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Asia Pac J Clin Trials Nerv Syst Dis 2018,  3:151

Transdiagnostic cognitive behavioral therapy based on unified protocol: new approach to emotional disorders

Department of Clinical Psychology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran

Date of Submission30-Jun-2018
Date of Decision01-Oct-2018
Date of Acceptance04-Oct-2018
Date of Web Publication19-Nov-2018

Correspondence Address:
Omid Saed
Department of Clinical Psychology, School of Medicine, Zanjan University of Medical Sciences, Zanjan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2542-3932.245225

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One of the new and evidence-based interventions recently developed to address psychological disorders is the unified protocol for transdiagnostic treatment of emotional disorders. The protocol was designed using transdiagnostic theories emphasizing the commonalities between disorders. The present work aimed to provide an overview of the unified protocol by reviewing the theories and studies carried out in this area.

Keywords: transdiagnostic approach; unified protocol; emotional disorders; psychopathology

How to cite this article:
Khakpoor S, Saed O. Transdiagnostic cognitive behavioral therapy based on unified protocol: new approach to emotional disorders. Asia Pac J Clin Trials Nerv Syst Dis 2018;3:151-5

How to cite this URL:
Khakpoor S, Saed O. Transdiagnostic cognitive behavioral therapy based on unified protocol: new approach to emotional disorders. Asia Pac J Clin Trials Nerv Syst Dis [serial online] 2018 [cited 2020 Jan 23];3:151-5. Available from: http://www.actnjournal.com/text.asp?2018/3/4/151/245225

  Introduction Top

Over the last few decades, diagnosis-specific cognitive-behavioral approaches have been recognized as evidence-based approaches for a range of disorders, especially emotional disorders, and several meta-analyses have demonstrated their efficacy (Butler et al., 2006; Hofmann et al., 2012). However, this dominant paradigm has limitations, such as low attention to comorbidities, multiple underlying theories for each specific diagnosis, multiple treatment protocols, patients’ limited access to the most effective treatment, and the difficulty of training a doctor to specialist level (Pearl and Norton, 2016). In response to these limitations and due to the expansion of our understanding of the nature of emotional disorders, a new generation of cognitive-behavioral approaches has been introduced to experts as the concept of transdiagnosis in the last two decades (Barlow et al., 2004).

The transdiagnostic approach refers to the therapeutic principles and common underlying psychosocial problems across mental disorders and does not necessarily compatible with specific diagnoses (McEvoy et al., 2009). This approach makes the commonality between disorders is greater than the difference between them. A review of studies conducted over the past two decades suggests that the transdiagnostic approach includes two main areas: First, this approach is a process-based approach, meaning that it emphasizes on common underlying processes among disorders. In this regard, various pathological theories have been identified and many transdiagnostic and cognitive-behavioral processes have been identified (Mansell et al., 2008). Second, this approach seeks to treat comorbid disorders through the development of new and unified therapeutic protocols (Barlow et al., 2004; Pearl and Norton, 2016). This has led to a wide range of studies to reach the appropriate treatment framework for emotional disorders. Each of these two areas is discussed further.

  Search Strategy and Selection Criteria Top

Inclusion criteria for the current review were the following: a) treatment modality was primarily transdiagnostic cognitive-behavioral therapy; b) the treatment protocol was applied in the individual format; and c) studies included unified model presented by Barlow. To identify studies which were appropriate for surveying transdiagnostic approach, we conducted systematic searches of the electronic databases American Psychological Association (PsychInfo), PubMed, Scopus, and Google Scholar up to 2017. In order to identify transdiagnostic studies the following parameters were searched: transdiagnostic OR unified protocol and cognitive-behavioral/behavior therapy AND mediation OR vulnerability and emotional disorder OR anxiety OR depression. In addition, references sections of all identified papers were scrutinized for additional published papers in this area. We restricted searches to studies in English, relating to humans, published after 01/01/1980. The full electronic searches are shown in [Table 1].
Table 1: Database search strategy

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  Psychopathology of Emotional Disorders Top

Findings from research suggest that there is a high comorbidity among emotional disorders, especially between anxiety and depression disorders (Watson et al., 1988; Kessler et al., 2005). Various psychopathological theories were presented to explain this level of comorbidity between emotional disorders. For example, Clark and Watson (1991) proposed “negative affect” in their tripartite model as a common underlying factor among anxiety and depression disorders. Barlow also proposed his “triple vulnerability model” based on research findings in the fields of genetics, personality, cognitive science, neuroscience and learning and emotion theories. According to this model, the negative affect is the result of two common vulnerabilities among emotional disorders. These two vulnerabilities, “general biological vulnerability” and “general psychological vulnerability” create a feeling of uncontrollability and unpredictability of the environment in the individual (Barlow, 2004, 2014). According to Barlow, these two vulnerabilities are activated under stressful conditions. However, it is also necessary to have a different level of susceptibility, namely “specific psychological vulnerability” for the development of psychological disorders (Barlow, 2004). Regarding the triple vulnerability model, it seems that two types of general vulnerability describe a more stable state in experience of anxiety. Evidences also support the more effective role of two general vulnerabilities in comparison with third vulnerability (Barlow, 2004). In this situation, a unified approach to emotional disorders seems to improve our understanding of this group of disorders.

