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Before the development of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP), evidence-based treatment options for commonly co-occurring anxiety, mood, and related disorders consisted of numerous single-disorder protocols that shared many similarities, reflecting the overlap among these disorders themselves. The UP distilled common elements of cognitive behavioral protocols into a unified intervention directly targeting core temperamental features underlying these disorders of emotion, namely neuroticism and associated emotion dysregulation. The UP has since become a leading "transdiagnostic" treatment for emotional disorders, which is now available in several formats (e.g., individual, group, digital) and has accumulated a strong evidence base, leading to international implementation. There is now also research evidence that the UP can be flexibly applied to a range of clinical presentations, including borderline personality disorder, trauma- and stressor-related disorders, eating disorders, alcohol use disorder, and comorbid chronic physical health conditions. Yet additional research is needed to evaluate the UP in routine clinical settings, with more heterogeneous patient populations, and under circumstances that mirror actual clinical practice. Thus, we must also continue to explore the benefits of large-scale UP training initiatives and implementation in major healthcare systems., (Copyright © 2024 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.)

There is preliminary evidence that the anticonvulsant medication Zonisamide (ZON) may be an effective, well-tolerated treatment for alcohol use disorder (AUD). However, further evaluation of its efficacy for treating patients with AUD is needed, and much remains unknown about ZON's therapeutic mechanisms. The present study aimed to evaluate the efficacy and tolerability of ZON in a double-blind, placebo-controlled, randomized trial. Eighty-one adults (ages 21-65) diagnosed with AUD were randomly assigned to receive either ZON (at a target dose of 400 mg/d) or a pill placebo over 12 weeks, followed by a two-week taper. All participants also received a computerized alcohol reduction program, Take Control (TC). Primary drinking outcomes were average daily drinks, percentage drinking days, and percentage heavy drinking days. Further, we evaluated changes in AUD clinical severity and performance on neuropsychological measures. For both groups, drinking outcomes generally decreased, as did AUD clinical severity, though group differences were not statistically significant. Neuropsychological testing performance was similar for both groups at baseline; however, at post-treatment, participants in the ZON group demonstrated poorer working memory and lower performance on verbal fluency tests compared to the placebo group, and these differences were statistically significant with moderate-large effect sizes. One serious adverse event was reported among individuals receiving ZON. Study findings indicate that ZON combined with TC does not demonstrate superior effectiveness for reducing average daily drinks in this clinical sample with principal AUD compared to placebo and TC, and treatment with ZON may be associated with reduced neurocognitive performance over time., Competing Interests: Declaration of competing interest Todd J. Farchione: Dr. Farchione receives royalties from Oxford University Press and research funding related to the reported work from the National Institute of Alcohol Abuse. He also received consulting (personal) fees from the MacArthur Foundation, the National Center of Neurology and Psychiatry in Japan, Brightside Health, Tage S.R.L., Allegheny Health Network, and Grupo Pacifico outside the submitted work. Laura J. Long: None. Matthew W. Gallagher: Dr. Gallagher received research funding from the National Institute of Alcohol and Alcohol Abuse during the conduct of the study. Daniella Spencer-Laitt: None. Marie Torre: None. Lauren S. Woodard: None. Andrew J. Curreri: None. Bonnie Brown: None. Margaret Ross: None. David H. Barlow: Dr. Barlow receives royalties for books and treatment manuals from Oxford University Press, Guilford Publications Inc., Cengage Learning, and Pearson Publishing. Grant monies for various projects come from the National Institute of Mental Health, the National Institute of Alcohol and Alcohol Abuse, and Colciencias (Government of Columbia Initiative for Science, Technology, and Health Innovation). Consulting and honoraria during the past several years have come from the Agency for Healthcare Research and Quality, the Foundation for Informed Medical Decision Making, the Department of Defense, the Renfrew Center, the Chinese University of Hong Kong, Universidad Católica de Santa Maria (Arequipa, Peru), New Zealand Psychological Association, Hebrew University of Jerusalem, Mayo Clinic, and various American Universities., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Digital supplements to tele-psychotherapy are increasingly needed. The purpose of this retrospective study was to investigate the association between outcomes and the use of supplemental video lessons based on the Unified Protocol (UP), an empirically supported transdiagnostic treatment., Participants included 7,326 adults in psychotherapy for depression and/or anxiety. Partial correlations were calculated between number of UP video lessons completed and change in outcomes after 10 weeks, controlling for number of therapy sessions and baseline scores. Then, participants were divided into those who did not complete any UP video lessons ( n  = 2355) and those who completed at least 7/10 video lessons ( n  = 549), and propensity-matched on 14 covariates. Repeated measures analysis of variance compared these groups ( n  = 401 in each group) on outcomes., Among the entire sample, symptom severity decreased as the number of UP video lessons completed increased, with the exception of lessons on avoidance and exposure. Those watching at least 7 lessons showed significantly greater reduction in both depression and anxiety symptoms than those who did not watch any., Viewing supplemental UP video lessons in addition to tele-psychotherapy had a positive and significant association with symptom improvement and may provide an additional tool for clinicians to implement UP components virtually.

