Emergence of Transdiagnostic Treatments for PTSD and Posttraumatic Distress

Cognitive therapy has been successfully used across a range of diagnoses.

“CT has since been successfully applied across a range of diagnoses [30–34]”

• cites [30] Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;100:316–36. sourceSupported
• cites [31] Dobson KS. A meta-analysis of the efficacy of cognitive therapy for depression. J Consult Clin Psych. 1989;57(3):414–9. doi: 10.1037/0022-006X.57.3.414 . sourceNot checked — no full text of the source
• cites [32] Gaffan EA, Tsaousis J, Kemp-Wheeler SM. Researcher allegiance and meta-analysis: the case of cognitive therapy for depression. J Consult Clin Psych. 1995;63(6):966–80. doi: 10.1037/0022-006X.63.6.966 . sourceNot checked — no full text of the source
• cites [33] Beck AT. Thinking and depression: I. Idiosyncratic content and cognitive distortions. Arch Gen Psych. 1963;9(4):324–33. sourceNot checked — no full text of the source
• cites [34] Hollon SD, DeRubeis RJ, Shelton RC, Amsterdam JD, Salomon RM, O’Reardon JP, et al. Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Arch Gen Psych. 2005;62(4):417–22. sourceNot checked — no full text of the source

No published empirical data compare a transdiagnostic approach with single-diagnosis protocols for PTSD.

“There are no published empirical data comparing a transdiagnostic approach to single-diagnosis protocols for PTSD.”

The mechanistically transdiagnostic approach has not yet been studied for PTSD and trauma-related disorders.

“However, the mechanistically transdiagnostic approach to these disorders has not yet been studied.”

Several studies have used modular/common elements and universally applied therapeutic approaches for PTSD and posttraumatic symptoms.

“Several studies have applied the modular/common elements and the universally applied therapeutics approach to PTSD and posttraumatic symptoms.”

Traditional psychotherapies have long used strategies such as cognitive change and the therapeutic relationship across diagnoses and clinical presentations.

“Traditional psychotherapies have historically applied these strategies (e.g., cognitive change, therapeutic relationship) across diagnoses and clinical presentations.”

• cites [28•]Not matched

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Single-disorder treatment protocols have shown positive effects on co-occurring conditions while focusing on the main disorder.

“Although single-diagnosis protocols have demonstrated beneficial effects on comorbidity while specifically targeting the primary disorder in treatment [5–9]”

• cites [5] Borkovec TD, Abel JL, Newman H. Effects of psychotherapy on comorbid conditions in generalized anxiety disorder. J Consult Clin Psych. 1995;63:479–83. sourceNot checked — no full text of the source
• cites [6] Brown TA, Antony MM, Barlow DH. Diagnostic comorbidity in panic disorder: effect on treatment outcome and course of comorbid diagnoses following treatment. J Consult Clin Psych. 1995;63:408–18. sourceNot checked — no full text of the source
• cites [7] Tsao JC, Lewin MR, Craske MG. The effects of cognitive-behavioral therapy for panic disorder on comorbid conditions. J Anxiety Disord. 1998;12:357–71. sourceNot checked — no full text of the source
• cites [8] Tsao JC, Mystkowski JL, Zucker BG, Craske MG. Effects of cognitive-behavioral therapy for panic disorder on comorbid conditions: replication and extension. Behav Ther. 2002;33:493–509. sourceNot checked — no full text of the source
• cites [9] Tsao JC, Mystkowski JL, Zucker BG, Craske MG. Impact of cognitive-behavioral therapy for panic disorder on comorbidity: a controlled investigation. Behav Res Ther. 2005;43:959–70. sourceNot checked — no full text of the source

In these transdiagnostic treatment studies, multiple co-occurring diagnoses improved during treatment, not only the primary diagnosis.

“In each approach, results have demonstrated that not just one diagnosis (e.g., panic disorder) but a range of comorbid diagnoses (e.g., several comorbid anxiety disorders) have improved over the course of treatment.”

• cites [10–14, 15•, 16]Not matched

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Because PTSD and trauma-related disorders have high rates of co-occurring conditions, a transdiagnostic approach may be especially useful.

“Given the high rates of comorbidity in PTSD and trauma-related disorders [17, 18], a transdiagnostic approach may be particularly useful.”

• cites [17] Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiat. 1995;52:1048–60. doi: 10.1001/archpsyc.1995.03950240066012 . sourceNot checked — no full text of the source
• cites [18] Brown TA, Campbell LA, Lehman CL, Grisham JR, Mancill RB. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. J Abnorm Psychol. 2001;110(4):585–99. sourceNot checked — no full text of the source

A transdiagnostic approach should, in theory, address co-occurring conditions more efficiently and effectively by targeting shared features across diagnoses.

“in principle, a transdiagnostic approach should target comorbidity more efficiently and effectively by focusing on commonalities across diagnoses.”

MATCH has shown strong empirical support in community-based settings.

“MATCH has demonstrated strong empirical support throughout community-based settings [23, 27•].”

• cites [23, 27•]Not matched

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Many different psychiatric diagnoses share common underlying vulnerabilities.

