Kristen K. Ellard

Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial.

This study further evaluates the efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP). A diagnostically heterogeneous clinical sample of 37 patients with a principal anxiety disorder diagnosis was enrolled in a randomized controlled trial (RCT) involving up to 18 sessions of treatment and a 6-month follow-up period. Patients were randomly assigned to receive either immediate treatment with the UP (n=26) or delayed treatment, following a 16-week wait-list control period (WLC; n=11). The UP resulted in significant improvement on measures of clinical severity, general symptoms of depression and anxiety, levels of negative and positive affect, and a measure of symptom interference in daily functioning across diagnoses. In comparison, participants in the WLC condition exhibited little to no change following the 16-week wait-list period. The effects of UP treatment were maintained over the 6-month follow-up period. Results from this RCT provide additional evidence for the efficacy of the UP in the treatment of anxiety and comorbid depressive disorders, and provide additional support for a transdiagnostic approach to the treatment of emotional disorders.

The Nature, Diagnosis, and Treatment of Neuroticism Back to the Future

We highlight the role of neuroticism in the development and course of emotional disorders and make a case for shifting the focus of intervention to this higher-order dimension of personality. Recent decades have seen great emphasis placed on differentiating disorders into Diagnostic and Statistical Manual of Mental Disorders diagnoses; however, evidence has suggested that splitting disorders into such fine categories may be highlighting relatively trivial differences. Emerging research on the latent structure of anxiety and mood disorders has indicated that trait neuroticism, cultivated through genetic, neurobiological, and psychological factors, underscores the development of these disorders. We raise the possibility of a new approach for conceptualizing these disorders—as emotional disorders. From a service-delivery point of view, we explore the possibility that neuroticism may be more malleable than previously thought and may possibly be amenable to direct intervention. The public-health implications of directly treating and even preventing the development of neuroticism would be substantial.

Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders

Anxiety and mood disorders are common, chronic, costly, and characterized by high comorbidity. The development of cognitive behavioral approaches to treating anxiety and mood disorders has left us with highly efficacious treatments that are increasingly widely accepted. The proliferation of treatment manuals targeting single disorders, sometimes with trivial differences among them, leaves the mental health professional with no clear way to choose one manual over another and little chance of ever becoming familiar with most of them, let alone trained to competence in their delivery. Deepening understanding of the nature of emotional disorders reveals that commonalities in etiology and latent structures among these disorders supersedes differences. Based on empirical evidence from the domains of learning, emotional development and regulation, and cognitive science, we have distilled a set of psychological procedures that comprise a unified intervention for emotional disorders. The Unified Protocol (UP) is a transdiagnostic, emotion‐focused cognitive behavioral treatment, which emphasizes the adaptive, functional nature of emotions, and seeks to identify and correct maladaptive attempts to regulate emotional experiences, thereby facilitating appropriate processing and extinction of excessive emotional responding to both internal (somatic) and external cues. The treatment components of the UP are briefly outlined. Theory and rationale supporting this new approach are described along with some preliminary evidence supporting its efficacy. Implications for the treatment of emotional disorders using the UP are discussed. Depression and Anxiety, 2010.

The Origins of Neuroticism

In this article, we provide a fresh perspective on the developmental origins of neuroticism—a dimension of temperament marked by elevated stress reactivity resulting in the frequent experience of negative emotions. This negative affectivity is accompanied by a pervasive perception that the world is a dangerous and threatening place, along with beliefs about one’s inability to manage or cope with challenging events. Historically, neuroticism has been viewed as a stable, genetically based trait. However, recent understanding of ongoing gene–environment interactions that occur throughout the life span suggests there may be a more complex and dynamic etiology. Thus, the purpose of this article is to offer a theory for understanding the development of neuroticism that integrates genetic, neurobiological, and environmental contributions to this trait. Given the strong correlation between neuroticism and the development of negative health outcomes—most notably, the full range of anxiety and mood disorders—an enhanced understanding of how neuroticism originates has implications for the treatment and prevention of a broad range of pathologies and, perhaps, even for the prevention of neuroticism itself.

United We Stand: Emphasizing Commonalities Across Cognitive-Behavioral Therapies

Cognitive behavioral therapy (CBT) has a rich history of alleviating the suffering associated with mental disorders. Recently, there have been exciting new developments, including multicomponent approaches, incorporated alternative therapies (e.g., meditation), targeted and cost-effective technologies, and integrated biological and behavioral frameworks. These field-wide changes have led some to emphasize the differences among variants of CBT. Here, we draw attention to commonalities across cognitive-behavioral therapies, including shared goals, change principles, and therapeutic processes. Specifically, we offer a framework for examining common CBT characteristics that emphasizes behavioral adaptation as a unifying goal and three core change principles, namely (a) context engagement to promote adaptive imagining and enacting of new experiences; (b) attention change to promote adaptive sustaining, shifting, and broadening of attention; and (c) cognitive change to promote adaptive perspective taking on events so as to alter verbal meanings. Further, we argue that specific intervention components, including behavioral exposure/activation, attention training, acceptance/tolerance, decentering/defusion, and cognitive reframing, may be emphasized to a greater or lesser degree by different treatment packages but are still fundamentally common therapeutic processes that are present across approaches and are best understood by their relationships to these core CBT change principles. We conclude by arguing for shared methodological and design frameworks for investigating unique and common characteristics to advance a unified and strong voice for CBT in a widening, increasingly multimodal and interdisciplinary, intervention science.

Neurobiological correlates of cognitions in fear and anxiety: a cognitive-neurobiological information-processing model.

