Transdiagnostic Cognitive-behavioral Treatment Research Articles

Factors Associated with Prospective Acceptability and Preferences for Unified Transdiagnostic Cognitive-Behavioral Treatments and Group Therapy in the Portuguese General Population

Group transdiagnostic cognitive-behavioral therapy (CBT) offers a promising solution for limited mental health access in Portugal. Understanding barriers to patient adherence is crucial for successful implementation. This study aimed to characterize the prospective acceptability and preferences for unified transdiagnostic CBT and group therapy in the Portuguese general population and explore their correlates. A sample of 243 participants (18–88 years old), recruited online, completed an online survey collecting information on sociodemographic and clinical characteristics, acceptability of transdiagnostic CBT treatments, specifically of Unified Protocol (UP), acceptability of group therapy, therapeutic format preferences, beliefs about group therapy and help-seeking attitudes. Most participants were receptive to and perceived as useful both unified transdiagnostic CBT and group therapy. Overall, participants presented significantly more favorable attitudes than unfavorable attitudes toward unified transdiagnostic CBT and group therapy (p < .001). Multivariate analyses revealed that (1) favorable attitudes toward transdiagnostic treatments were negatively associated with being employed and positively associated with living in an urban area, and higher efficacy scores; (2) unfavorable attitudes toward transdiagnostic treatments were positively associated with being married/cohabitating and negatively associated with vulnerability scores; (3) being female, living in an urban area, and higher efficacy and myth scores emerged as positive predictors of favorable attitudes toward group therapy; and (4) efficacy and vulnerability scores and help-seeking propensity emerged as negative predictors of unfavorable attitudes toward group therapy. These findings highlight the importance of delineating strategies to increase knowledge and acceptance of unified transdiagnostic CBT and group therapy in the Portuguese population, addressing specific individual characteristics.

The Feasibility and Efficacy of a Group-Based, Brief Transdiagnostic Cognitive-Behavioral Treatment for Adolescents with Internalizing Problems.

The present study aimed to assess the efficacy of a group-based, brief transdiagnostic cognitive-behavioral therapy (CBT) program for adolescents with internalizing problems, such as anxiety and depressive disorders, seeking help in a primary health care clinic in Iceland. The group-based CBT program consisted of eight weekly 110-min sessions covering psychoeducation, cognitive restructuring, behavioral activation, exposure, problem-solving, social skills, and mindfulness. The study recruited 53 participants, who were randomly assigned to either receive the group treatment or be placed on a wait-list for monitoring purposes. Measures were taken at baseline, during treatment (week 4), at posttreatment (week 8), and at 2-, 4-month, and 1-year follow-ups. The primary outcome measures were the self-reported total scores of total anxiety and depression using the Revised Children's Anxiety and Depression Scale (RCADS). The study found a significant effect of time and time * treatment interaction on the depression and anxiety total scores. The secondary outcome measures, RCADS parent-rated depression and anxiety total scores, did not show significant effects of time * treatment interaction. However, during naturalistic follow-up, a significant reduction in parent-reported depression and anxiety total scores was observed. The study also observed good treatment adherence, as well as high satisfaction among parents and youth. The results suggest that this group-based, brief transdiagnostic CBT group treatment is feasible and effective in reducing depressive and anxiety symptoms in adolescents with internalizing problems and highlights the importance of addressing comorbidity in treatment.

Adaptation of a Transdiagnostic Cognitive-Behavioral Treatment for Adolescents with Comorbid Mental Health Conditions and High Risk Behavior

ABSTRACT Millions of adolescents seek treatment for mental health concerns and high-risk behaviors (e.g., suicidality, non-suicidal self-injury, substance use) each year. Use of services for mental health crises have only increased since the onset of the COVID-19 pandemic. Evidence-based treatments that can be readily employed in community settings are sorely needed to address the growing adolescent mental health crisis. To be most effective, they must be able to accommodate the common comorbidity and high-risk behaviors present among the treatment-seeking adolescent population, and be designed in a manner that can be readily adopted by clinicians that serve these youth within community-based organizations. Following the Replicating Effective Programs (REP) framework, we describe the adaptation and pre-implementation process of a transdiagnostic and modular cognitive-behavioral treatment, which integrates motivational interviewing and dialectical behavior therapy techniques, to address multiple adolescent mental health conditions and high-risk behaviors. Using a mixed-methods design, we collected data from community clinicians and/or other stakeholders on perceptions of the training protocol and treatment manual, self-efficacy and knowledge in manual use, use of modules with clients, and treatment adherence, to inform our REP efforts around modifications to the training and treatment manual. We present these data and describe modifications made using the Framework for Reporting Adaptations and Modifications (FRAME) to evidence-based interventions. Overall, data support our intensive training model and transdiagnostic treatment for use by clinicians in community settings. Stakeholder engagement, adaptations to the training and treatment materials, and participation in post-training consultation, appeared to facilitate successful pre-implementation efforts.