The present study expands on the growing body of research on the effects of cognitive behavioral therapy (CBT) on positive affect. More specifically, we explore how CBT may promote increases in the Joviality subscale of the Positive and Negative Affect Schedule-Expanded Form (PANAS-X), a measure of self-rated affect that captures positive emotions, including joy and excitement, and how change in joviality may be associated with concurrent symptom change. We utilized data from a randomized equivalence trial comparing the efficacy of the unified protocol (UP) for transdiagnostic treatment of emotional disorders, a transdiagnostic CBT, against various well-established single disorder protocols (SDP) and waitlist control. First, we generated affect profiles for patients receiving CBT (either UP or SDP) or waitlist control, based on their baseline and posttreatment positive affect (PA) and negative affect (NA), compared with a clinical reference sample. We found that the affect profile for most patients receiving CBT shifted from high NA/low PA to low NA/high PA. Further, participants receiving CBT were more likely than individuals in the waitlist control to achieve this outcome. We then examined the PANAS-X Joviality subscale, which has been subject to very limited previous research. Change in joviality was associated with improvement in symptoms of both anxiety ( B = -0.81, p = .00) and depression ( B = -0.94, p = .00). Joviality increased more rapidly in individuals with more severe anxiety but not severe depression. We discuss the possible clinical implications of these preliminary results, including the role of treatment innovations incorporating a focus on increasing positive affect, particularly the emotions associated with joviality, while simultaneously decreasing negative affect. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Adjustment problems and disorders are highly prevalent among university students worldwide. These problems can cause significant interference in academic and social functioning and increase vulnerability to other mental health disorders. Unfortunately, only half of students in need receive psychological help. Furthermore, few studies have evaluated psychological interventions for adjustment disorders in students. New, more scalable forms of treatment for students with an adjustment disorder need to be developed, evaluated, and implemented. The study aims to determine the effectiveness of an online transdiagnostic cognitive behavioural intervention for students experiencing adjustment disorder and to assess mediators of change., Method/design: In this three-arm randomized controlled trial, we plan to recruit 214 Polish students diagnosed with an adjustment disorder. Participants who meet initial eligibility criteria will be randomly assigned to one of three 6-week conditions: (1) online cognitive behavioural therapy intervention based on an existing, empirically supported transdiagnostic protocol, the unified protocol; (2) online progressive muscle relaxation training as an active control group; or (3) waiting-list control group. Both interventions are asynchronous, interactive, and include minimal amount of therapist support. Assessments will consist of self-report questionnaires, daily diary measures, and neurocognitive tasks for evaluating cognitive functioning. These will be conducted at baseline, post-treatment, and 1-month follow-up. Daily diary measures will be taken during the first and last week of treatment (or waitlist period). Primary outcome measures will include adjustment disorder severity; secondary outcome measures will consist of other negative (psychopathology: depression, anxiety, and stress) and positive (life satisfaction) indexes of mental health as well as process measures (e.g. mindfulness, experiential avoidance, cognitive fusion)., Discussion: To our knowledge, the current study is the first to evaluate the effectiveness of a psychological intervention for students with adjustment disorder. Therefore, it may have important practical implications for students with this disorder. It can potentially guide the development of a scalable, validated treatment option., Trial Registration: Clinical Trials, NCT05768308, registered 14 March 2023, https://www., Clinicaltrials: gov/ct2/show/NCT05768308., (© 2023. The Author(s).)

Importance: A transdiagnostic treatment, the Unified Protocol, is as effective as single diagnostic protocols in comorbid emotional disorders in clinical populations. However, its effects on posttraumatic stress disorder and other emotional disorders in individuals living in war and armed conflict contexts have not been studied., Objective: To evaluate the efficacy of a cultural and contextual adaptation of the Unified Protocol (CXA-UP) on posttraumatic stress disorder, anxiety, and depression compared to waitlist control in individuals exposed to armed conflict in Colombia., Design, Setting, and Participants: From April 2017 to March 2020, 200 participants 18 years and older were randomly assigned to the CXA-UP or to a waitlist condition. CXA-UP consisted of 12 to 14 twice-a-week or weekly individual 90-minute face-to-face sessions. Outcomes were assessed at baseline, posttreatment, and 3 months following treatment. Analyses were performed and compared for all randomly allocated participants (intent-to-treat [ITT]) and for participants who completed all sessions and posttreatment measures (per protocol [PP]). The study took place at an outpatient university center and included individuals who were registered in the Colombian Victims Unit meeting DSM-5 diagnostic criteria for posttraumatic stress disorder, anxiety, or depression or were severely impaired by anxiety or depression. Individuals who were receiving psychological therapy, were dependent on alcohol or drugs, were actively suicidal or had attempted suicide in the previous 2 months, had psychosis or bipolar disorder, or were cognitively impaired were excluded., Intervention: CXA-UP or waitlist., Main Outcomes and Measures: Primary outcomes were changes in anxiety, depression, and somatic scores on the Patient Health Questionnaire and Posttraumatic Stress Disorder Checklist for DSM-5., Results: Among the 200 participants (160 women [80.0%]; 40 men [20.0%]; mean [SD] age, 43.1 [11.9] years), 120 were randomized to treatment and 80 to waitlist. Results for primary outcomes in the ITT analysis showed a significant pretreatment-to-posttreatment reduction when comparing treatment and waitlist on the posttraumatic stress disorder checklist for DSM-5 scores (slope [SE], -31.12 [3.00]; P < .001; Cohen d, 0.90; 90% CI, 0.63-1.19), 9-item Patient Health Questionnaire (PHQ-9) (slope [SE],-11.94 [1.30]; P < .001; Cohen d, 0.77; 90% CI, 0.52-1.06), PHQ-anxiety (slope [SE], -6.52 [0.67]; P < .001; Cohen d, 0.82; 90% CI, 0.49-1.15), and PHQ-somatic (slope [SE], -8.31 [0.92]; P < .001; Cohen d, 0.75; 90% CI, 0.47-1.04)., Conclusions and Relevance: In this study, significant reductions and large effect sizes in all measures of different emotional disorders showed efficacy of a single transdiagnostic intervention in individuals exposed to armed conflicts., Trial Registration: ClinicalTrials.gov Identifier: NCT03127982.

