Asia Pacific Journal of Clinical Trials: Nervous System Diseases

: 2018  |  Volume : 3  |  Issue : 4  |  Page : 151--155

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

Sahel Khakpoor, Omid Saed 
 Department of Clinical Psychology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran

Correspondence Address:
Omid Saed
Department of Clinical Psychology, School of Medicine, Zanjan University of Medical Sciences, Zanjan


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.

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;3:151-155

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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 2019 Feb 20 ];3:151-155
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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

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}

 Psychopathology of Emotional Disorders

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

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

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

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

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. [40]


1Achenbach TM, Edelbrock CS (1978) The classification of child psychopathology: a review and analysis of empirical efforts. Psychol Bull 85:1275-1301.
2Aldao A (2012) Emotion regulation strategies as transdiagnostic processes: A closer look at the invaiance of their from and function. J Clin Psychol 2012;17:261-277.
3Barlow DH (2004) Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.
4Barlow DH, Allen LB, Choate ML (2004) Toward a unified treatment for emotional disorders. Behav Ther 47:838-853.
5Barlow DH, Ellard KK, Sauer-Zavala S, Bullis JR, Carl JR (2014) The origins of neuroticism. Perspect Psychol Sci 9:481-496.
6Barlow DH, Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL, Allen LB, Ehrenreich-May J (2011) Unified protocol for transdiagnostic treatment of emotional disorders: therapist guide. New York: Oxford University Press, Inc.
7Boswell JF, Thompson-Hollands J, Farchione TJ, Barlow DH (2013) Intolerance of uncertainty: a common factor in the treatment of emotional disorders. Clin Psychol 69:630-645.
8Boswell JF, Iles BR, Gallagher MW, Farchione TJ (2017) Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders. Psychotherapy (Chic) 54:231-236.
9Boswell JF, Sauer-Zavala SE, Gallagher MW, Delgado NK, Barlow DH (2012) Readiness to change as a moderator of outcome in transdiagnostic treatment. Psychother Res 22:570-578.
10Boswell JF, Farchione TJ, Sauer-Zavala S, Murray HW, Fortune MR, Barlow DH (2013) Anxiety sensitivity and interoceptive exposure: a transdiagnostic construct and change strategy. Behav Ther 44:417-431.
11Butler AC, Chapman JE, Forman EM, Beck AT (2006) The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 26:17-31.
12Carleton RN (2012) The intolerance of uncertainty construct in the context of anxiety disorders: theoretical and practical perspectives. Expert Rev Neurother 12:937-947.
13Clark LA, Watson D (1991) Tripartite model of anxiety and depression: psychometric evidence and taxonomic implications. J Abnorm Psychol 100:316-336.
14Deacon B, Abramowitz J (2006) Anxiety sensitivity and its dimensions across the anxiety disorders. J Anxiety Disord 20:837-857.
15Eaton NR (2014) Transdiagnostic psychopathology factors and sexual minority mental health: evidence of disparities and associations with minority stressors. Psychol Sex Orientat Gend Divers 1:244.
16Eaton NR, Krueger RF, Oltmanns TF (2011) Aging and the structure and long-term stability of the internalizing spectrum of personality and psychopathology. Psychol Aging 26:987-993.
17Eaton NR, Rodriguez-Seijas C, Carragher N, Krueger RF (2015) Transdiagnostic factors of psychopathology and substance use disorders: a review. J Affect Disord 188:22-27.
18Eaton NR, Keyes KM, Krueger RF, Noordhof A, Skodol AE, Markon KE, Grant BF, Hasin DS (2013) Ethnicity and psychiatric comorbidity in a national sample: evidence for latent comorbidity factor invariance and connections with disorder prevalence. Soc Psychiatry Psychiatr Epidemiol 48:701-710.