ThinkSMART®: A pilot study of a transdiagnostic cognitive-behavioral treatment for adolescents with executive functioning weaknesses

Executive functions are a broad term used to describe the cognitive functions necessary to help individuals complete tasks and achieve goals. Executive functioning weaknesses are a hallmark feature of psychopathology, particularly in youth. These weaknesses are associated with chronic impairment across academic, social and family domains and do not typically improve into adulthood. Despite these negative outcomes, few behavioral interventions have been successfully developed to target executive functioning outside of ADHD, particularly in adolescents with various types of psychopathology. The thinkSMART® program was created to target the broad heterogeneity of adolescents with executive function weakness. We discuss the rationale for the development of the program, as well as outline the primary skill areas addressed. We also present an open-trial pilot study using the program in adolescents ages 12–17 who identify as having executive functioning weaknesses. Preliminary findings highlight the acceptability and feasibility of the program, as well as the initial efficacy in improving adolescents’ day-to-day executive functioning. We discuss the limitations and benefits of providing broad skills and compensatory strategies to improve adolescent executive functioning.

The Nature, Timing, and Symptom Trajectories of Dropout From Transdiagnostic and Single-Diagnosis Cognitive-Behavioral Therapy for Anxiety Disorders

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.

A transdiagnostic minority stress intervention for gender diverse sexual minority women's depression, anxiety, and unhealthy alcohol use: A randomized controlled trial.

To remedy the notable gap in evidence-based treatments for sexual minority women, this study tested the efficacy of a minority-stress-focused cognitive-behavioral treatment intended to improve this population's mental and behavioral health. The intervention, EQuIP (Empowering Queer Identities in Psychotherapy), was adapted from a transdiagnostic cognitive-behavioral treatment as also recently adapted for sexual minority men. Sexual minority women at risk of mental and behavioral health problems (n = 19) and expert providers with this population (n = 12) shaped the treatment's development, including by supporting its primary focus on universal and minority-stress-focused processes underlying this population's disproportionately poor mental and behavioral health. The resulting treatment was then delivered to young adult sexual minority women (n = 60; M age = 25.58; 41.67% racial/ethnic minority; 43.33% transgender/nonbinary) experiencing depression/anxiety and past 90-day heavy alcohol use. Compared to waitlist (n = 30), participants randomized to immediately receive EQuIP (n = 30) experienced significantly reduced depression and anxiety (d = 0.85, 0.86, respectively); effects for alcohol use problems were smaller (d = 0.29) and marginally significant. In pre- to post-intervention pooled analyses, effect sizes for minority stress processes (mean d = .25) and universal risk factors (mean d = .48), through which the treatment was expected to work, were small and moderate, respectively, and in the expected direction. This study provides initial support for a minority-stress-focused transdiagnostic cognitive-behavioral treatment for sexual minority women. These first results can launch exploration of other mechanisms and modalities through which to equip this population with evidence-based support. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Applying a Transdiagnostic Cognitive-Behavioral Treatment to Adolescents at High Risk for Serious Mental Illness: Rationale and Preliminary Findings

Given the chronic and deleterious course of serious mental illness (SMI; schizophrenia and bipolar disorder), significant efforts have been undertaken to improve prediction of SMI and provide treatment for adolescents in the early, putatively prodromal stage of these illnesses. While risk assessments and disorder-specific treatments for adolescents at risk for SMI have shown some efficacy, significant issues remain around disorder-specific treatments for these youth. There is substantial heterogeneity of psychopathology within adolescents at high risk for SMI that leads to many false-positives and varying diagnostic outcomes. As a result, initial treatment focusing on broad symptoms and skills has been proposed in place of disorder-specific treatments. We discuss the rationale for providing an already-developed and empirically supported transdiagnostic treatment for emotional disorders (termed the Unified Protocol) as a first-line staging of treatment for adolescents experiencing early SMI symptoms. Additionally, we outline the open trial we are piloting using this transdiagnostic treatment in adolescents between the ages of 13 – 17 who have begun experiencing distressing yet subsyndromal psychosis or bipolar mood symptoms. Preliminary findings suggest feasibility and acceptability as well as initial efficacy in improving psychiatric symptoms, quality of life, and difficulties regulating emotions. We also present case studies from our open trial. A unified, cognitive-behavioral treatment for early presentations of SMI has important clinical and public health benefits, including streamlining treatment and providing broad skills that are applicable to a wide range of psychopathology.