Abstract: Although evidence-based psychological treatments such as cognitive behavioral therapy (CBT) have strong empirical support for reducing anxiety and depression symptoms, CBT outcome research often does not report race and ethnicity variables, or assess how well CBT works for people from historically excluded racial and ethnic groups. This study presents post hoc analyses comparing treatment retention and symptom outcomes for participants of color ( n = 43) and White participants ( n = 136) from a randomized controlled efficacy trial of CBT. χ 2 tests and one-way ANCOVA showed no observable differences between the two samples on attrition or on clinician-rated measures of anxiety and depression at posttreatment and follow-up. Moderate to large within-group effect sizes on anxiety and depression were found for Black, Latinx, and Asian American participants at almost all time points. These preliminary findings suggest that CBT for anxiety and comorbid depression may be efficacious for Black, Asian American, and Latinx individuals., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

This study examined the association of three specific COVID-19-related workplace stressors (percentage of nursing work with COVID-positive [COVID+] patients, number of COVID-19-related patient deaths witnessed, and living separately from family for safety) and their associations with posttraumatic stress symptoms (PTSS) and symptoms of major depressive disorder (MDD) and generalized anxiety disorder (GAD) among 391 nurses (93.6% White, 93.4% utilize she/her pronouns). Cross-sectional data were collected via an online survey. Institutional betrayal (i.e., the perception that an institution failed to protect a member who depends on and trusts it) was examined as a moderator of these associations. Although institutional betrayal was not a significant moderator in the three individual models, it held small-to-medium-sized positive main effects with PTSS and symptoms of GAD and MDD in both the individual and combined models. In the individual models, the percentage of nursing work with COVID+ patients was significantly positively associated with all three mental health conditions, f 2 = .019-.195, whereas it only showed a significant effect with PTSS in the combined model, f 2 = .138. Living separately from family was significantly positively associated with PTSS and MDD symptoms in both the individual, f 2 = .037 and .015, respectively, and combined models, f 2 = .025 and .013, respectively. Number of patient deaths held a significant positive association with PTSS alone, f 2 = .022, in the individual model only. The findings are discussed in light of ways in which health care settings can better support and prioritize mental health among nursing staff., (© 2023 International Society for Traumatic Stress Studies.)

Background: Cognitive behavioral therapy (CBT) is an effective treatment for depression in persons with Parkinson's disease (PwPD), but there are significant barriers preventing PwPD from receiving care in person. Telehealth CBT circumvents many of these barriers., Objectives: We conducted a pilot randomized controlled trial evaluating the efficacy, feasibility, and acceptability of telehealth transdiagnostic CBT intervention for depression in PwPD., Methods: Twelve PwPD with Major Depressive Disorder were enrolled, half randomly assigned to the treatment-immediate condition (TI) and half to the waitlist control condition (WLC). TI and WLC participants received 12 CBT sessions and assessments before treatment, immediately after treatment, and at the 6-week follow-up., Results: The intervention was efficacious for treating depression in PwPD, with secondary benefits to anxiety, apathy, learning, memory, and quality of life. Improvements were largely maintained at follow-up. The intervention was highly feasible and acceptable., Conclusions: Telehealth transdiagnostic CBT was an effective intervention for PwPD with depression., (© 2022 International Parkinson and Movement Disorder Society.)

Background: Research has shown that internet-based cognitive behavioural therapy (iCBT) can be a very promising solution to increase access to and the dissemination of evidence-based treatments to all of the population in need. However, iCBT is still underutilized in clinical contexts, such as primary care. In order to achieve the effective implementation of these protocols, more studies in ecological settings are needed. The Unified Protocol (UP) is a transdiagnostic CBT protocol for the treatment of emotional disorders, which includes depression, anxiety and related disorders, that has shown its efficacy across different contexts and populations. An internet-based UP (iUP) programme has recently been developed as an emerging internet-based treatment for emotional disorders. However, the internet-delivered version of the UP (iUP) has not yet been examined empirically. The current project seeks to analyse the effectiveness of the iUP as a treatment for depression, anxiety and related emotional disorders in a primary care public health setting., Methods: The current study will employ a parallel-group, randomized controlled trial design. Participants will be randomly assigned to (a) the internet-based Unified Protocol (iUP), or (b) enhanced waiting list control (eWLC). Randomization will follow a 2:1 allocation ratio, with sample size calculations suggesting a required sample of 120 (iUP=80; eWLC=40). The Mini-International Neuropsychiatric Interview (M.I.N.I.) will be used for assessing potential participants. The Overall Anxiety Severity and Impairment Scale (OASIS) and the Overall Depression Severity and Impairment Scale (ODSIS) as well as other standardized questionnaires will be used for assessments at baseline, 4 weeks, 8 weeks and 12 weeks from baseline and for the iUP condition during the follow-up., Discussion: Combining the advantages of a transdiagnostic treatment with an online delivery format may have the potential to significantly lower the burden of emotional disorders in public health primary care setting. Anxiety and depression, often comorbid, are the most prevalent psychological disorders in primary care. Because the iUP allows for the treatment of different disorders and comorbidity, this treatment could represent an adequate choice for patients that demand mental health care in a primary care setting., Trial Registration: ISRCTN18056450 https://doi.org/10.1186/ISRCTN18056450 ., (© 2022. The Author(s).)

Background: Individuals with alcohol use disorder (AUD) have difficulty diverting attention away from alcohol-related stimuli and towards non-alcohol-related goals (i.e., alcohol-related attention interference). It remains unclear whether regulatory brain function differs during alcohol and non-alcohol-related interference. This study compares brain reactivity during the alcohol and classic Stroop and whether such brain function relates to AUD severity., Methods: 46 participants with AUD completed alcohol and classic color-word Stroop tasks during fMRI. Brain activity was compared during alcohol and classic Stroop interference in the rostral and dorsal anterior cingulate cortices (rACC and dACC) and correlated with self-reported AUD severity. Exploratory whole-brain analyses were also conducted., Results: Behavioral interference (i.e., slower reaction times) was observed during alcohol and classic Stroop. rACC activity was significantly higher during the alcohol > neutral contrast versus the incongruent > congruent contrast. dACC activity did not differ between the Stroop tasks. dACC activity during incongruent > congruent was positively associated with AUD severity., Conclusions: Activity in ACC subregions differed during alcohol and non-alcohol interference. Increased alcohol-related activity in the rACC, a region linked to emotional conflict resolution, suggests an interfering effect of self-relevant alcohol cues on non-alcohol-related processing. AUD severity was related to greater dACC reactivity during classic Stroop interference, suggesting that non-drug-related cognitive control impairments are more pronounced in those with more problematic alcohol use., (Copyright © 2022 Elsevier B.V. All rights reserved.)

