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

BACKGROUND Comorbid anxiety in bipolar disorder (BD) is associated with greater illness severity, reduced treatment response, and greater impairment. Treating anxiety in the context of BD is crucial for improving illness course and outcomes. The current study examined the feasibility, acceptability and preliminary efficacy of the Unified Protocol (UP), a transdiagnostic cognitive behavioral therapy, as an adjunctive treatment to pharmacotherapy for BD and comorbid anxiety disorders. METHODS Twenty-nine patients with BD and at least one comorbid anxiety disorder were randomized to pharmacotherapy treatment-as-usual (TAU) or TAU with 18 sessions of the UP (UP+TAU). All patients completed assessments every four weeks to track symptoms, functioning, emotion regulation and temperament. Linear mixed-model regressions were conducted to track symptom changes over time and to examine the relationship between emotion-related variables and treatment response. RESULTS Satisfaction ratings were equivalent for both treatment groups. Patients in the UP+TAU group evidenced significantly greater reductions over time in anxiety and depression symptoms (Cohen's d's>0.80). Baseline levels of neuroticism, perceived affective control, and emotion regulation ability predicted magnitude of symptom change for the UP+TAU group only. Greater change in perceived control of emotions and emotion regulation skills predicted greater change in anxiety related symptoms. LIMITATIONS This was a pilot feasibility and acceptability trial; results should be interpreted with caution. CONCLUSIONS Treatment with the UP+TAU was rated high in patient satisfaction, and resulted in significantly greater improvement on indices of anxiety and depression relative to TAU. This suggests that the UP may be a feasible treatment approach for BD with comorbid anxiety.This work was supported by a Postdoctoral National Research Service Award from the National Institutes of Health [F32 MH098490] to K. Ellard. (F32 MH098490 - Postdoctoral National Research Service Award from the National Institutes of Health)Accepted manuscrip

Neural correlates of emotion acceptance vs worry or suppression in generalized anxiety disorder

Recent emotion dysregulationmodels of generalized anxiety disorder (GAD) propose chronic worry in GAD functions as a maladaptive attempt to regulate anxiety related to uncertain or unpredictable outcomes. Emotion acceptance is an adaptive emotion regulation strategy increasingly incorporated into newer cognitive behavioral therapy (CBT) approaches to GAD to counter chronic worry. The current study explores themechanisms of emotion acceptance as an alternate emotion regulation strategy to worry or emotion suppression using functionalmagnetic resonance imaging. Twenty-one female participants diagnosed with GAD followed counterbalanced instructions to regulate responses to personally relevant worry statements by engaging in either emotion acceptance, worry or emotion suppression. Emotion acceptance resulted in lower ratings of distress than worry and was associated with increased dorsal anterior cingulate cortex (dACC) activation and increased ventrolateral prefrontal cortex (VLPFC)-amygdala functional connectivity. In contrast, worry showed significantly greater distress ratings than acceptance or suppression and was associated with increased precuneus, VLPFC, amygdala and hippocampal activation. Suppression did not significantly differ fromacceptance in distress ratings or amygdala recruitment, but resulted in significantly greater insula and VLPFC activation and decreased VLPFC-amygdala functional connectivity. Emotion acceptance closely aligned with activation and connectivity patterns reported in studies of contextual extinction learning and mindful awareness.National Institute of Mental Health (U.S.) (Grant F31 MH084422

An examination of the neural correlates of emotion acceptance versus worry in generalized anxiety disorder

Thesis (Ph.D.)--Boston University PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at [email protected]. Thank you.Worry in generalized anxiety disorder (GAD) has been conceptualized as an emotion regulation strategy whereby distress triggered by uncertain outcomes is temporarily avoided through internal verbalizations and associated reductions in autonomic arousal. However, worry is ineffective, as subsequent exposure to worry topics elicits continued distress and generalizes to new topics. One potential mechanism by which worry may perpetuate distress is by preventing the development of greater tolerance of internal distress. By contrast, acceptance as an emotion regulation strategy is associated with reduced distress and increased willingness to re-engage in previously distressing tasks. Acceptance may exert its influence by keeping patients in contact with internal distress and preventing avoidance, allowing for repeated exposure and the subsequent development of greater distress tolerance. The present study used functional magnetic resonance imaging to explore neural mechanisms ofworry and acceptance in a sample of21 women meeting DSM-IV criteria for GAD. During scanning, participants read personally relevant worry statements, and were presented with randomized instructions to observe and accept their reactions (Accept), worry as usual (Worry), or suppress reactions (Suppress). Participants were then randomized to receive either brief training in acceptance-based regulation strategies, or no training. Pre-training, the Worry condition was associated with increased limbic (amygdala, insula, hippocampus) and ventromedial prefrontal cortex (vmPFC) activation relative to both the Accept and Suppress conditions, whereas the Accept condition was associated with greater dorsomedial PFC (dmPFC) activation, and the Suppress condition was associated with greater dorsolateral PFC activation. Following training in emotion acceptance, the Training group evidenced significant reductions in amygdala and hippocampus activation in the Worry condition. These results were not found in the No-Training group. Additionally, decreased activation in the Worry and Accept conditions was found in the Training group relative to No-Training in the subgenual anterior cingulate, a vmPFC region implicated in extinction learning. Decreased activation in this region was significantly correlated with participant ratings of lower subjective distress and greater regulation success. Results ofthis study suggest potential mechanisms by which emotion acceptance may exert effects in the regulation of distress are through neural pathways implicated in both cognitive control and extinction learning

Moving On From Here—Recognizing Your Accomplishments and Looking to Your Future

Chapter 14 concludes the treatment program and reviews the key concepts and skills that have been learned. The progress that has been made is evaluated, and suggestions for developing a practice plan, being your own therapist, forming long-term goals, maintaining progress and managing setbacks are made

Maintaining Motivation and Setting Goals for Treatment

Chapter 4 discusses how to maintain motivation and set goals for the treatment program. An exercise in decisional balance is outlined, as well as the process of setting manageable goals for treatment

Understanding Your Emotions

Chapter 5 provides details on understanding your emotions, a rationale for placing a focus on emotions, the purposes of emotions such as fear, sadness/depression, anxiety, and anger. The different components of emotional experiences (cognitive, behavioral, and physiological) are also explored

Understanding Behaviors 1: Avoiding Your Emotions

Chapter 9 discusses how to understand behaviors of emotion avoidance. Emotion avoidance is introduced, followed by types of emotion avoidance strategies (subtle behavioral avoidance, cognitive avoidance strategies, the use of safety signals) and a demonstration exercise of emotion avoidance strategies

Putting It into Practice: Facing Your Emotions in the Situations in which They Occur

Chapter 12 discusses methods of putting what has been learned throughout the therapy sessions into practice and facing your emotions in the situations in which they occur. Emotion exposures are introduced (situationally-based, imaginal, and physical sensation exposures) along with methods for practicing emotion exposures, and key pointers to remember about exposure practice

Understanding Behaviors 2: Emotion-Driven Behaviors

Chapter 10 outlines how to understand emotion-driven behaviors (EDBs), including what EDBs are, examples of EDBs, how EDBs maintain the emotional response, and methods of countering patterns of avoidance and EDBs (adopting patterns of approach as opposed to avoidance, the power of alternative action

Recognizing and Tracking Your Emotional Responses

Chapter 6 encourages the client to recognise and track their emotional responses, using the ARC model to monitor emotional experiences. Learned behaviors are also explored