We review likely neurobiological substrates of cognitions related to fear and anxiety. Cognitive processes are linked to abnormal early activity reflecting hypervigilance in subcortical networks involving the amygdala, hippocampus, and insular cortex, and later recruitment of cortical regulatory resources, including activation of the anterior cingulate cortex and prefrontal cortex to implement avoidant response strategies. Based on this evidence, we present a cognitive–neurobiological information-processing model of fear and anxiety, linking distinct brain structures to specific stages of information processing of perceived threat.

Transdiagnostic Treatment of Bipolar Disorder and Comorbid Anxiety with the Unified Protocol: A Clinical Replication Series.

Bipolar disorder (BD) is a chronic, debilitating disorder with recurrent manic and depressive episodes. More than 75% of bipolar patients have a current or lifetime diagnosis of a comorbid anxiety disorder. Comorbid anxiety in BD is associated with greater illness severity, greater functional impairment, and poorer illness-related outcomes. Effectively treating comorbid anxiety in individuals with BD has been recognized as one of the biggest unmet needs in the field of BD. Recently, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) was developed to be applicable to the full range of anxiety and mood disorders, based on converging evidence from genetics, cognitive and affective neuroscience, and behavioral research suggesting common, core emotion-related pathology. Here, the authors present a preliminary evaluation of the efficacy of the UP for the treatment of BD with comorbid anxiety, in a clinical replication series consisting of three cases.

Suppression of Emotions in Essential Dyspepsia and Chronic Duodenal Ulcer: A Case-Control Study

It remains controversial whether psychologic factors contribute to the onset or chronicity of non-ulcer dyspepsia (NUD) and duodenal ulcer. Although such patients on conventional psychologic testing have no clearly defined specific personality type, an inability to express emotion, which may result in excessive autonomic arousal, has been suggested to be important on theoretic grounds. The aim of this study was to assess whether the latter defect is associated with the subgroup of NUD patients with essential dyspepsia and with patients with chronic duodenal ulcer. Eighty-one patients with essential dyspepsia and 53 patients with duodenal ulcer studied after endoscopy were compared with 82 randomly selected dyspepsia-free community controls. All were assessed with the Courtauld emotional control scale, a valid and objective self-report measure. Control of anger, anxiety, unhappiness, and total emotional control over negative reactions were similar in all three groups. It is concluded that patients with essential dyspepsia and duodenal ulcer who present for investigation are unlikely to repress emotional reactions consciously.

Transdiagnostic treatment of bipolar disorder and comorbid anxiety using the Unified Protocol for Emotional Disorders: A pilot feasibility and acceptability trial

BACKGROUND Comorbid anxiety in bipolar disorder (BD) is associated with greater illness severity, reduced treatment response, and greater impairment. Treating anxiety in the context of BD is crucial for improving illness course and outcomes. The current study examined the feasibility, acceptability and preliminary efficacy of the Unified Protocol (UP), a transdiagnostic cognitive behavioral therapy, as an adjunctive treatment to pharmacotherapy for BD and comorbid anxiety disorders. METHODS Twenty-nine patients with BD and at least one comorbid anxiety disorder were randomized to pharmacotherapy treatment-as-usual (TAU) or TAU with 18 sessions of the UP (UP+TAU). All patients completed assessments every four weeks to track symptoms, functioning, emotion regulation and temperament. Linear mixed-model regressions were conducted to track symptom changes over time and to examine the relationship between emotion-related variables and treatment response. RESULTS Satisfaction ratings were equivalent for both treatment groups. Patients in the UP+TAU group evidenced significantly greater reductions over time in anxiety and depression symptoms (Cohens ds>0.80). Baseline levels of neuroticism, perceived affective control, and emotion regulation ability predicted magnitude of symptom change for the UP+TAU group only. Greater change in perceived control of emotions and emotion regulation skills predicted greater change in anxiety related symptoms. LIMITATIONS This was a pilot feasibility and acceptability trial; results should be interpreted with caution. CONCLUSIONS Treatment with the UP+TAU was rated high in patient satisfaction, and resulted in significantly greater improvement on indices of anxiety and depression relative to TAU. This suggests that the UP may be a feasible treatment approach for BD with comorbid anxiety.

Memory performance predicts response to psychotherapy for depression in bipolar disorder: A pilot randomized controlled trial with exploratory functional magnetic resonance imaging

OBJECTIVE This pilot randomized controlled trial compared Cognitive Behavior Therapy (CBT) and Supportive Psychotherapy (SP) for the treatment of depression in bipolar I disorder. We also examined whether exploratory verbal memory, executive functioning, and neural correlates of verbal memory during functional magnetic resonance imaging (fMRI) predicted change in depression severity. METHODS Thirty-two adults (ages 18-65) with DSM-IV bipolar I disorder meeting current criteria for a major depressive episode were randomized to 18 weeks of CBT or SP. Symptom severity was assessed before, at the mid-point, and after the 18-week intervention. All participants completed a brief pre-treatment neuropsychological testing battery (including the California Verbal Learning Test-2nd Edition, Delis Kaplan Executive Functioning System [DKEFS] Trail-making Test, and DKEFS Sorting Test), and a sub-set of 17 participants provided usable fMRI data while completing a verbal learning paradigm that consisted of encoding word lists. RESULTS CBT and SP yielded comparable improvement in depressive symptoms from pre- to post-treatment. Better retention of learned information (CVLT-II long delay free recall vs. Trial 5) and recognition (CVLT-II hits) were associated with greater improvement in depression in both treatments. Increased activation in the left dorsolateral prefrontal cortex and right hippocampus during encoding was also related to depressive symptom improvement. LIMITATIONS Sample size precluded tests of clinical factors that may interact with cognitive/neural function to predict treatment outcome. CONCLUSION Neuropsychological assessment and fMRI offer additive information regarding who is most likely to benefit from psychotherapy for bipolar depression.