  Transdiagnostic Factors Top

Various studies were designed to achieve a unified approach. Early attempts to find common factors that underlie psychological disorders began with the work of Achenbach & Edelbrock. They tried to categorize childhood behavioral problems by more general factors than existing diagnostic criteria (Achenbach and Edelbrock, 1978). Subsequently, with the advent of the transdiagnostic approach, the search for transdiagnostic factors got expanded. Transdiagnostic factors are common underlying factors among emotional disorders. According to the triple vulnerability model, the biological components and early life experiences can lead to develop the underlying vulnerabilities or the transdiagnostic factors in individuals. These factors can interact with the individual experiences of each person during their lifetime, causing and maintaining emotional disorders. Various factors have been identified so far such as perceived control (Gallagher et al., 2014), intolerance of uncertainty (Carleton, 2012), anxiety sensitivity (Deacon and Abramowitz, 2006), emotion regulation (Aldao, 2012), experiential avoidance (Spinhoven et al., 2014), and negative repetitive thinking (Hsu et al., 2015). Eaton et al. (2015) generally divided the transdiagnostic factors into two categories: internal and external transdiagnostic factors. Internal transdiagnostic factors are often associated with mood and anxiety disorders while external transdiagnostic factors explain the common variance of substance use disorders, impulse control, and antisocial personality disorder. Researches are indicated that the transdiagnostic factors can be considered as an underlying vulnerability to emotional disorders between ethnicities (Eaton et al., 2013), genders (Eaton, 2014), and ages (Eaton et al., 2011).

  Unified and Transdiagnostic Treatments Top

Along with the search for common processes among emotional disorders, attempts have been made to achieve a unified and efficient treatment for these disorders, and ultimately led to the formation of two main therapeutic flows. The first flow is a pragmatic approach which has been formed based on the work of Erickson et al. (2009) This approach is based on the belief that effective treatments for a particular disorder can also be used to treat other disorders. For example, interoceptive exposure that is mainly used to treat panic disorder can be used to treat social anxiety disorder too (Erickson et al., 2009). In contrast, the second is a theory-oriented approach and runs from bottom up. It identifies processes or underlying factors that are thought to be present in a wide range of emotional disorders, and develops treatments around them. In this regard, according to the evidence, Barlow presented his initial treatment model, the unified protocol (UP), in 2004. UP is a personalized transdiagnostic treatment designed for emotional disorders. The overall aim of the UP is to address the underlying factors, emotion regulation strategies and maladaptive behaviors, and is described as emotion-focused cognitive-behavioral therapy (CBT). Compared with traditional CBT, UP clearly emphasizes the interaction between thoughts, feelings and behaviors in creating emotional experiences, as well as the role of emotion in modifying these experiences.

The initial version of this protocol included sessions that consisted of three main sections: the change in the antecedent cognitive reappraisal, prevention of emotional avoidance and modification of emotion-driven action tendencies, and a sub-division called psychoeducation (Barlow et al., 2004). These sections were eventually practiced and used by interoceptive and situational exposure. This version was reviewed and evaluated in a pilot study. The results of this study showed that UP reduces the severity and frequency of symptoms of pincipal and co-occurring disorders before and after treatment and influences negative affect. However, only one-third of the participants showed high end-state function. Also, despite a decrease in negative affect, this reduction was reported in moderate level (Ellard et al., 2010). These preliminary evidences resulted in changes in the protocol and publication of the revised version in 2011. Instead of sessions, the new version is made up of modules that enhance the flexibility of this protocol in working with a diverse range of patients. In addition, in the revised version, techniques were added to enhance the patient’s motivation, and positive emotions were more strongly emphasized. These changes were made in response to the findings of Westra et al. (2009), suggesting that the motivational interview could increase the effectiveness of CBT for anxiety disorders. The final version of the UP generally consists of 8 modules and has five main sections: 1 - emotion awareness, 2 - cognitive flexibility, 3 - prevention of experiential avoidance, 4 - awareness and tolerance of emotion-driven physical sensations, and 5 - interoceptive and situation-based emotion-focused exposure. Other sections include enhancing motivation, psychoeducation and relapse prevention (Barlow et al., 2011). In this version, each dimension of thoughts, feelings and behaviors, and their interaction are more clearly addressed, and emotional experiences are considered within the context of present moment. Additionally, the maladaptive emotion regulation strategies in each of these dimensions are searched and adaptive emotional regulation skills are trained. Many studies support the efficacy of this protocol in the treatment of a wide range of emotional disorders (Norton and Paulus, 2016; Pearl and Norton, 2016; Saed et al., 2016).