“research has accumulated demonstrating that many disparate psychiatric diagnoses share core underlying vulnerabilities [1••, 2, 3]”

• Also stated in: § Mechanistically Transdiagnostic Approach · boosted

  “The idea that a core psychological vulnerability can underlie classes of psychiatric disorders is supported by a considerable body of research that has heavily influenced treatment design in this transdiagnostic category in general and of the UP in particular [1••, 2, 13].”

• cites [1••, 2, 3]Not matched

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The feasibility and effectiveness of transdiagnostic treatment have been studied and supported most extensively for anxiety disorders, eating disorders, and depression.

“The feasibility and effectiveness of a transdiagnostic approach have received the most extensive study and empirical support for treating anxiety disorders, eating disorders, and depression [10–14, 15•, 16].”

• cites [10–14, 15•, 16]Not matched

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CETA has shown success in treating trauma-exposed populations in low- and middle-income countries in waitlist-controlled trials.

“the Common Elements Treatment Approach [CETA; 24], another modular/common elements approach, has demonstrated success in treating trauma-exposed populations in low- and middle-income countries in waitlist-controlled trials [25••, 26••].”

• cites [25••, 26••]Not matched

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One CETA study suggested that the approach produced larger effect sizes than single-diagnosis treatments for reducing various comorbid symptoms.

“As discussed above, one study employing CETA suggested that this approach yielded larger effect sizes than single-diagnosis treatments in reducing a range of comorbid symptoms [26••].”

• cites [26••]Not matched

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The mechanistically transdiagnostic approach has been successfully applied to anxiety disorders and eating disorders.

“This approach has been applied successfully to a range of disorders, such as anxiety disorders [11] and eating disorders [10].”

• cites [11] Norton P. An open trial of a transdiagnostic cognitive-behavioral group therapy for anxiety disorder. Behav Ther. 2008;39(3):242–50. doi: 10.1016/j.beth.2007.08.002 . sourceNot checked — no full text of the source
• cites [10] Fairburn C, Cooper Z, Shafran R. Cognitive behaviour therapy for eating disorders: a ‘transdiagnostic’ theory and treatment. Behav Res Ther. 2003;41(5):509–28. doi: 10.1016/S0005-7967(02)00088-8 . sourceNot checked — no full text of the source

The mechanistically transdiagnostic approach is effective for emotional disorders.

“This approach is also effective for emotional disorders [13, 14, 15•]”

• cites [13, 14, 15•]Not matched

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Diagnostic-specific measurement is problematic for capturing the effects of a mechanistically transdiagnostic approach, which targets core processes rather than only diagnostic symptoms.

“This is problematic in capturing the effect of the mechanistically transdiagnostic approach, which targets core processes rather than just diagnostic symptoms.”

The UP has shown initial efficacy in reducing symptoms in samples meeting criteria for various emotional disorders.

“The UP has demonstrated initial efficacy in reducing symptoms across samples of participants who met the criteria for a range of emotional disorders”

• cites [13, 14, 15•]Not matched

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The Multidimensional Emotional Disorder Inventory (MEDI) was developed with seven empirically derived dimensional categories to create a profile approach for categorizing symptom presentations based on transdiagnostic vulnerabilities and phenotypes.

“More recently, a self-report measure, the Multidimensional Emotional Disorder Inventory (MEDI), was developed with seven empirically derived dimensional categories for generating a profile approach to categorizing symptom presentations based on transdiagnostic vulnerabilities and phenotypes (e.g., neurotic temperament, positive temperament, autonomic arousal, intrusive cognitions) [60, 61•].”

• cites [60, 61•]Not matched

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Because CETA and CPT were not directly compared and site differences may have influenced treatment response, no firm conclusion can be made that CETA is superior to CPT.

“Because CETA and CPT were not directly compared and differences between sites may have accounted for overall treatment responsiveness, no firm conclusions can be drawn about the superiority of CETA over CPT.”

Taken together, features of the mechanistically transdiagnostic approach and the benefits seen when other transdiagnostic approaches are used for PTSD suggest that a mechanistic approach like the UP may be especially effective for trauma-related disorders.

“Taken together, these aspects of the mechanistically transdiagnostic approach, coupled with the benefits demonstrated when other transdiagnostic approaches are applied to PTSD, suggest that a mechanistic approach such as the UP may be particularly effective in treating trauma-related disorders.”

Research has shown that transdiagnostic approaches such as CETA are effective even when delivered by lay providers with little or no prior mental health treatment experience.

“Research has demonstrated that transdiagnostic approaches such as CETA are effective even among lay providers with little to no previous exposure to providing mental health treatment [24•, 25••, 26••].”

• cites [24•, 25••, 26••]Not matched

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In studies of CETA, participants receiving it experienced significant symptom reduction.

“In each of these studies, participants who received CETA had significant symptom reduction.”

• cites [24•, 25••, 26••]Not matched

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Some studies have used instruments that measure both shared underlying processes and distinct symptom aspects.

“To address this issue, some studies [12, 57] have utilized instruments designed to measure both common underlying processes as well as distinct aspects of symptoms [58, 59].”