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).

The COVID-19 pandemic, and the social distancing practices that followed, have been associated with increased prevalence of emotional disorders. However, not all individuals affected by COVID-19-related social distancing experienced elevations in emotional disorder symptoms. Understanding this phenomenon is of crucial public health significance given the burden of emotional disorders on individuals and systems. In this narrative review, we consider the differential impact of COVID-19-related social distancing on mental health outcomes from a transdiagnostic perspective. We argue that individuals high in negative affect and aversive reactivity to emotion, that is, neuroticism, and who respond to such emotional experiences with emotion-motivated avoidant coping, are most likely to experience emotional disorders in the context of COVID-19 social distancing. We acknowledge the pro-social and adaptive function of some types of avoidance during the pandemic, which may have initially buffered against negative mental health outcomes. Implications of this conceptualization for treatment of emotional disorders in the present sociocultural context are discussed.

The purpose of this study is to evaluate the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders adapted for homeless women (UPHW). Eighty-one homeless women participated in this single-blinded quasi-experimental clinical trial, involving up to 12 sessions of group treatment, and 3-and 6-month follow-ups. The participants received either immediate treatment with the UPHW ( n  = 46) or delayed treatment, following a 12-week wait-list control period (WLC; n  = 35). Primary outcomes included depression and anxiety. Secondary measures comprised positive and negative affect, psychological well-being, health perception, and social support. The UPHW resulted in significant improvement on measures of anxiety, depression and negative affect. Improvements in anxiety and depression were maintained over a 3-month follow-up period, but not at 6-month. The reliability of the clinical changes showed significant differences between UPHW and WLC for depression. Moreover, the inter-session assessment in the UPHW group showed a linear trend reduction for depression and anxiety scores along the 12 sessions. The clinical implications on the UPHW in social settings are also discussed.

Background: The present study aims to investigate the effectiveness of the Unified Protocol (UP), a transdiagnostic treatment of emotional disorders (EDs), when applied in a group format in the public mental health system in Spain., Methods: 488 participants with a primary diagnosis of ED were randomized to the UP group or to the treatment as usual (TAU; individual, disorder-specific cognitive behavioral therapy). Personality, depression and anxiety symptoms, affect, and quality of life were assessed at pre-treatment, 3 months after treatment onset (coinciding with the end of the UP treatment), and 6 and 9 months after treatment onset (follow-ups). The moderating effect of the treatment condition and the number of sessions received in the evolution of study outcomes was investigated with a linear mixed model analysis., Results: A significant improvement in outcomes occurred in both conditions, except for extraversion in the TAU. Improvements in depression, anxiety and quality of life were larger in the UP condition. After the treatment, improvements were maintained at follow-ups in all study outcomes. An interaction between Time*Condition*Sessions was found for depression., Conclusion: The results add to the existing evidence on the effectiveness of the UP and may be important for implementation purposes in the Spanish or other similar public mental health systems. Trial registration number NCT03064477 (March 10, 2017).

Exposure therapy works through inhibitory learning, whereby patients are exposed to stimuli that elicit anxiety in order to establish safety associations. Mindful emotion awareness, or nonjudgmental and present-focused attention toward emotions, may facilitate engagement in exposures, which may in turn enhance therapeutic outcome. This study utilizes a single-case experimental design ( n = 6) to investigate the effect of mindful emotion awareness training on the use of avoidant strategies during exposures, distress during exposures, overall mindfulness, experiential avoidance, and symptom reduction in a sample of participants with social anxiety disorder. Data were analyzed using a combination of visual inspection and quantitative effect size metrics commonly applied in single-case experimental designs. To further investigate the relationship between distress and avoidant strategy use, contemporaneous and cross-lagged correlations were run. Results highlight individual differences in responses to mindful emotion awareness training and exposure exercises. Given these individual differences, repeated assessment and monitoring over the course of treatment may help clinicians most effectively identify treatment skills that will be most helpful for individual patients.

The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is an emotion-focused, cognitive-behavioral intervention developed to address the full range of anxiety, depressive, and related disorders. The UP consists of core therapeutic skills that, though unique in focus, are each designed to promote an approach-oriented stance toward emotional experiences. The goal of the present investigation was to characterize changes in these skills for patients that received a course of treatment with the UP, as well as to examine associations between skills and symptoms changes. Patients with principal anxiety disorders, assigned to receive treatment with the UP (N = 88) as part of a randomized controlled trial, were included in this study. They completed validated self-report measures of UP skills (Understanding Emotions, Mindful Emotion Awareness, Cognitive Flexibility, Countering Emotional Behaviors, and Interoceptive Awareness and Tolerance), as well as clinician-rated measures of psychological symptoms. Skill measures improved significantly over the course of 12 to 16 UP treatment sessions and changes in these skills measures were associated with improvements in anxiety symptoms. Determining whether improvement on all the skills learned during a course of treatment with UP is associated with symptom remission is critical to establishing the most streamlined and efficient interventions that may ultimately be best suited to widespread dissemination., (Copyright © 2021. Published by Elsevier Ltd.)

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., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition., Method: Patients with principal anxiety disorders (N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms., Results: At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT (t(218) = -2.17, p = 0.03, d = -0.32) and WL conditions(t(207) = -2.33, p = 0.02, d = -0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms., Conclusions: Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.

Alcohol Use Disorder (AUD) and anxiety disorders (ANX) are each highly prevalent and frequently co-occur, resulting in a complex clinical presentation. The existing literature to date has not yet identified how to best treat comorbid AUD/ANX, partially due to limitations in understanding what factors and mechanisms are implicated in their co-occurrence. This manuscript describes the rationale and methods for an ongoing randomized-controlled trial designed to evaluate the efficacy of a cognitive behavioral intervention, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), compared to Take Control (TC), a psychosocial and motivational treatment serving as a control condition in this study, for comorbid AUD/ANX. Sixty individuals with comorbid AUD/ANX will be randomized to UP or TC, and complete assessments at pre- and post-treatment, as well as one- and six-month follow-up points. We hypothesize that the UP, compared to TC, will result in significantly greater reductions in drinking-related outcomes, as well as anxiety and depressive-related outcomes. Additionally, the current study is designed to evaluate exploratory aims to contribute to our theoretical understanding of why AUD and ANX frequently co-occur. Specifically, we will examine the relationship between changes in AUD and ANX symptoms in relation to changes in emotional disorder mechanisms, such as emotion regulation. Because the UP is a transdiagnostic treatment that specifically targets underlying components of emotional disorders generally, it may be well suited to effectively target comorbid AUD/ANX., (Copyright © 2021. Published by Elsevier Inc.)

