for SGMY but do not provide skills-based training to deal with the increasingly complex lives of youth. This pragmatic trial could make a significant contribution to the field of intervention research by simultaneously moving AFFIRM into practice and evaluating its impact.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13462.

Transdiagnostic psychiatry: a systematic review

The usefulness of current psychiatric classification, which is based on ICD/DSM categorical diagnoses, remains questionable. A promising alternative has been put forward as the "transdiagnostic" approach. This is expected to cut across existing categorical diagnoses and go beyond them, to improve the way we classify and treat mental disorders. This systematic review explores whether self-defining transdiagnostic research meets such high expectations. A multi-step Web of Science literature search was performed according to an a priori protocol, to identify all studies that used the word "transdiagnostic" in their title, up to May 5, 2018. Empirical variables which indexed core characteristics were extracted, complemented by a bibliometric and conceptual analysis. A total of 111 studies were included. Most studies were investigating interventions, followed by cognition and psychological processes, and neuroscientific topics. Their samples ranged from 15 to 91,199 (median 148) participants, with a mean age from 10 to more than 60 (median 33) years. There were several methodological inconsistencies relating to the definition of the gold standard (DSM/ICD diagnoses), of the outcome measures and of the transdiagnostic approach. The quality of the studies was generally low and only a few findings were externally replicated. The majority of studies tested transdiagnostic features cutting across different diagnoses, and only a few tested new classification systems beyond the existing diagnoses. About one fifth of the studies were not transdiagnostic at all, because they investigated symptoms and not disorders, a single disorder, or because there was no diagnostic information. The bibliometric analysis revealed that transdiagnostic research largely restricted its focus to anxiety and depressive disorders. The conceptual analysis showed that transdiagnostic research is grounded more on rediscoveries than on true innovations, and that it is affected by some conceptual biases. To date, transdiagnostic approaches have not delivered a credible paradigm shift that can impact classification and clinical care. Practical "TRANSD"iagnostic recommendations are proposed here to guide future research in this field.

Application of a transdiagnostic treatment for emotional disorders to body dysmorphic disorder: A randomized controlled trial

BACKGROUND

Body dysmorphic disorder (BDD) is a common disorder which is associated with a high rate of comorbidity and functional impairment. Although research shows that cognitive-behavioral therapy can be an efficacious treatment for BDD, there is growing evidence that dysregulated emotion is a core deficit. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) is a transdiagnostic, emotion focused cognitive-behavioral therapy protocol that has been developed to target emotion regulation processes that play an important role in the development and maintenance of many emotional disorders METHODS: : In the present study, 128 patients meeting criteria for BDD were randomized to either the UP (n = 64) or waitlist/treatment-as-usual (WL/TAU) condition. Diagnoses were determined using semi-structural interviews and patients also completed the Brown Assessment of Beliefs Scale (BABS), the Appearance Anxiety Inventory (AAI), the Difficulties in Emotion Regulation Scale (DERS), the Beck Depression Inventory (BDI) and the Clinical Global Impression (CGI).

RESULTS

Repeated measure ANOVA indicated that the UP significantly decreased depression, BDD symptoms and body-related anxiety, as well as significantly improving emotional regulation all with large effect sizes compared to the TAU/WL condition. Treatment gains as well as remission of comorbid conditions were maintained at the three-month follow-up.

LIMITATIONS

Our study limitations include restricted follow-up periods and excluding participants who were actively suicidal.

CONCLUSIONS

To our knowledge, this is the first examination of the UP for BDD, and results suggest that this disorder shares common mechanisms with other disorders of emotion, and that the UP may be an additional efficacious treatment for this condition.

An ARFID case report combining family-based treatment with the unified protocol for Transdiagnostic treatment of emotional disorders in children

BACKGROUND

This case report discusses the presentation and treatment of a nine-year-old female with a history of significant weight loss and food refusal using a combined approach of Family-Based Treatment (FBT) and the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C).

CASE PRESENTATION

The patient was diagnosed with avoidant/restrictive food intake disorder (ARFID), separation anxiety disorder, and a specific phobia of choking, and subsequently treated with a modified version of FBT, in conjunction with the UP-C. At the end of treatment, improvements were seen in the patient's weight and willingness to eat a full range of foods. Decreases in anxiety regarding eating/choking, fears of food being contaminated with gluten, and fears of eating while being away from parents were also observed.