• cites [12] Norton PJ, Hope DA. Preliminary evaluation of a broad-spectrum cognitive-behavioral group therapy for anxiety. J Behav Ther Exp Psy. 2005;36:79–97. sourceNot checked — no full text of the source
• cites [57] Norton PJ, Whittal ML. Thematic similarity and clinical outcome in obsessive–compulsive disorder group treatment. Depress Anxiety. 2004;20(4):195–7. sourceNot checked — no full text of the source
• cites [58] Watson D, Clark LA. The mood and anxiety symptom questionnaire. Unpublished manuscript, University of Iowa, Department of Psychology, Iowa City. 1991 sourceNot checked — no full text of the source
• cites [59] Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales (2nd Ed). Sydney: Psychology Foundation; 1995. sourceNot checked — no full text of the source

A mechanistic approach like the UP might be especially suitable for PTSD and trauma-related disorders because it guides therapists on which skills to emphasize to match the patient's needs.

“Another reason why a mechanistic approach such as the UP might be particularly well suited to the treatment of PTSD and trauma-related disorders is its provision of guidance for therapists on what skills to emphasize to ideographically map onto the patient’s needs.”

There are theoretical reasons why each transdiagnostic approach may work for PTSD and trauma-related disorders.

“The lack of PTSD representation in previous studies investigating the mechanistically transdiagnostic approach is unfortunate, as there are theoretical reasons why each approach may be effective with these disorders.”

Assessment has mostly been guided by diagnostic specificity.

“Measurement has been largely driven by diagnostic specificity.”

• cites [4] McEvoy PM, Nathan P, Norton PJ. Efficacy of transdiagnostic treatments: a review of published outcome studies and future research directions. J Cogn Psychot. 2009;23(1):20–33. doi: 10.1891/0889-8391.23.1.20 . sourceNot checked — no full text of the source

Because negative affect is central in PTSD, the UP might be especially effective for this disorder.

“Because negative affect has been found to play a central role in PTSD [1••, 47, 48••], the UP might be particularly effective with this disorder.”

• cites [1••, 47, 48••]Not matched

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The Unified Protocol is an empirically supported mechanistically transdiagnostic treatment that targets a core vulnerability across various clinical presentations.

“The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders [UP; [42]] is an empirically supported mechanistically transdiagnostic protocol that targets a core underlying vulnerability, rather than a diagnostic category, across a range of clinical presentations [13, 14, 15•].”

• cites [13, 14, 15•]Not matched

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Modular/common elements (e.g., CETA) and universally applied therapeutic (e.g., ACT) transdiagnostic approaches have begun to be applied to PTSD and trauma-related disorders with encouraging results.

“A transdiagnostic approach, in the form of the modular/common elements approach (e.g., CETA) and universally applied therapeutics approach (e.g., ACT), has begun to be applied to PTSD and trauma-related disorders with encouraging results.”

The small magnitude of change with ACT and its lack of difference from PCT suggest that not all theoretically transdiagnostic treatments will work for trauma survivors.

“The relatively small magnitude of change associated with ACT and lack of difference from PCT suggest that not all theoretically transdiagnostic treatments will be effective in treating trauma survivors.”

The results suggest CETA may be an effective treatment for trauma-related disorders.

“However, the results do suggest that CETA may be an effective approach to treating trauma-related disorders.”

Training therapists in multiple protocols to address varied symptom presentations is costly in dollars, time, and energy.

“Furthermore, the cost of training therapists in multiple protocols to treat the variety of symptom presentations is substantial in terms of dollars, time, and energy [56].”

• cites [56] Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psych. 2005;62(6):629–40. doi: 10.1001/archpsyc.62.6.629 . sourceNot checked — no full text of the source

A transdiagnostic approach like CETA may be especially useful in clinics with fewer resources.

“This suggests that a transdiagnostic approach such as CETA may be particularly useful in clinics with fewer resources.”

A transdiagnostic approach may be especially useful for addressing implementation and dissemination barriers.

“A transdiagnostic approach may be particularly useful on this front.”

The small effect sizes in the ACT study may be due to factors other than the transdiagnostic approach.

“Moreover, the small effect sizes may be attributable to a range of factors beyond the use of a transdiagnostic approach.”

CETA has consistently been delivered by lay providers who had little or no prior familiarity with mental health treatment.

“Additionally, in the empirical literature, CETA has consistently been delivered by lay providers, with little to no previous familiarity with mental health treatment.”

• cites [24•, 25••, 26••]Not matched

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Preliminary research suggests that applying a transdiagnostic approach to PTSD and other trauma-related disorders may be effective for these disorders and their related comorbidities.

“Preliminary research suggests that applying a transdiagnostic approach to PTSD and other trauma-related disorders may be effective in treating these disorders and their related comorbidities.”

Higher-order factors of high negative affect and low positive affect are linked to the development and maintenance of many psychiatric disorders.

“this literature has consistently found that higher-order factors of high negative affect and low positive affect are associated with the development and maintenance of a range of psychiatric disorders [1••].”

• cites [1••]Not matched

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