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention., (Copyright © 2021. Published by Elsevier Ltd.)

There has been increasing interest in transdiagnostic cognitive-behavioral therapy (CBT), which is more cost efficient yet yields similar effect sizes when compared to disorder-specific CBT. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders was adapted for Hong Kong Chinese adults with common mental disorders, such as depression and anxiety. It was piloted in community settings and delivered in a group format. Thirty-one Chinese adults (female = 93.5%, mean age = 44 years) with heterogeneous anxiety and depressive disorders were recruited from a number of public-funded community mental health centers in Hong Kong to participate in a pilot trial of a locally adapted variant of UP. Treatment consisted of 14 group sessions plus one individual session. Each group included six to nine participants. The diagnostic and outcome measures included Anxiety Disorders Interview Schedule for DSM-IV, The Chinese versions of Beck Depression Inventory-Revised (C-BDI-II), Beck Anxiety Inventory (C-BAI), Positive Affect subscale of Positive and Negative Affect Scale, and Work and Social Adjustment Scale. Results indicate significant improvement across a number of outcome measures, with moderate-to-large effect sizes for measures of depression (d = 1.11), anxiety (d = 0.67), positive affect (d = 0.54), and work and social functioning (d = 0.49). Furthermore, 45.2% and 29.0% of the participants scored within the normal range of C-BDI-II and C-BAI at posttreatment, respectively, compared to 3.2% and 6.5% at pretreatment. This pilot, uncontrolled trial demonstrated potential effectiveness of a locally adapted variant of group UP for Chinese adults with common mental disorders. It achieved comparable effect sizes to those observed in western populations., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To examine whether the Unified Protocol (UP) remains equivalent to single-disorder protocols (SDPs) in the treatment of anxiety disorders at 12-month follow-up., Method: We report results from the 12-month follow-up of a recent randomized equivalence trial [1]. Data are from 179 participants (55.31% female sex, 83.24% White, average age 30.66) who met criteria for a principal anxiety disorder and were randomized to either the UP or SDP conditions. Consistent with the parent trial, the primary outcome was principal diagnosis clinician severity rating (CSR) from the Anxiety Disorder Interview Schedule (ADIS). Secondary outcomes included anxiety, depression, and impairment. Missing data were accommodated using multiple imputation (10,000 imputed data sets) under a missing at random assumption. Equivalence between the UP and SDPs was tested using slope difference scores from latent growth models and 95% confidence interval of between-condition effect sizes., Results: The results indicated that the UP and SDP conditions remained equivalent with regard to principal diagnosis clinician severity rating at 12-month follow-up. In addition, there were no significant differences between conditions on secondary outcomes at 12-month follow-up., Conclusions: The UP continues to yield outcomes comparable to SDPs at 12-month follow-up, and therefore provides a single intervention that can be used to treat the most commonly occurring psychiatric disorders with durable effects., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The Unified Protocol for Transdiagnostic Treatment (UP; Barlow et al., 2011) has recently demonstrated statistically equivalent therapeutic effects compared to leading cognitive behavioral therapy (CBT) protocols for anxiety disorders designed to address disorder-specific symptoms (i.e., single-disorder protocols [SDP]); Barlow et al., 2017). Although all treatment protocols included similar evidence-based CBT elements, investigation of those related to symptom improvement in the UP is warranted. Because the UP is unique from the SDPs for its inclusion of mindfulness, the present study evaluated mindfulness as a primary treatment element. We explored whether UP participants, compared to SDP, demonstrated greater improvements in mindfulness from pre- to posttreatment, and whether these improvements predicted posttreatment severity across anxiety disorder diagnoses. Participants were individuals with a principle anxiety disorder (N = 179) randomized to receive either the UP or SDP. Results indicated significant improvements pre- to posttreatment in mindfulness for participants receiving either the UP or SDP. However, at posttreatment, mindfulness scores were significantly greater for the UP condition. At the diagnosis level, posttreatment scores in mindfulness were significantly greater in the UP condition than the respective SDP conditions for principal Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SOC). Moreover, results suggest that change in mindfulness is related to posttreatment severity, when moderated by treatment condition, but only for participants with principal GAD. Taken together, the UP is effective in improving mindfulness in a sample with heterogeneous anxiety disorders, but this change seems particularly relevant for reduction in symptom severity for individuals with principal GAD., (Copyright © 2020. Published by Elsevier Ltd.)