CONCLUSIONS

These findings highlight promising results from this combined treatment approach, referred to as FBT + UP for ARFID. Further research is needed to evaluate the use of this treatment in patients presenting with a variety of ARFID symptoms.

The unified protocol for anxiety and depression with comorbid borderline personality disorder: a single case design clinical series

This study used a single case experimental design to investigate the use of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) among a sample of individuals with depression and anxiety who also presented with borderline personality disorder (BPD). Eight women received individual treatment with the UP over the course of 14–16 treatment sessions, and were assessed for anxiety and depression severity on a weekly basis over a 2–6 week baseline period and throughout treatment. Three of the eight participants demonstrated reliable pre- to post-treatment clinical improvements on depression and stress scales, and one participant demonstrated a reliable reduction on an anxiety scale. Two participants demonstrated a reliable improvement in overall anxiety. The results indicate that the UP applied to individuals diagnosed with primary BPD may lead to clinical improvement in depression, stress and anxiety for some individuals. However, the majority of individuals with BPD in our sample did not show strong improvement, and this suggests the need for additional sessions of UP or an intervention that focuses on the symptoms of BPD specifically for some women.

Key learning aims

(1)

Anxiety Sensitivity and Distress Tolerance Typologies and Relations to Posttraumatic Stress Disorder: A Cluster Analytic Approach

A growing literature suggests a relationship between a high anxiety sensitivity (AS; the fear of anxiety and its related consequences)/low distress tolerance (DT; the capacity tolerate internal negative states) profile and posttraumatic stress disorder (PTSD) symptoms. However, specific profiles have not been identified or examined specifically in veteran samples. Thus, the aims of the present study were to establish empirically derived profiles created from response patterns on the Anxiety Sensitivity Index and Distress Tolerance Scale and to examine associations with PTSD symptom clusters among a sample of combat-exposed veterans (N = 250). A cluster analytic approach was utilized to identify AS/DT profiles, and a series of MANOVAs with post hoc analyses was conducted to examine the relationship between each AS/DT profile and each PTSD symptom cluster. Results indicated a three-cluster solution including a high AS/low DT "at risk" profile, a low AS/high DT "resilient" profile, and an average AS/DT "intermediate" profile. The at-risk profile was associated with significantly greater symptoms in each PTSD cluster (i.e., hyperarousal, avoidance, re-experiencing) when compared to the other two profiles. The at-risk profile was also associated with greater depressive symptoms and lower self-reported resilience. These findings extend the previous literature by identifying a high AS/low DT "at risk" profile and its associations with PTSD symptoms, underscoring the potential utility in targeting these affect-regulation constructs for clinical intervention.

A randomized clinical trial of the Unified Protocol for Transdiagnostic treatment of emotional and gastrointestinal symptoms in patients with irritable bowel syndrome: evaluating efficacy and mechanism of change

OBJECTIVE

The aim of this randomized controlled trial was to evaluate the efficacy of Unified Protocol (UP) for transdiagnostic treatment of psychological problems, such as anxiety, depression, and stress, and treating the intensity of gastrointestinal symptoms in individuals with Irritable Bowel Syndrome (IBS). Another aim of the study was to test whether emotion regulation mediates the effect of UP.

METHODS

Among 91 patients diagnosed with IBS (using ROME III criteria), 64 patients were eligible to participate in the study based on the inclusion/exclusion criteria. These patients were randomly assigned to either an intervention group (n = 32) that participated in 12 weekly UP treatment sessions or to a wait-list control group (n = 32). All patients completed the Depression, Anxiety, and Stress Scale (DASS-42), Emotion Regulation Questionnaire (ERQ), and Gastrointestinal Symptoms Rating Scale (GSRS) pre- and post-intervention. The data were analyzed with SPSS 20.0 software.

RESULTS

The results of intention-to-treat (ITT) analysis indicated a significant decrease in depression, anxiety, stress, and gastrointestinal symptoms, as well as significant improvements in emotion regulation scores in the intervention group post intervention. All results were significant at P < .001. Mediation analyses indicated that changes in emotion regulation mediated the effect of UP on changes in emotional and gastrointestinal symptoms.