The new transdiagnostic cognitive behavioral treatments: Commentary for clinicians and clinical researchers

Recognition of the limitations of the current categorical diagnostic system and increased understanding of commonalities across clinical problems associated with negative emotion, including anxiety and depression, has led to the development of transdiagnostic psychological interventions. This new approach holds promise in shifting our emphasis from diagnostic categories to treating core construct that cut across disorders. This paper identifies some of the similarities and differences across various cognitive-behavioral transdiagnostic protocols and key challenges in assessment and case conceptualization for clinicians wishing to use this approach. Some key needs in the research literature that would be particularly helpful to clinicians are also identified.

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.

LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach.

We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual men's co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record

Purging Anxiety: A Case Study of Transdignostic CBT for a Complex Fear of Vomiting (Emetophobia)

Emetophobia is defined as a specific phobia of vomiting, currently diagnosed as specific phobia “other” type in DSM-5 (American Psychiatric Association, 2013). Though there is a dearth of research conducted on emetophobia and its treatment, there is limited data from case studies (Hunter & Antony, 2009; Maack, Deacon, & Zhao, 2013) and one open trial of group therapy (Ahlen, Edberg, Di Schiena, & Bergström, 2014), providing initial evidence regarding the efficacy of targeted cognitive-behavioral treatment (CBT) in treating emetophobia. To date, no study has evaluated transdiagnostic CBT for emetophobia. Given suggestions that emetophobia frequently has a complex presentation, which shares elements with multiple anxiety disorder diagnoses, including specific phobia, panic disorder, obsessive–compulsive disorder, and generalized anxiety disorder, (e.g., Boschen, 2007; Veale, 2009; Veale & Lambrou, 2006), a transdiagnostic approach could prove promising. Transdiagnostic CBT has exhibited success in treating a range of anxiety disorders (Reinholt & Krogh, 2014) and in reducing comorbid symptoms more effectively than diagnosis-specific CBT (Norton et al., 2013). It was expected that a transdiagnostic treatment approach would be beneficial in treating emetophobia due to the treatment’s flexibility in targeting multiple features of anxiety disorders concurrently.

The effects of venlafaxine and cognitive behavioral therapy alone and combined in the treatment of co-morbid alcohol use-anxiety disorders

The effects of the antidepressant venlafaxine (VEN-225 mg daily) and transdiagnostic cognitive behavioral treatment (CBT) alone and in combination on alcohol intake in subjects with co-morbid alcohol use disorders (AUDs) and anxiety disorders were compared. Drinking outcomes and anxiety were assessed for 81 subjects treated for 11 weeks with one of 4 conditions: 1) VEN–CBT, 2) VEN-Progressive Muscle Relaxation therapy (PMR), 3) Placebo (PLC)-CBT and 4) a comparison group of PLC-PMR. For subjects who reported taking at least one dose of study medication, the Time × Group interaction was significant for percent days of heavy drinking and drinks consumed per day. For the measure of percent days heavy drinking, the paired comparison of PLC-CBT versus PLC-PMR group indicated that the PLC-CBT group had greater drinking reductions, whereas other groups were not superior to the comparison group. In Week 11, the proportion of subjects in the PLC-CBT group that had a 50% reduction from baseline in percent days heavy drinking was significantly greater than those in the comparison group. Of the 3 “active treatment” groups only the PLC-CBT group had significantly decreased heavy drinking when contrasted to the comparison group. This finding suggests that the transdiagnostic CBT approach of Barlow and colleagues may have value in the management of heavy drinking in individuals with co-morbid alcoholism and anxiety.

Intervention strategies and clinical process in transdiagnostic cognitive–behavioral therapy.

A number of evidence-based cognitive-behavioral treatments (CBT) have been developed to target specific anxiety and mood disorders. Many in the field of psychotherapy have focused their attention toward the identification and consolidation of core treatment principles and mechanisms of change that cut across different treatment approaches and diagnostic categories. This focus has led to the development of transdiagnostic CBT treatments that aim to integrate common principles of human functioning and change strategies found in existing evidence-based CBT interventions for various disorders. The Unified Protocol (UP) is a transdiagnostic emotion-focused CBT treatment designed to be applicable to disorders that involve a prominent emotional component. This article describes three core intervention strategies typically used to facilitate clinical process (e.g., new learning) in the UP: (a) increasing emotional awareness, (b) encouraging repeated practice, and (c) providing opportunities for corrective experiences. Clinical examples, along with a brief discussion of the theoretical basis and research support for each of these intervention strategies, are provided.

Interpersonal predictors of early therapeutic alliance in a transdiagnostic cognitive-behavioral treatment for adolescents with anxiety and depression.