Cognitive behavioral therapy (CBT) has been found to be very effective in reducing many forms of mental illness, but much less is known about whether CBT also promotes mental health or well-being. The goals of the present study were to (a) quantify the magnitude and timing of changes in overall well-being and specific facets of well-being during different CBTs for anxiety disorders, (b) determine whether these effects vary across transdiagnostic and disorder-specific CBT, and (c) examine how changes in well-being during treatment relate to changes in anxiety. A total of 223 adults (55.6% female, Mage = 31.1 years) were randomized to 1 of 5 CBT protocols for anxiety disorders at an outpatient clinic. Analyses included standardized mean gain effect sizes (ESsg) and latent growth curve modeling. Moderate-to-large increases in overall well-being and the 3 components of subjective, psychological, and social well-being were observed, mainly during the second half of CBT, and these increases were maintained at a 6-month follow-up. The magnitude of effects was comparable for transdiagnostic and disorder-specific CBT protocols and greater than in the waitlist condition. Parallel process latent growth curve models indicated that trajectories of change in well-being across treatment were strongly correlated with trajectories of change in clinician-rated and self-reported anxiety. Together, these findings suggest that different CBT protocols for anxiety consistently produce robust and lasting changes in well-being, and these changes are strongly linked to changes in anxiety during treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Quality of life is lower among individuals with anxiety disorders; however, this construct is rarely a focus in treatment research. This study explores changes in quality of life in a randomized, controlled trial of several cognitive-behavioral treatments (CBTs) for anxiety disorders. Adults with heterogeneous anxiety disorders ( N = 223) were randomly assigned to (a) unified protocol for transdiagnostic treatment of emotional disorders, (c) a single-disorder protocol targeting their principal diagnosis, or (c) a waitlist control condition, and assessed at baseline, posttreatment, and 6-month follow-up. At baseline, the sample evidenced deficits in quality of life, with no significant differences in quality of life across diagnoses or condition. Results suggest improved quality of life among participants in treatment, at similar rates across treatment condition and diagnostic category, and at levels significantly higher than the waitlist. Improvements were maintained through 6-month follow-up. This study supports CBT as effective in promoting quality of life.

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., Competing Interests: Declaration of Competing Interest Drs. Barlow, Farchione, and Sauer-Zavala receive royalties from Oxford University Press for their work on the Unified Protocol, the treatment manual under study in the present manuscript. The additional authors declare that they do not have any conflicts of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

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., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: This study evaluated changes in positive affect within cognitive-behavioral treatments (CBT) for anxiety disorders. It was hypothesized that there would be significantly greater increases in positive affect in CBT conditions compared to the waitlist, and particularly higher in the Unified Protocol (UP) than the single disorder protocols (SDP) given the UP's focus on emotions (including positive emotions) rather than symptoms., Method: Patients with heterogeneous anxiety disorders (N = 223) were randomly assigned to the UP, SDP or waitlist. Linear mixed model regression (intent to treat) analyses were used to compare change in positive affect, quality of life, and savoring between patients in the treatment conditions (UP and SDP) versus waitlist conditions. Between condition effect sizes were calculated to assess the magnitude of difference within conditions at post-treatment., Results: Results indicated a significant Group (treatment vs. waitlist) × Time (pre- post-treatment) interaction (F(1, 154.36) = 6.75; p = .01) for positive affect in which the treatment group showed significant improvements in positive affect pre- to post-treatment (ESsg = 0.37, SEsg = 0.09, 95% CI [0.20: 0.54]) and the waitlist condition did not. There were no differences between UP and SDP conditions in positive affect at baseline or at post-treatment., Conclusions: These results suggest CBT, which typically focuses on reductions in negative affect, may also improve positive affect. The importance of future research evaluating, targeting, and improving positive affect in CBT trials is discussed. Clinicaltrials.gov Identifier: NCT01243606., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Resource allocation theory suggests that rumination depletes cognitive resources that could be directed toward task-relevant processes. We propose a new approach to the treatment of rumination that specifically targets this misappropriation of cognitive resources, wherein individuals engage in an attentionally demanding task in order to interrupt the ruminative cycle. We argue that this strategy would serve to free cognitive resources from rumination and facilitate performance on other tasks. Thus, the present study served as an initial test of this novel approach. This study employed a within-subjects design, in which participants were 30 college students who completed self-report measures of baseline mood state, anxiety, depression, and trait rumination. Subsequently, they underwent sad mood and rumination inductions followed by random assignment to either a low attentional demand disengagement strategy (DS) followed by a high attentional demand DS or vice versa. Reading comprehension was assessed at baseline and following each of the two DSs. The high attentional demand DS condition was associated with better performance on the reading comprehension task compared to the low attentional demand DS condition. These results provide initial support for our novel approach to targeting rumination and demonstrate that attentionally demanding DSs may successfully free cognitive resources that might otherwise be consumed by rumination. Thus, future research into attentionally demanding DSs that interrupt ruminative cycles is warranted. This approach could be a useful adjunct for interventions targeting disorders driven by rumination, such as depression., (© Copyright 2019 Springer Publishing Company, LLC.)

This article describes the early sessions of a transdiagnostic cognitive-behavioral treatment for emotional disorders that is designed to target temperamental characteristics, particularly neuroticism and resulting emotion dysregulation, underlying all anxiety, depressive, and related disorders. These sessions facilitate clinical improvement by setting realistic expectations, fostering a collaborative therapeutic alliance, and improving motivation for change. Addressing these common factors in early sessions strengthens patient engagement, which is necessary for patients to benefit most greatly from subsequent treatment elements. We begin with a brief description of the treatment protocol and theoretical model. Next, we describe how the early sessions, specifically, are used to help facilitate application of later treatment skills that target specific psychopathological mechanisms. Finally, we present a clinical case example and utilize clinical vignettes from the early sessions to illustrate the therapy process. Specific clinical exchanges are highlighted to offer advice on how therapists can most effectively implement these procedures. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

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 (ES SG : UP = -1.72; SDP = -1.98), social anxiety (ES SG : UP = -1.33, -0.86; SDP = -1.60, -1.54), and depression (ES SG : 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., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Dysregulated anger is often present in the emotional (i.e., anxiety, mood, and related) disorders; however, it is rarely targeted in treatment. Transdiagnostic treatments, which focus on processes that contribute to dysregulated emotions across the range of psychopathology, might represent an efficient way to treat this anger. Using a subset of data from a recently completed equivalency trial comparing the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) to single diagnosis protocols (SDPs) for specific disorders, this study began exploring whether the UP led to great reductions in anger compared with the SDPs. Results indicated that there was a small, nonsignificant, decrease in anger in the UP condition, whereas there was a moderate, nonsignificant increase in anger in the SDP condition. At posttreatment, UP patients had significantly lower anger scores than patients who received an SDP. These preliminary results suggest that transdiagnostic treatments may be well poised to target dyregulated anger in the context of emotional disorders.

