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

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

The fables of pity: Rousseau, Mandeville and the animal-fable

Copyright @ 2012 Edinburgh University PressPrompted by Derrida’s work on the animal-fable in eighteenth-century debates about political power, this article examines the role played by the fiction of the animal in thinking of pity as either a natural virtue (in Rousseau’s Second Discourse) or as a natural passion (in Mandeville’s The Fable of the Bees). The war of fables between Rousseau and Mandeville – and their hostile reception by Samuel Johnson and Adam Smith – reinforce that the animal-fable illustrates not so much the proper of man as the possibilities and limitations of a moral philosophy that is unable to address the political realities of the state

Evidence-based implementation practices applied to the intensive treatment of eating disorders: Summary of research and illustration of principles using a case example

Implementation of evidence‐based practices (EBPs) in intensive treatment settings poses a major challenge in the field of psychology. This is particularly true for eating disorder (ED) treatment, where multidisciplinary care is provided to a severe and complex patient population; almost no data exist concerning best practices in these settings. We summarize the research on EBP implementation science organized by existing frameworks and illustrate how these practices may be applied using a case example. We describe the recent successful implementation of EBPs in a community‐based intensive ED treatment network, which recently adapted and implemented transdiagnostic, empirically supported treatment for emotional disorders across its system of residential and day‐hospital programs. The research summary, implementation frameworks, and case example may inform future efforts to implement evidence‐based practice in intensive treatment settings.Published versio

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

Transmitted Drug Resistance in the CFAR Network of Integrated Clinical Systems Cohort: Prevalence and Effects on Pre-Therapy CD4 and Viral Load

Human immunodeficiency virus type 1 (HIV-1) genomes often carry one or more mutations associated with drug resistance upon transmission into a therapy-naïve individual. We assessed the prevalence and clinical significance of transmitted drug resistance (TDR) in chronically-infected therapy-naïve patients enrolled in a multi-center cohort in North America. Pre-therapy clinical significance was quantified by plasma viral load (pVL) and CD4+ cell count (CD4) at baseline. Naïve bulk sequences of HIV-1 protease and reverse transcriptase (RT) were screened for resistance mutations as defined by the World Health Organization surveillance list. The overall prevalence of TDR was 14.2%. We used a Bayesian network to identify co-transmission of TDR mutations in clusters associated with specific drugs or drug classes. Aggregate effects of mutations by drug class were estimated by fitting linear models of pVL and CD4 on weighted sums over TDR mutations according to the Stanford HIV Database algorithm. Transmitted resistance to both classes of reverse transcriptase inhibitors was significantly associated with lower CD4, but had opposing effects on pVL. In contrast, position-specific analyses of TDR mutations revealed substantial effects on CD4 and pVL at several residue positions that were being masked in the aggregate analyses, and significant interaction effects as well. Residue positions in RT with predominant effects on CD4 or pVL (D67 and M184) were re-evaluated in causal models using an inverse probability-weighting scheme to address the problem of confounding by other mutations and demographic or risk factors. We found that causal effect estimates of mutations M184V/I ( pVL) and D67N/G ( and pVL) were compensated by K103N/S and K219Q/E/N/R. As TDR becomes an increasing dilemma in this modern era of highly-active antiretroviral therapy, these results have immediate significance for the clinical management of HIV-1 infections and our understanding of the ongoing adaptation of HIV-1 to human populations

Measurement of the WW Boson Mass

A measurement of the mass of the $W$ boson is presented based on a sample of 5982 $W \rightarrow e \nu$ decays observed in $p\overline{p}$ collisions at $\sqrt{s}$ = 1.8~TeV with the D\O\ detector during the 1992--1993 run. From a fit to the transverse mass spectrum, combined with measurements of the $Z$ boson mass, the $W$ boson mass is measured to be $M_W = 80.350 \pm 0.140 (stat.) \pm 0.165 (syst.) \pm 0.160 (scale) GeV/c^2$.Comment: 12 pages, LaTex, style Revtex, including 3 postscript figures (submitted to PRL

Direct Measurement of the Top Quark Mass at D0

We determine the top quark mass m_t using t-tbar pairs produced in the D0 detector by \sqrt{s} = 1.8 TeV p-pbar collisions in a 125 pb^-1 exposure at the Fermilab Tevatron. We make a two constraint fit to m_t in t-tbar -> b W^+bbar W^- final states with one W boson decaying to q-qbar and the other to e-nu or mu-nu. Likelihood fits to the data yield m_t(l+jets) = 173.3 +- 5.6 (stat) +- 5.5 (syst) GeV/c^2. When this result is combined with an analysis of events in which both W bosons decay into leptons, we obtain m_t = 172.1 +- 5.2 (stat) +- 4.9 (syst) GeV/c^2. An alternate analysis, using three constraint fits to fixed top quark masses, gives m_t(l+jets) = 176.0 +- 7.9 (stat) +- 4.8 (syst) GeV/C^2, consistent with the above result. Studies of kinematic distributions of the top quark candidates are also presented.Comment: 43 pages, 53 figures, 33 tables. RevTeX. Submitted to Phys. Rev.

Measurement of Dijet Angular Distributions and Search for Quark Compositeness

We have measured the dijet angular distribution in $\sqrt{s}$=1.8 TeV $p\bar{p}$ collisions using the D0 detector. Order $\alpha^{3}_{s}$ QCD predictions are in good agreement with the data. At 95% confidence the data exclude models of quark compositeness in which the contact interaction scale is below 2 TeV.Comment: 11 pages, Latex, 3 postscript figure

Limits on Anomalous WWgamma and WWZ Couplings

Limits on the anomalous WWgamma and WWZ couplings are presented from a simultaneous fit to the data samples of three gauge boson pair final states in pbar-p collisions at sqrt(s)=1.8 TeV: Wgamma production with the W boson decaying to enu or munu, W boson pair production with both of the W bosons decaying to enu or munu, and WW or WZ production with one W boson decaying to enu and the other W boson or the Z boson decaying to two jets. Assuming identical WWgamma and WWZ couplings, 95 % C.L. limits on the anomalous couplings of -0.30<Delta kappa<0.43 (lambda = 0) and -0.20<lambda<0.20 (Delta kappa = 0) are obtained using a form factor scale Lambda = 2.0 TeV. Limits found under other assumptions on the relationship between the WWgamma and WWZ couplings are also presented.Comment: 13 pages, 3 figures, submitted to Physical Review