Transdiagnostic Approaches to the Treatment of Anxiety and Emotional Disorders:

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1 Transdiagnostic Approaches to the Treatment of Anxiety and Emotional Disorders: Peter J. Norton, Ph.D. Disclosures Funded by grants and awards from: American Psychological Association National Institute of Mental Health University of Nebraska Lincoln University of Houston Royalties received from: Anti-Anxiety Workbook (Guilford) Group Cognitive-Behavioral Therapy for Anxiety: A Transdiagnostic Treatment Manual (Guilford) 2 1

2 What are Transdiagnostic Models and Transdiagnostic CBT? Transdiagnostic Models of Emotional Disorders Proposes that different anxiety (and related) disorders reflect predominantly morphological variations vs ontological differences * Norton, P. J. & Paulus, D. J. (in press). Transdiagnostic models of anxiety disorder: Theoretical and empirical underpinnings. Clinical Psychology Review. doi: /j.cpr Transdiagnostic CBT for Emotional Disorders Intervention applicable across anxiety (and related) diagnoses, broadly targeting distorted cognitions and stimulus disengagement 3 Why Transdiagnostic CBT? 1. Match with theoretical models 2. Practical constraints 4 2

3 Evolution of Anxiety Diagnoses DSM (in theory) Anxiety Disorders Obs-Comp Disorders Panic Social Disorder Phobia GAD OCD MDD PTSD PDD Depressive Disorders Trauma Disorders 3

4 DSM (in reality) Negative Affect Disorder Anxiety Disorders Panic Social Disorder Phobia GAD OCD Obs-Comp Disorders Prev. / Contin. Comorbidity Genetics Neurobiology MDD PDD PTSD Learning Cognition Development Depressive Disorders Trauma Disorders Norton, P. J. & Paulus, D. J. (in press). Transdiagnostic models of anxiety disorder: Theoretical and empirical underpinnings. Clinical Psychology Review. doi: /j.cpr Transdiagnostic CBT for Anxiety (and Emotional Disorders) Designed for use with groups of clients experiencing a range of NA Disorders Norton (2012). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford. Barlow, et al. (2010). Unified protocol for transdiagnostic treatment of emotional disorders. New York: Oxford Nathan et al. (2004). Mood management course: A Cognitive Behavioural Group Treatment Programme for Anxiety Disorders and Depression. Perth: CCI. Andrews, et al. Mixed Depression and Anxiety Course. and several others unpublished 4

5 Why Transdiagnostic CBT? 1. Match with theoretical models 2. Practical constraints 9 Practical Constraints PD/A GAD SpPh SAD Sep. Anx IAD OCD PTSD Sel. Mute 5

6 Practical Constraints OCD Panic Disorder Neg. Aff. Disorder MDD GAD PDD Social Phobia PTSD History of Transdiagnostic CBT for Anxiety Scopus Database: Transdiagnostic and Anxiety (Accessed: 03/03/2017) 12 6

7 History of Transdiagnostic CBT for Anxiety Special Issues and Sections: 2017 (vol. 46) Journal of Anxiety Disorders (Guest Ed.: P.J. Norton) 2012 (vol. 31) Clinical Psychology Review (Guest Ed. W. Mansell) 2009 (vol. 23) Journal of Cognitive Psychotherapy (Guest Eds.: S. Taylor & D.A. Clark) 2008 (vol. 1) International Journal of Cognitive Therapy (Guest Ed.: W. Mansell) 13 Does tcbt work? 7

8 Nebraska Pilot Trial 23 patients meeting DSM-IV criteria for a primary diagnosis of any Anxiety Disorder Inclusion Criteria: Age 19 or older Ability to read and communicate in English Accept possibility of randomization to delayed-treatment condition No evidence of dementia or neurocognitive conditions No suicidality, significant substance abuse, or other condition requiring immediate intervention Norton, P. J. & Hope, D. A. (2005). Preliminary evaluation of a broad-spectrum cognitive-behavioral group therapy for anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 36, Diagnostic Measures Condition Immediate Delayed Clin. sig. Anx. Dx at Posttreatment? Pre-treatment? Yes 33.3% 100% 100% No 66.7% 0.0% 0.0% c 2 (1) = 10.24, p =.001 8

9 Diagnostic Measures CSR of Primary Diagnosis Pre-Tx Post-Tx Immediate Delayed F (1,15) = 7.55, p =.015 Unified Protocol Open trial of Unified Protocol [n = 15 (GAD, SAD, OCD, PDA)] Ellard, K. K. et al. (2010). Unified Protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice, 17,

10 F-SET RCT (vs. waitlist) of F-SET [n = 96 (GAD, SAD, PD/A)] Schmidt, N. B. et al. (2012). Randomized controlled trial of False safety behavior elimination therapy: A unified cognitive behavioral treatment for anxiety psychopathology. Behavior Therapy, 43, Does it work equally for different Anxiety Disorder diagnoses? 10