Background: Research increasingly supports a transdiagnostic conceptualization of emotional disorders (ie applying the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses), and many international researchers are currently investigating this issue., Objective: The aim of this study was to evaluate the efficacy and acceptability of a Web-based transdiagnostic program using a sample of Romanian adults diagnosed with anxiety and/or depression., Methods: Volunteer participants registered for the study and completed a series of online self-report measures. Participants who fulfilled basic inclusion criteria on these measures were contacted for a telephone diagnostic interview using the Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Axis I Disorders (SCID-I). Enrolled participants were randomized to either the active treatment group (N=69) or the wait-list control group (N=36) using a 2:1 ratio. The transdiagnostic treatment was based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al, 2011) that addresses common underlying mechanisms of anxiety and depression. Participants randomized to the active treatment condition received 10 weeks of Web-based treatment based on the UP. Throughout treatment, graduate students in clinical psychology provided guidance that consisted of asynchronous written communication on a secure Web platform. After the intervention, participants in both study conditions were invited to complete a set of self-report measures and a postintervention SCID-I interview conducted by a different team of graduate students blinded to participants' group and diagnostic status. Six months later, participants in the active treatment group were invited to complete an online follow-up assessment., Results: During the intervention, active treatment participants completed on average 19 homework assignments (SD 12.10), and we collected data from 79.0% (83/105) at postintervention and 51% (35/69) at follow-up for self-report measures. Postintervention SCID-I interviews were collected from 77.1% (81/105) participants. Relative to the wait-list control group, the transdiagnostic intervention yielded overall medium to large effect sizes for the primary outcome measures (within-group Hedges g=0.52-1.34 and between-group g=0.39-0.86), and also for anxiety sensitivity (g=0.80), symptom interference (g=0.48), and quality of life (g=0.38). Significant within-groups effects only were reported for the active treatment group on Panic Disorder Severity Scale-Self Report (PDSS-SR, g=0.58-0.65) and Yale-Brown Obsessive Compulsive Scale (Y-BOCS, g=0.52-0.58)., Conclusions: Insignificant between-group differences for the Y-BOCS and PDSS-SR could be explained by the small number of participants with the associated primary diagnostic (eg, only 3 participants with obsessive compulsive disorder) by the choice of outcome measure (PDSS-SR was not rated among the evidence-based measures) and by the fact that these disorders may be more difficult to treat. However, the overall results suggest that the transdiagnostic intervention tested in this study represents an effective treatment option that may prove easier to disseminate through the use of Web-based delivery systems., Trial Registration: ClinicalTrials.gov CT02739607; https://clinicaltrials.gov/ct2/show/study/NCT02739607 (Archived by WebCite at http://www.webcitation.org/6yY1VeYIZ)., (©Bogdan Tudor Tulbure, Andrei Rusu, Florin Alin Sava, Nastasia Sălăgean, Todd J Farchione. Originally published in JMIR Mental Health (http://mental.jmir.org), 24.05.2018.)

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., 2011a; Barlow, Sauer-Zavala, et al., in press) 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 versus 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 = .037, SE = .05, 95% CI [.005, .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., Competing Interests: Conflict of Interest Disclosures: Dr. Barlow receives royalties from Oxford University Press (which includes royalties for all five treatment manuals included in this study), Guilford Publications Inc., Cengage Learning, and Pearson Publishing. Grant monies for various projects come from the National Institute of Mental Health, the National Institute of Alcohol and Alcohol Abuse, and Colciencias (Government of Columbia Initiative for Science, Technology, and Health Innovation). Consulting and honoraria during the past several years have come from the Agency for Healthcare Research and Quality, the Foundation for Informed Medical Decision Making, the Department of Defense, the Renfrew Center, the Chinese University of Hong Kong, Universidad Católica de SantaMaria (Arequipa, Peru), New Zealand Psychological Association, Hebrew University of Jerusalem, Mayo Clinic, and various American Universities. There are no disclosures for the remaining authors.

Considerable work and attention has supported the use of behavioral activation (BA) strategies in the treatment of depressive disorders. Although not often recognized, BA, both implicitly and explicitly, appears to be conceptually and empirically relevant to the treatment of diverse problem areas, including the anxiety disorders. This article addresses the role of BA strategies in transdiagnostic cognitive-behavioral therapy (CBT) for anxiety and related disorders, including in cases without comorbid depression. Following a brief introduction to a transdiagnostic CBT model of anxiety and related disorders, this article will: (a) provide a rationale for the integration of BA strategies as a potentially potent facilitator of therapeutic change; (b) identify relevant treatment targets of BA in anxiety disorders; and (c) illustrate the implementation and impacts of these strategies using a clinical case example. Finally, suggestions for future research and implications for training and practice will be noted. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Behavioral activation (BA) is a treatment approach that uses functional analysis and context-dependent strategies to enhance environmental positive reinforcement for adaptive, healthy behavior, and decrease behavioral avoidance. BA has gained considerable support for the treatment of depression and can be broadly applied across a wide range of settings and clinical populations. In this article, we provide a brief description of BA as a therapeutic behavioral strategy for depression and present a clinical case example illustrating the integration of BA with other components of a transdiagnostic cognitive-behavioral treatment for emotional disorders. Implications for clinical practice and avenues for future research will be discussed. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

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., Trial Registration: clinicaltrials.gov Identifier: NCT01243606.

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 paper 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 approach., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT., Method: The current trial is a second-step stratified randomized design comparing two treatment conditions-selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)-in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively., Results: Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms., Conclusions: These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368., (© 2015 Wiley Periodicals, Inc.)

