Experiential avoidance as a mechanism of change across cognitive-behavioral therapy in a sample of participants with heterogeneous anxiety disorders

Despite the substantial evidence that supports the efficacy of cognitive-behavioral therapy for the treatment of anxiety and related disorders, our understanding of mechanisms of change throughout treatment remains limited. The goal of the current study was to examine changes in experiential avoidance across treatment in a sample of participants (N = 179) with heterogeneous anxiety disorders receiving various cognitive-behavioral therapy protocols. Univariate latent growth curve models were conducted to examine change in experiential avoidance across treatment, followed by parallel process latent growth curve models to examine the relationship between change in experiential avoidance and change in anxiety symptoms. Finally, bivariate latent difference score models were conducted to examine the temporal precedence of change in experiential avoidance and change in anxiety. Results indicated that there were significant reductions in experiential avoidance across cognitive-behavioral treatment, and that change in experiential avoidance was significantly associated with change in anxiety. Results from the latent difference score models indicated that change in experiential avoidance preceded and predicted subsequent changes in anxiety, whereas change in anxiety did not precede and predict subsequent changes in experiential avoidance. Taken together, these results provide additional support for reductions in experiential avoidance as a transdiagnostic mechanism in cognitive-behavioral therapy.First author draf

Examining hope as a transdiagnostic mechanism of change across anxiety disorders and CBT treatment protocols.

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.R01 MH090053 - NIMH NIH HHSAccepted manuscrip

Current definitions of “transdiagnostic” in treatment development: A search for consensus

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

Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: an investigation of mediation

Patients’ outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Client workbook, Oxford University Press, New York, 2011a; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Patient workbook. New York: Oxford University Press, 2017b) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP vs. SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance [B = 0.037, SE = 0.05, 95% CI (.005, 0.096)]. Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.This study was funded by grant R01 MH090053 from the National Institutes of Health. (R01 MH090053 - National Institutes of Health)First author draf

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 (ESɢ: UP = −1.72; SDP = −1.98), social anxiety (ESɢ: UP = −1.33, −0.86; SDP = −1.60, −1.54), and depression (ESɢ: 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.Please note the following financial disclosures/conflicts of interest: Dr. Barlow reported receiving royalties from Oxford University Press, United Kingdom (which includes royalties for the treatment manuals included in this study); Guilford Publications Inc., United States; Cengage Learning, United States; Pearson Publishing, United Kingdom. He reported receiving grants from the National Institute of Mental Health, United States (R01 MH090053) and the National Institute of Alcohol and Alcohol Abuse, United States (R01 AA023676). He reported serving as a consultant for and receiving honoraria from the Agency for Healthcare Research and Quality, United States; the Foundation for Informed Medical Decision Making, United States; the Department of Defense, United States; the Renfrew Center, United States; the Chinese University of Hong Kong, Hong Kong;Universidad Catolica de Santa Maria, Peru); New Zealand Psychological Association, New Zealand; Hebrew University of Jerusalem, Israel; Mayo Clinic, United States; and various American universities. (R01 MH090053 - National Institute of Mental Health, United States; R01 AA023676 - National Institute of Alcohol and Alcohol Abuse, United States)Accepted manuscrip

Telehealth cognitive behavioral therapy for depression in Parkinson’s disease: a case study

Parkinson's disease (PD) is characterized as a motor disorder, but the majority of individuals with PD also suffer from nonmotor symptoms, including mental health difficulties, such as depression, anxiety, and apathy, as well as decreased cognitive function, daily function, sleep quality, and quality of life. Cognitive behavioral therapy (CBT) is an effective treatment for depression in PD, but motor disability, work schedule, transportation issues, and care partner burden may cause difficulty in attending weekly face-to-face therapy sessions. A promising avenue in the delivery of CBT is telehealth. CBT administered live via videoconference technology may circumvent many of the barriers that prevent those with PD from receiving treatment. This case study evaluates the preliminary efficacy, feasibility, and acceptability of 12-week telehealth CBT for depression in PD. CBT administered via telehealth was feasible, acceptable, and efficacious for a study participant with PD and major depressive disorder. In addition to effectively treating depression, the telehealth intervention improved quality of life and aspects of cognitive functioning, as well as symptoms of anxiety, apathy, and subjective cognitive impairment, all of which are prevalent nonmotor symptoms of PD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).American Parkinson Disease AssociationAccepted manuscrip

Development of a single-session, transdiagnostic preventive intervention for young adults at risk for emotional disorders

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.Accepted manuscrip

Treating depressive disorders with the unified protocol: A preliminary randomized evaluation.

OBJECTIVES: This study aims to examine the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) for individuals diagnosed with a depressive disorder. METHOD: Participants included 44 adults who met criteria for major depressive disorder, persistent depressive disorder, or another specified depressive disorder according to the Anxiety Disorder Interview Schedule (ADIS). These individuals represent a subset of patients from a larger clinical trial comparing the UP to single-disorder protocols (SDPs) for discrete anxiety disorders and a waitlist control (WLC) condition (Barlow et al., 2017); inclusion criteria for the parent study required participants to have a principal anxiety disorder. RESULTS: Significant reductions in depressive symptoms were observed within the UP condition across clinician-rated and self-report measures of depression from baseline to post-treatment, as well as to the 12-month follow-up assessment. Compared to the WLC group, individuals in the UP condition demonstrated significantly lower levels on our continuous, clinician-rated measure of depressive symptoms at post-treatment. There were no differences between the UP and SDP conditions on depressive symptoms at post-treatment or at the 12-month follow-up timepoint. CONCLUSIONS: In this exploratory set of analyses, the UP evidenced efficacy for reduction of depressive symptoms, adding to the growing support for its utility in treating depression.R01 MH090053 - NIMH NIH HHSAccepted manuscrip

The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders a randomized clinical trial

IMPORTANCE: Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments. OBJECTIVE: To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders. DESIGN, SETTING, AND PARTICIPANTS: From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat. INTERVENTIONS: The UP or SDPs. MAIN OUTCOMES AND MEASURES: Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs. RESULTS: Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen d, −1.08; 95% CI, −1.43 to −0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-month follow-up (β, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. CONCLUSIONS AND RELEVANCE: The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders.This study was funded by grant R01 MH090053 from the National Institute of Mental Health. (R01 MH090053 - National Institute of Mental Health)First author draf

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

Despite substantial evidence supporting the efficacy of cognitive behavioral therapy for reducing many forms of mental illness, less is known about whether CBT also promotes mental health or well being. We will discuss results of a recent study (Gallagher et al., 2019) examining changes in well being d uring different CBT treatments for anxiety disorders and how these changes relate to anxiety. In that study, 223 adults (55.6% female, Mage=31.1 yrs) were randomized to one of five CBT protocols for anxiety disorders at an outpatient clinic. Effect sizes w ere calculated to examine the timing and magnitude of changes in well being as a result of CBT. Further, parallel process latent growth curve models were conducted to examine the extent to which trajectories of changes in well being correlated with the tra jectories of change in both clinician rated and self reported anxiety during active treatment. Results indicated that there were moderate to large increases in overall well being and the three components of subjective, psychological, and social well being, mainly during the second half of CBT, and these increases were maintained at a 6 month follow up. Further, trajectories of change in well being across treatment were strongly correlated with trajectories of change in clinician rated and self reported anxi ety. Together, these findings suggest that different CBT protocols for anxiety consistently produce robust and lasting changes in different domains of positive mental health and increases in well being are strongly linked to changes in anxiety during treatment.Published versio