CONCLUSION

UP was effective and influential in emotion regulation among the intervention group and caused a decline in emotional and gastrointestinal symptoms. Hence, this intervention is promising, but larger RCTs are needed to more investigate its efficacy. Future studies could also examine the efficacy of the UP in other medical conditions with co-occurring psychological conditions. The study is registered at the irct.ir database under registration number IRCT2017010431765N1.

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.

The Effectiveness of Transdiagnostic Cognitive Behavioral Therapy for Comorbid Insomnia: A Case Report

Objective: Similar cognitive and behavioral factors underlie and perpetuate insomnia and emotional disorders. This brief case report aims to evaluate the effectiveness of the Unified Protocol (UP), a transdiagnostic treatment designed to target emotional disorders in treating comorbid insomnia. Method: The patient was a 32-year-old male, who met the DSM-IV-TR criteria for chronic insomnia, major depressive disorder, and generalized anxiety disorder. After 3 baseline weeks, the patient underwent 14 sessions of UP and was retested after 1-month follow-up. Consensus Sleep Diary (CSD), Insomnia Severity Index (ISI), and Pittsburgh Sleep Quality Index (PSQI) were completed during baseline, treatment, and follow-up. Results: The treatment led to improvements in sleep onset latency, time awake after sleep onset, terminal awakenings, sleep quality, and insomnia severity. These gains were maintained at 1-month follow-up. Conclusion: UP is effective in improving different symptoms of chronic insomnia. Controlled clinical studies with more cases are required to investigate the effects of UP in the treatment of insomnia.

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

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

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

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

Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC)

The diagnosis of mental disorder initially appears relatively straightforward: Patients present with symptoms or visible signs of illness; health professionals make diagnoses based primarily on these symptoms and signs; and they prescribe medication, psychotherapy, or both, accordingly. However, despite a dramatic expansion of knowledge about mental disorders during the past half century, understanding of their components and processes remains rudimentary. We provide histories and descriptions of three systems with different purposes relevant to understanding and classifying mental disorder. Two major diagnostic manuals—the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders—provide classification systems relevant to public health, clinical diagnosis, service provision, and specific research applications, the former internationally and the latter primarily for the United States. In contrast, the National Institute of Mental Health’s Research Domain Criteria provides a framework that emphasizes integration of basic behavioral and neuroscience research to deepen the understanding of mental disorder. We identify four key issues that present challenges to understanding and classifying mental disorder: etiology, including the multiple causality of mental disorder; whether the relevant phenomena are discrete categories or dimensions; thresholds, which set the boundaries between disorder and nondisorder; and comorbidity, the fact that individuals with mental illness often meet diagnostic requirements for multiple conditions. We discuss how the three systems’ approaches to these key issues correspond or diverge as a result of their different histories, purposes, and constituencies. Although the systems have varying degrees of overlap and distinguishing features, they share the goal of reducing the burden of suffering due to mental disorder.

Transdiagnostic Therapy

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

A comprehensive model of predictors of persistence and recurrence in adults with major depression: Results from a national 3-year prospective study

Identifying predictors of persistence and recurrence of depression in individuals with a major depressive episode (MDE) poses a critical challenge for clinicians and researchers. We develop using a nationally representative sample, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 34,653), a comprehensive model of the 3-year risk of persistence and recurrence in individuals with MDE at baseline. We used structural equation modeling to examine simultaneously the effects of four broad groups of clinical factors on the risk of MDE persistence and recurrence: 1) severity of depressive illness, 2) severity of mental and physical comorbidity, 3) sociodemographic characteristics and 4) treatment-seeking behavior. Approximately 16% and 21% of the 2587 participants with an MDE at baseline had a persistent MDE and a new MDE during the 3-year follow-up period, respectively. Most independent predictors were common for both persistence and recurrence and included markers for the severity of the depressive illness at baseline (as measured by higher levels on the general depressive symptom dimension, lower mental component summary scores, prior suicide attempts, younger age at onset of depression and greater number of MDEs), the severity of comorbidities (as measured by higher levels on dimensions of psychopathology and lower physical component summary scores) and a failure to seek treatment for MDE at baseline. This population-based model highlights strategies that may improve the course of MDE, including the need to develop interventions that target multiple psychiatric disorders and promotion of treatment seeking to increase access to timely mental health care.

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

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

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

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