The present study explored whether distress reduction in response to strong negative emotions, a putative transdiagnostic mechanism of action, is facilitated by mindfulness strategies. Seven patients (mean age=31.14years, SD=12.28, range 19-48 years, 43% female, 86% Caucasian) with heterogeneous anxiety disorders (i.e., panic disorder with or without agoraphobia, social anxiety, generalized anxiety) were assigned a randomized order of weeklong blocks utilizing either mindfulness- or avoidance-based strategies while ascending a 6-week emotion exposure hierarchy. Participants completed three exposures per block and provided distress and avoidance use ratings following each exposure. Anxiety severity, distress aversion, and distraction/suppression tendencies were also assessed at baseline and the conclusion of each block. Visual, descriptive, and effect size results showing exposures utilizing mindfulness were associated with higher overall distress levels, compared with those utilizing avoidance. Within blocks, the majority of participants exhibited declining distress levels when employing mindfulness strategies, as opposed to more static distress levels in the avoidance condition. Systematic changes in anxiety severity, distress aversion, and distraction/suppression were not observed. These results suggest mindfulness strategies may be effective in facilitating emotion exposure; however, a minimum dosage may be necessary to overcome initial distress elevation. Potential transdiagnostic change mechanisms and clinical implications are discussed., (Copyright © 2015. Published by Elsevier Ltd.)

Both maladaptive and adaptive emotion regulation strategies have been linked with psychopathology. However, previous studies have largely examined them separately, and little research has examined the interplay of these strategies cross-sectionally or longitudinally in patients undergoing psychological treatment. This study examined the use and interplay of adaptive and maladaptive emotion regulation strategies in 81 patients receiving cognitive-behavioral interventions for comorbid alcohol use and anxiety disorders. Patients completed measures of emotion regulation strategy use and symptoms of psychopathology pre- and post-treatment. Cross-sectionally, higher use of maladaptive strategies (e.g., denial) was significantly related to higher psychopathology pre- and post-treatment, whereas higher use of adaptive strategies (e.g., acceptance) only significantly related to lower psychopathology post-treatment. Prospectively, changes in maladaptive strategies, but not changes in adaptive strategies, were significantly associated with post-treatment psychopathology. However, for patients with higher pre-treatment maladaptive strategy use, gains in adaptive strategies were significantly associated with lower post-treatment psychopathology. These findings suggest that psychological treatments may maximize efficacy by considering patient skill use at treatment outset. By better understanding a patient's initial emotion regulation skills, clinicians may be better able to optimize treatment outcomes by emphasizing maladaptive strategy use reduction predominately, or in conjunction with increasing adaptive skill use., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The aim of this study is to conduct a preliminary examination of long-term outcomes on a broad range of affective disorder symptoms treated with a newly developed intervention: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP)., Method: Maintenance of treatment gains at long-term follow-up (LTFU) were explored in patients (N=15, mean age=32.27; 60% female) who completed a clinical trial of the UP., Results: Treatment gains observed at 6-month follow-up (6MFU) on measures of clinical severity, general symptoms of depression and anxiety, and a measure of symptom interference in daily functioning were largely maintained 12months later (at an average of 18months posttreatment), and any significant changes from 6MFU to LTFU reflected small increases in symptoms that remained, on average, in the subclinical range., Conclusions: These findings provide the first initial support for the durability of broad treatment gains following transdiagnostic treatment., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background and Objectives: Obsessive-compulsive disorder (OCD) and eating disorders (EDs) show phenotypic similarities and have been independently associated with deficits in decision-making and maladaptive perfectionism. However, research directly comparing the two disorders is sparse and the significance of observed similarities remains in question. Therefore, the present study compared decision-making in OCD and EDs in relationship to perfectionistic personality traits., Methods: Sixty-one women were enrolled in the study comprising 3 mutually exclusive groups: 19 with OCD, 17 with EDs, and 21 healthy controls. Decision-making performance on the Iowa Gambling Task under two conditions, ambiguity and risk, was examined in relationship to perfectionistic traits., Results: Behavioral results indicated that EDs participants, relative to both OCD and control participants, were impaired in decision-making under conditions of risk. Heightened perfectionism was associated with less risky decision-making in OCD, but more risky decision-making in EDs., Limitations: Sample size was small and all participants were women, which may limit generalizability., Conclusion: Results support decision-making deficits in EDs, which may be related to a dysfunctional determination of risk versus reward. This study is the first to suggest that the relationship between perfectionism and risk taking may manifest differently in these phenotypically similar disorders., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N=54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS., (Copyright © 2013. Published by Elsevier Ltd.)

Unlabelled: Intolerance of uncertainty (IU) is a characteristic predominantly associated with generalized anxiety disorder (GAD); however, emerging evidence indicates that IU may be a shared element of emotional disorders., Aims: This study aimed to examine IU across diagnostic categories, change in IU during transdiagnostic treatment, and the relationship between change in IU and treatment outcome., Method: Patients diagnosed with heterogeneous anxiety and depressive disorders received up to 18 weeks of a transdiagnostic cognitive-behavioral therapy intervention. Patient self-reported IU and self-report and clinician-rated symptom/functioning measures were administered at pretreatment and posttreatment., Results: When controlling for negative affectivity, IU correlated with measures of depressive symptoms and worry severity at pretreatment. Patients with GAD and panic disorder exhibited the highest pretreatment IU scores, yet IU scores did not differ significantly based on the presence or absence of a specific diagnosis. A significant decrease in IU was observed, and change in IU was related to reduced anxiety and depressive symptom levels at posttreatment across diagnostic categories., Discussion: Change in IU can be observed across problem areas in transdiagnostic treatment and such change is correlated with treatment outcome., (© 2013 Wiley Periodicals, Inc.)

Thought-action fusion (TAF) is a cognitive error that has been frequently investigated within the context of obsessive-compulsive disorder (OCD). However, evidence suggests that this error may also be present in disorders other than OCD, indicating that TAF is related to higher order factors rather than a specific diagnosis. We explored TAF in a sample of patients with mixed diagnoses undergoing treatment with a transdiagnostic CBT protocol. Elevated TAF levels at baseline were not specific to patients with OCD. However, the presence of any generalized anxiety disorder (GAD) diagnosis was unexpectedly the strongest predictor of likelihood TAF. Likelihood TAF, a particular component of TAF, was reduced after transdiagnostic treatment, and this reduction was not affected by the presence of a GAD diagnosis. Results indicate that TAF is responsive to treatment and should be assessed and, perhaps, treated in disorders beyond OCD.