11 Houston Open Trial Treatment-only no-control trial 52 participants with any anxiety disorder Including comorbid diagnoses 32 with Social Anxiety Disorder 25 with Panic Disorder/Agoraphobia 16 with GAD 6 with Specific Phobia 2 with OCD Norton, P. J. (2008). An open trial of a transdiagnostic cognitive-behavioral group therapy for anxiety disorder. Behavior Therapy, 39, Houston Open Trial Weekly anxiety ratings (STAI) measures given to all group attendees Analyzed individual change using Mixed-effect Regression Modeling 11

12 STAI STAI 5/07/2017 Houston Open Trial Session Panic Session Social All GAD Variable ML ML Estimate Estimate se se z z p p Intercept <.001 Session Slope <.001 <.001 Session GAD higher Slope intercept <.001 <.001 No Dx by Slope interactions Log L = Log L = Unified Protocol Open trial of Unified Protocol [n = 15] Primary diagnoses (GAD=3, SAD=5, OCD=3, PDA=2, GAD+Ag=1, GAD+SAD=1) Comorbid diagnoses (GAD=3, SAD=3, OCD=1, PDA=2, MDD=2, Dys=1, SpPh=1 Hypoch=1, ADNOS=1) Ellard, K. K. et al. (2010). Unified Protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice, 17,

13 Does it work as well as traditional Diagnosis-Specific CBT? Comparative Outcome Trial - Dx-Specific RCT comparing transdiagnostic CBT (n = 23; Panic: 5, Social: 12, GAD: 6) diagnosis-specific CBT (n = 23; Panic: 6, Social: 13, GAD: 4) Barlow & Craske Mastery of your Anxiety and Panic Heimberg Cognitive-Behavioral Group Therapy for Social Phobia Dugas & Robichaud Cognitive-Behavioral Treatment for Generalized Anxiety Disorder Norton, P. J. & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: A preliminary randomized controlled trial. Depression and Anxiety, 30,

14 Comparative Outcome Trial - Dx-Specific +Δ =.60 SD Mean DIFF = 0 CSR CGI-S PDSS SPDQ GADQ BDI STAI-Slp -Δ =.60 SD Treatment Effects replicated those from Norton & Hope (2005), Norton (2008), and Norton (2012b) Transdiagnostic vs. Diagnosis-Specific CBT Meta-Analytic review of 67 clinical trials (n = 3872) of tcbt or dxcbt tcbt: g = 1.059, ( ) dxcbt: g = 0.951, ( ) p =.008 Pearl, S. & Norton, P. J. (2017). Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis. Journal of Anxiety Disorders, 46,

15 Summary of Efficacy Evidence It works It works as well as other treatments Supported by meta- analyses It works equally across diagnoses What effect does it have on comorbid diagnoses? 15

16 Comorbidity in Anxiety & Depression Comorbidity the presence of two or more diagnoses Over 60% comorbidity rates Majority will have a 2 nd (or more) anxiety or depressive diagnoses Average = 2.1 diagnoses [CATEGO RY NAME] [CATEGO RY NAME] Comorbidity is usually ignored Most treatment approaches: 1. Treat principal diagnosis first THEN 2. Treat comorbid diagnoses sequentially, as necessary 16

17 Treatment of Primary Diagnosis 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Allen et al. 32.5% Tsao et al. 21.4% Tsao et al. 38.7% Tsao et al. 57.1% Study Brown et al. 57.1% Borkovec et al. 47.8% ** Mean: 40.07% Como (complet e) Como Como (incompl ete) No Como Norton, P. J., Barrera, T. L., Mathew, A. R., Chamberlain, L. D., Szafranski, D. D., Reddy, R., & Smith, A. H. (2013). Effect of transdiagnostic CBT for anxiety on comorbid diagnoses. Depression and Anxiety, 30, Sequential Treatment For the remaining 60% weeks of CBT for Primary Diagnosis Plus weeks of CBT for Comorbid Diagnosis Plus? weeks of CBT for additional Comorbid Diagnoses? 17

18 Nebraska Pilot Trial 23 patients with a primary Anxiety Disorder 18 had comorbid diagnoses (9 w/ multiple comorbid) Comorbid MDD/Dys = 10 Comorbid PD = 5 Comorbid SAD = 5 Comorbid GAD = 3 Comorbid SpPh = 1 Comorbid Alcohol Abuse = 1 Comorbid PTSD = 1 Comorbid OCD = 1 Comorbid Anxiety NOS = 1 Norton, P. J. & Hope, D. A. (2005). Preliminary evaluation of a broad-spectrum cognitive-behavioral group therapy for anxiety. Journal of Behavior Therapy and Experimental Psychiatry, 36, Diagnostic Measures CSR of Primary Diagnosis CSR of Comorbid Diagnoses Pre-Tx Post-Tx Pre-Tx Post-Tx Immediate Immediate F (1,15) = 7.55, p =.015 F (1,15) = 7.80, p =