The importance of therapeutic alliance in predicting treatment success is well established, but less is known about client characteristics that predict alliance. This study examined alliance predictors in adolescents with anxiety and/or depressive disorders (n=31) who received a transdiagnostic cognitive-behavioral treatment, the Unified Protocol for the Treatment of Emotional Disorders in Youth (Ehrenreich, Buzzella, Trosper, Bennett, & Barlow, 2008) in the context of a larger randomized controlled trial. Alliance was assessed at session three by therapists, clients, and independent observers. Results indicated that alliance ratings across the three informant perspectives were significantly associated with one another, but that pretreatment interpersonal variables (e.g., social support, attachment security, and social functioning in current family and peer relationships) were differentially associated with varying informant perspectives. Adolescent and observer ratings of alliance were both predicted by adolescent self-reports on measures reflecting how they perceive their interpersonal relationships. In addition, adolescent-reported symptom severity at pretreatment predicted observer ratings of alliance such that adolescents who indicated greater anxiety and depressive symptoms were rated as having stronger early alliances by independent observers. Therapists perceived having weaker early alliances with adolescents evidencing clinically significant depression at intake as compared with adolescents diagnosed with anxiety disorders alone. Future research is needed to examine whether identification of relevant interpersonal factors at intake can help improve initial therapeutic engagement and resulting outcomes for the psychosocial treatment of adolescents with anxiety and depressive disorders.

A Randomized Clinical Trial of Transdiagnostic Cognitve-Behavioral Treatments for Anxiety Disorder by Comparison to Relaxation Training

Transdiagnostic cognitive-behavioral treatments (CBT) for anxiety disorders have been gaining increased attention and empirical study in recent years. Despite this, all of the research on transdiagnostic anxiety treatments to date have either not used a control condition, or have relied on no-treatment or delayed-treatment controls, thus limiting inferences about comparative efficacy. The current study was a randomized clinical trial examining the efficacy of a 12-week transdiagnostic cognitive-behavioral group treatment in comparison to a 12-week comprehensive relaxation training program. Results from 87 treatment initiators suggested significant and statistically equivalent/noninferior outcomes across conditions, although relaxation was associated with a greater rate of dropout despite no differences in treatment credibility. No evidence was found for any differential effects of transdiagnostic CBT for any primary or comorbid diagnoses.

Self-induced vomiting in eating disorders: Associated features and treatment outcome

Self-induced vomiting is adopted by people with a variety of eating disorders (ED) to control body shape and weight. We tested the prevalence, the associated features and the role on treatment outcome of self-induced vomiting in 152 ED patients consecutively admitted to an inpatient cognitive-behavioral treatment (CBT), based on the transdiagnostic CBT for ED. The Eating Disorder Examination, together with the Beck Depression Inventory, the State-Trait Anxiety Inventory and the Temperament and Character Inventory were recorded at entry and at end of treatment. Self-induced vomiting was reported in 35.5% of cases, and 21.1% had multiple purging with vomiting. Individuals with vomiting and those with multiple purging had significantly higher BMI and a higher frequency of bulimic episodes, but individuals with multiple purging were also characterized by higher levels of depression, longer ED duration, more severe ED psychopathology and lower self-directness. Individuals with vomiting had higher eating concern and novelty seeking compared with those without purging behaviors. However, the three groups had similar dropout rates and outcomes in response to inpatient CBT, in keeping with the transdiagnostic theory of EDs.

Transdiagnostic Group CBT for Anxiety: Clinical Experience and Practical Advice

Cognitive-behavioral treatments (CBT) for the six anxiety disorders are potent, but only a small portion of patients receive them. Among several factors limiting their broad dissemination is the diagnostically specific nature of CBT for anxiety; the multiplicity of protocols makes them ill-suited for many mental health programs. This article describes the development of a transdiagnostic treatment approach for anxiety disorders as one way to close the dissemination gap. In particular, we describe our experience with two generations of mixed anxiety groups, where our previous controlled and uncontrolled studies found medium effect sizes within the range of effect sizes found with diagnosis-specific treatments. We also describe lessons learned from the two protocols, which may be of value in the development of transdiagnostic approaches.

Transdiagnostic Cognitive-Behavioral Treatments for Mood and Anxiety Disorders: Introduction to the Special Issue

Transdiagnostic cognitive-behavioral approaches attempt to develop broad theories of clinical conditions (e.g., general theories of mood and anxiety disorders) and corresponding treatment protocols that can be applied to a range of clinical conditions. These can be contrasted with diagnosis-specific theories and treatments, which focus on particular clinical conditions (e.g., theories of panic disorder and panic-specific treatments). In this introductory article we trace the history of transdiagnostic and diagnosis-specific cognitive-behavioral approaches. Both have their origins in the late 1950s and early 1960s. Over the subsequent decades there was waning interest in transdiagnostic approaches and a corresponding increase in interest in diagnosis-specific approaches to theory and treatment. Over the past several years, however, interest has been revived in transdiagnostic approaches. We summarize the reasons for this growing interest and provide an overview of the following articles in this special issue.