19Ehrenreich-May J, Chu BC (2013) Transdiagnostic treatments for children and adolescents: Principles and practice. New York: Guilford Publications.
20Ehrenreich-May J, Rosenfield D, Queen AH, Kennedy SM, Remmes CS, Barlow DH (2017) An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in adolescents. J Anxiety Disord 46:46-55.
21Ehrenreich JT, Goldstein CR, Wright LR, Barlow DH (2009) Development of a unified protocol for the treatment of emotional disorders in youth. Child Fam Behav Ther 31:20-37.
22Ellard KK, Fairholme CP, Boisseau CL, Farchione TJ, Barlow DH (2010) Unified protocol for the transdiagnostic treatment of emotional disorders: protocol development and initial outcome data. Cogn Behav Pract 17:88-101.
23Ellard KK, Deckersbach T, Sylvia LG, Nierenberg AA, Barlow DH (2012) Transdiagnostic treatment of bipolar disorder and comorbid anxiety with the unified protocol: a clinical replication series. Ellard KK1Behav Modif 36:482-508.
24Erickson DH, Janeck AS, Tallman K (2009) Transdiagnostic group CBT for anxiety: Clinical experience and practical advice. J Cogn Psychother 23:34-43.
25Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL, Thompson-Hollands J, Carl JR, Gallagher MW, Barlow DH (2012) Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behav Ther 43:666-678.
26Gallagher MW, Bentley KH, Barlow DH (2014) Perceived control and vulnerability to anxiety disorders: a meta-analytic review. Cognit Ther Res 38:571-584.
27Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A (2012) The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res 36:427-440.
28Hsu KJ, Beard C, Rifkin L, Dillon DG, Pizzagalli DA, Björgvinsson T (2015) Transdiagnostic mechanisms in depression and anxiety: the role of rumination and attentional control. J Affect Disord 188:22-27.
29Kessler RC, Chiu W, Demler O, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month dsm-iv disorders in the national comorbidity survey replication. Arch Gen Psychiatry 62:617-627.
30Lopez ME, Stoddard JA, Noorollah A, Zerbi G, Payne LA, Hitchcock CA, Meier EA, Esfahani AM, Ray DB (2015) Examining the efficacy of the unified protocol for transdiagnostic treatment of emotional disorders in the treatment of individuals with borderline personality disorder. Cogn Behav Pract 22:522-533.
31Mansell W, Harvey A, Watkins ER, Shafran R (2008) Cognitive behavioral processes across psychological disorders: a review of the utility and validity of the transdiagnostic approach. Int J Cogn Ther 1:181-191.
32McEvoy PM, Nathan P, Norton PJ (2009) Efficacy of transdiagnostic treatments: A review of published outcome studies and future research directions. J Cogn Psychother 23:20-33.
33Norton PJ, Paulus DJ (2016) Toward a unified treatment for emotional disorders: update on the science and practice. Behav Ther 47:854-868.
34Pearl SB, Norton PJ (2016) Transdiagnostic versus diagnosis specific therapies cognitive behavioural for anxiety: a meta-analysis. J Anxiety Disord 7:1-14.
35Saed O, Masjedi A, Taremian F, Bakhtyari M, Morsali Y (2016) The efficacy of transdiagnostic cognitive behavior therapy on reducing symptoms severity of obsessive compulsive disorder with co-occurring anxiety and mood disorders. Int J Appl Behav Sci 2:1-10.
36Seager I, Rowley AM, Ehrenreich-May J (2014) Targeting common factors across anxiety and depression using the unified protocol for the treatment of emotional disorders in adolescents. J Ration Emot Cogn Behav Ther 32:67-83.
37Spinhoven P, Drost J, Rooij Md, Hemert AMv, Penninx BW (2014) A longitudinal study of experiential avoidance in emotional disorders. Behav Ther 45:840-850.
38Varkovitzky RL, Sherrill AM, Reger GM (2017) Effectiveness of the unified protocol for transdiagnostic treatment of emotional disorders among veterans with posttraumatic stress disorder: a pilot study. Behav Modif 42:210-230.
39Watson D, Clark LA, Tellegen A (1988) Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 54:1063-1070.
40Westra HA, Arkowitz H, Dozois DJ (2009) Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: a preliminary randomized controlled trial. J Anxiety Disord 23:1106-1117.