19 Transdiagnostic CBT on Comorbidity Reanalysis of data from previous clinical trials (Norton, 2008; Norton, 2012b; Norton & Barrera, 2012) 48 clients with comorbid diagnoses of clinical severity Clients with comorbidity showed a decline in the CSR ratings of their comorbid diagnoses of 3.06 units (sd = 1.82). Majority (n = 32; 66.7%) no longer met criteria for any clinically significant comorbid diagnosis at post-treatment. Norton, P. J., Barrera, T. L., Mathew, A. R., Chamberlain, L. D., Szafranski, D. D., Reddy, R., & Smith, A. H. (2013). Effect of transdiagnostic CBT for anxiety on comorbid diagnoses. Depression and Anxiety, 30, Transdiagnostic CBT on Comorbidity 100.0% In benchmark studies, 40.07% showed remission of comorbid diagnosis 80.0% 60.0% 40.0% 20.0% 0.0% Brown et al. (1995) Borkovec et al. Tsao et al. 57.1% (1995) Tsao et al. (1998) 47.8% Allen et al. (2002) 42.9% (2010) 38.7% 32.5% Tsao et al. (2005) 21.4% Study Norton et al. (2013) 66.7% Ellard et al. (2010) 64% HESF Como (complet Como e) (complet e) Como (incompl Como ete) (incompl ete) No Como 19

20 Transdiagnostic CBT on Comorbidity DEPRESSION COMORBIDITY 42 Anxiety patients with comorbid Depression 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percent with comorbid Depression 100% Pre-Treatment 28.60% Post-Treatment Talkovsky, A. M., Green, K. L., Osegueda, A. J., & Norton, P. J. (2017). Transactional effects of depression in transdiagnostic group cognitive behavioral therapy for anxiety. Journal of Anxiety Disorders, 46, Summary of Efficacy Evidence It works It works equally It works better at treating the whole patient across diagnoses (primary and comorbid diagnoses) It works as well as other treatments Supported by metaanalyses 20

21 Moving Forward Brief tcbt Efficacy in Adults 5-session tcbt program for GAD, social phobia, and panic disorder in comparison to controls Participants in tcbt experienced significantly less anxiety (d = 2.01) and depression (d = 2.16) than no-treatment controls Change in avoidance strategies mediated the group changes in anxiety symptoms Riccardi, C.J., Korte, K.J., & Schmidt, N.B. (2017). False safety behaviour elimination therapy: A randomized study of a brief individual transdiagnostic treatment for anxiety disorders. Journal of Anxiety Disorders, 46,

22 tcbt Efficacy in Adolescents RCT comparing Unified Protocol to control (n = 51) Mostly GAD, Social Phobia, and Depression Significantly greater improvement among those in UP compared to controls Gains maintained at 3- and 6-month follow-up Ehrenreich-May, J., et al. (2017). An initial waitlist-controlled trial of the unified protocol for the treatment of emotional disorders in children. Journal of Anxiety Disorders, 46, tcbt with Military Veterans military veterans completing group tcbt Significant reductions in anxiety and fear from pre- to post-treatment Reductions in anxiety and fear were predicted by changes in Threat perceptions cognitive Experiential avoidance behavioral Espejo, E.P., Gorlick, A., & Castriotta, N. (2017). Changes in threat-related cognitions and experiential avoidance in group-based transdiagnostic CBT for anxiety disorders. Journal of Anxiety Disorders, 46,

23 tcbt with Military Veterans - 2 Trained 28 mental health providers in tcbt 6 months after training, therapists rated perceived effectiveness of tcbt (1-5 scale): Depression = 3.8 Panic Disorder = 4.3 PTSD = 4.0 Social Phobia = 4.0 GAD = 3.5 OCD = 4.7 Gros, D.F., Szafranski, D.D., & Shead, S.D. (2017). A real world dissemination and implementation of transdiagnostic behaviour therapy (TBT) for veterans with affective disorders. Journal of Anxiety Disorders, 46, Internet-Delivered tcbt Large treatment effect sizes for depression and anxiety Anxiety: (tcbt = GAD) > MDD Depression: (tcbt = MDD) > GAD For comorbid GAD+MDD: tcbt > (MDD = GAD) Newby, J.M., Mewton, L., & Andrews, G. (2017). Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care. Journal of Anxiety Disorders, 46,

24 tcbt for Anxiety, Depression, and Substance Use Developed a combined tcbt + Substance Abuse treatment with 29 comorbid patients Moderate, but not consistent, improvement in stress and anxiety scores Significant decreases in alcohol use No change in drug use Milosevic, I., Chudzik, S.M., Boyd, S., & McCabe, R.E. (2017). Evaluation of an integrated group cognitive-behavioural treatment for comorbid mood, anxiety, and substance use disorders: A pilot study. Journal of Anxiety Disorders, 46, tcbt for Anxiety + Chronic Headache Combined tcbt with CBT for headache for 63 adolescents RCT comparing combined treatment to treatment as usual (TAU) Both groups improved, but significantly greater for combined treatment than TAU Anxiety Headache Sharma, P., Mehta, M., & Sagar, R. (2017). Efficacy of transdiagnostic cognitive-behavioural group therapy for anxiety disorders and headache in adolescents. Journal of Anxiety Disorders, 46,

25 Transdiagnostic Approaches to the Treatment of Anxiety and Emotional Disorders: Peter J. Norton, Ph.D. 25