by Michael D. Anestis, M.S.
The other day, I received an email from a reader in Australia asking whether I might consider writing an article about the transdiagnostic treatment of emotional disorders. I was intrigued by the idea and, as it happens, I stumbled upon a newly published article on this very topic last night as I was scanning the table of contents for the latest issue of Cognitive and Behavioral Practice. In this study, conducted by Kristen Ellard, Christopher Fairholme, Christina Boisseau, Todd Farchione, and David Barlow (2010) of Boston University, the authors reported findings from two open trials of a treatment protocol aimed at tackling all anxiety disorders as well as depression and dysthymia.
Before describing the study itself, let me touch on its rationale. Readers of PBB are well aware at this point that Joye and I advocate for the use of evidence-based treatments. We believe that psychotherapy and psychopharmacology should be data driven, with approaches that produce the best results in systematic investigations being prioritized as the frontline treatments. That being said, one problem with this approach is that, as the years go by, in increasingly large number of evidence-based treatments have been developed, which places a heavy burden upon clinicians who must keep up with emerging treatments and attain training in new approaches in order to remain ahead of the curve. Now, to an extent, I think that this burden is part of the job - being a doctor is not easy and, while difficult, keeping up with emerging science is critical - but at the same time, I acknowledge that there are practical considerations here.
One potential solution to this issue is the development of transdiagnostic treatments (click here to read our description of a transdiagnostic treatment for eating disorders). In other words, instead of designing treatments aimed to address one specific diagnosis, researchers and clinicians might create a better system by developing treatments that are equally effective at addressing a wider range of diagnoses. Along these lines, the study by Ellard and her colleagues (2010) presented some compelling data on a transdiagnostic treatment for emotional disorders, defined in this case as any anxiety disorder, depression, or dysthymia. Their treatment, which they refer to as the Unified Protocol for the Treatment of Emotional Disorders (UP), is an emotion-focused cognitive behavioral treatment. The core elements of UP are quite similar to those of standard cognitive behavioral therapy (CBT) - treating avoidance behavior, exposure exercises, cognitive restructuring - but a key difference rests in the focus on emotions. The UP protocol includes elements of mindfulness and places a heavy priority upon developing healthy emotion regulation strategies. The lack of focus on emotions in CBT has always been a point of minor frustration for me, as my research focuses on the impact of affect on behavior, so this is an exciting idea to me.
In this particular article, the authors presented the results from two small open trials conducted at the Center for Anxiety and Related Disorders (CARD) . In the first trial, 18 participants with a primary diagnosis of an anxiety disorder were included. Participants received a maximum of fifteen 60-minute sessions (mean number of sessions = 13). Participants were considered responders if they demonstrated a 30% or greater change on at least two broad measures (e.g., diagnostic interview, diagnosis specific self-report questionnaire). Additionally, participants were considered to have reached high end-state functioning if they no longer met criteria for their principle diagnosis and fell within the normal range on at least one of the remaining broad assessment measures. The results of this study indicated that 56% of participants qualified for responder status on their principle diagnosis and 50% of those individuals (33% of the total sample) met criteria for high end-state functioning. 71% of the individuals in this study met responder status on comorbid disorders and 70% of those individuals (50% of total sample) met criteria for high end-state functioning. Finally, although there was a significant treatment effect on negative affect, which is a unifying component of all emotional disorders, only 56% of participants were within the normal range on this variable by the end of treatment.
Overall, the results from the first trial were positive, but rather modest. Like any good scientists, however, the authors took this as a motivating force. They revised the manual and treatment protocol and, once they were comfortable with the changes, ran a second open trial. For complete information on the changes made to the protocol, I recommend that you consult the original article. In the second trial, 15 participants provided data for pre- and post-treatment and 11 provided data at 6-month follow-up. In this case, a maximum of eighteen 60-minute sessions were allowed (mean number of sessions = 17). 73% of the participants in this trial reached responder status and 82% of those individuals (60% of total sample) met criteria for high end-state functioning for their principle diagnosis. Additionally, 64% of the participants reached responder status for comorbid diagnoses and all of those individuals also met criteria for high end-state functioning. With respect to negative affect, 67% of the participants fell within the normal range on that variable post-treatment, indicating that the UP protocol did an excellent job of addressing what is considered to be a core component of all emotional disorders.
At 6-month follow-up, the results from the second open trial looked even better. At that point, 85% of participants reached responder status and 82% of those individuals (69% of the total sample) met criteria for high end-state functioning on their principle diagnosis. Additionally, 80% met responder status for comorbid disorders and 63% of those individuals (50% of the total sample) met criteria for high end-state functioning. Finally, 82% of the participants fell within the normal range of negative affect at 6-month follow-up.
So what did we learn from these two trials? First of all, after making some substantial revisions to the treatment protocol, the authors were able to produce impressive results in their second trial. These results support the notion that emotional disorders can potentially be treated by one unified treatment protocol that emphasizes their shared characteristics (e.g., chronically high levels of negative affect). If this is shown to be true through a number of independent trials, a situation may develop in which clinicians who seek to use evidence-based procedures will be able to simply learn one unified protocol rather than learning a series of treatments, each of which has been designed for one particular diagnosis.
An important point to keep in mind is that these results are preliminary in nature. The open trials involved no comparison condition, meaning that we can not rule out the passage of time as a key component in treatment response. Additionally, there was no randomization, the sample size was extremely small, and the follow-up period was rather short. These limitations aside, the study provides remarkably valuable early evidence for an effective transdiagnostic treatment for emotional disorders.
What do you think about this approach? By zooming out with a transdiagnostic approach, are we losing sight of the nuances inherent in individual diagnoses? Does a transdiagnostic approach need to outperform the top treatment for all of the diagnoses it claims to treat before it can be accepted as a frontline approach or is there a lower standard given the value of being able to use a single protocol for a range of conditions? Have any of your had any experience implementing the UP protocol?
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If you would like to learn more about this or other topics discussed on PBB, I encourage you to consult our online store for scientifically-based psychological resources.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center.
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