Along with the development of a UP for adults, studies have also been conducted to use this protocol in the treatment of children and adolescents with emotional disorders. First, in 2009, the initial version of the UP for adolescents was investigated by Ehrenreich et al. (2009) in a case study. The results led to the development of a revised version of this protocol. The revised version of the UP for children and adolescents, as its adult version, consists of five main sections adapted for child and adolescent age groups (Ehrenreich-May and Chu, 2013). Although this field requires more evidence, the few trials conducted on this version support the efficacy of the UP for adolescents (Seager et al., 2014; Ehrenreich-May et al., 2017).

  Review of Literature on UP for the Transdiagnostic Treatment of Emotional Disorders Top

McEvoy et al. (2009) examined the efficacy of transdiagnostic treatments of emotional disorders in their meta-analysis. Their results showed that transdiagnostic treatments generally improve the symptoms of principal diagnosis and comorbid disorders, as well as performance in comparison with the control group. The results also indicated that patients were more satisfied and accompanied with this treatment, and had more positive therapeutic expectations. In a clinical trial, Ellard et al. (2010) reviewed a revised version of the UP. Their results showed a significant improvement in the severity of clinical symptoms, the general severity of depression and anxiety, negative affect levels, and the degree of interference of symptoms with daily life. In another trial conducted by Farchione et al. (2012), the efficacy of the revised version of the UP for the treatment of anxiety disorders compared to the control group was investigated. The results indicated that the treatment was associated with a reduction in the severity of symptoms both in the principal and comorbid diagnosis, as well as the reduction in functional impairment compared to the control group.

Lopez et al. (2015) used the UP for the treatment of people with borderline personality disorder. They find out that treatment was successful in reducing symptoms in half of the patients (4 out of 8 patients). Limited evidence also supports the efficacy of this protocol in the treatment of patients with bipolar disorder associated with anxiety disorder (Ellard et al., 2012). In a pilot study, Varkovitzky et al. (2017) examined the efficacy of the transdiagnostic group CBT based on UP for post-traumatic stress disorder among veterans. Their results showed a significant reduction in symptoms of post-traumatic stress disorder, depression, and difficulty in emotion regulation.

In another study, Seager et al. (2017) reviewed a revised version of the UP for adolescents and introduced it as an effective treatment for emotional disorders. In a clinical trial, Ehrenreich-May et al. (2017) also examined the efficacy of this protocol, and offered promising results in support of the use of the UP for the treatment of adolescent emotional disorders.

Among the studies on the UP, some studies have examined the mediators of the outcomes in this treatment. Boswell et al. (2012) reviewed the readiness to change as a moderating factor of outcomes in the UP. They suggest that this factor can moderate the severity of the relationship between symptom severity and treatment outcomes (Boswell et al., 2012). Evidence from another study indicates that perceived control of patients could be a predictor of the UP outcomes (Gallagher et al., 2014). The intolerance of uncertainty has also been studied as a mediator of the therapeutic implications of the UP. It seems that changes in the intolerance of uncertainty can significantly predict the severity of symptoms after treatment (Boswell et al., 2013). Boswell et al. (2013) found that the reduction in anxiety sensitivity was associated with the reduction in the severity of symptoms after treatment, and anxiety sensitivity could be considered as one of the mediators of the UP outcomes. The role of behavioral activation in CBT of anxiety disorders was also investigated. In this study, authors attempted to provide a rationale for using behavioral activation strategies in therapeutic change and identified the therapeutic goals associated with behavioral activation in anxiety disorders.

  Conclusions and Future Directions Top

In the last few decades, with the advent of the transdiagnostic approach, a new attitude has been created in the etiology and treatment of emotional disorders. This approach suggests that emotional disorders have shared bases that have defined as transdiagnostic factors. Evidences suggest that the UP for the transdiagnostic treatment of emotional disorders can address these common factors and thereby reduce the symptoms of emotional disorders.

In spite of extensive evidence supporting the efficacy of the UP, this area requires further and more accurate exploration. In recent years, there has been a growing trend in the application of the transdiagnostic treatment of different age groups, and therapeutic protocols have been developed for children and adolescents. Given the limited evidence to support the efficacy of this protocol in the treatment of emotional disorders in children and adolescents, it seems that this area requires more clinical studies and trials.

One of the important issues in the study of the efficacy of treatments is to identify its effective mechanism. In other words, recognizing the UP mechanism of action and identifying the unit role of the transdiagnostic structures as the mediator of treatment outcomes can help to improve and extend this treatment. The existing evidence on UP indicates that this protocol has been used to treat anxiety and depression disorders while treatment of the disorders such as bipolar disorder, impulse control disorders, personality disorders or problems such as procrastination using UP has not been reported. Therefore, it seems necessary to carry out studies that examine the efficacy of transdiagnostic approach in other psychological disorders.

  References Top

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We would like to thank Deputy of Research and Technology for his assistance in this work.
Author contributions
Conception and design of the work: OS; data collection and manuscript preparation: SK and OS. Both authors approved the final version of this manuscript for publication.
Conflicts of interest
None declared.
Financial support
Copyright license agreement
The Copyright License Agreement has been signed by both authors before publication.
Plagiarism check
Checked twice by iThenticate.
Peer review
Externally peer reviewed.


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