DEPRESSION AND ANXIETY 27 : 882–890 (2010)

Review
CONCEPTUAL BACKGROUND, DEVELOPMENT,
AND PRELIMINARY DATA FROM THE UNIFIED
PROTOCOL FOR TRANSDIAGNOSTIC TREATMENT
OF EMOTIONAL DISORDERS
Zofia A. Wilamowska, M.A., Johanna Thompson-Hollands, M.A., Christopher P. Fairholme, M.A.,
Kristen K. Ellard, M.A., Todd J. Farchione, Ph.D., and David H. Barlow, Ph.D.

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 under-
standing 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
27:882–890, 2010. r 2010 Wiley-Liss, Inc.

Key words: anxiety disorders; treatment; Unified Protocol

INTRODUCTION Center for Anxiety and Related Disorders, Boston University,

In the 1960s, psychological approaches to treating Boston, Massachusetts
emotional disorders began to be derived from basic Correspondence to: Zofia A. Wilamowska, Center for Anxiety
psychological science, specifically from theories and and Related Disorders, Boston University, 648 Beacon Street, 6th
data pertaining to learning, emotional development Floor, Boston, MA 02215. E-mail: [email protected]
and regulation and, somewhat later, cognitive science.
No conflict of interest was declared.
By the 1980s, investigators began to focus on mechan-
isms of action and theories of behavior change. In Received for publication 25 March 2010; Revised 1 July 2010;
considering exposure procedures, it was clear that Accepted 1 July 2010
‘‘exposure’’ was simply a dry theoretical description of a DOI 10.1002/da.20735
process, with no heuristic value. Various theoretical Published online in Wiley Online Library (wileyonlinelibrary.com).

r 2010 Wiley-Liss, Inc.

 Review: Conceptual Basis of the Unified Protocol 883

accounts of fear reduction began to be investigated, among them, and little chance of even becoming
such as habituation and extinction as well as more familiar with most of them, let alone trained to
cognitively based accounts that targeted constructs, competence. This state of affairs is substantially
such as cognitive schemas, self-efficacy, and emotional diminishing the public health significance of the
processing. These theories of behavior change and current evidence-based psychological treatments.
increased knowledge of psychopathology led directly to
new interventions. For instance, in our work with the COMMONALITIES IN EMOTIONAL
treatment of panic disorder with agoraphobia (PD/A), DISORDERS
interoceptive exposure was developed as an adjunct to
situational exposure based on the recognition that the Empirical conceptions of the anxiety and mood
context of anxiety and fear was internal as well disorders are emerging that emphasize their common-
external.[1] In addition to exposure-based procedures, alities rather than their differences.[14–16] Major
cognitive therapy, first developed to treat depression, developments in at least four areas support these
became a staple among treatments for anxiety dis- conceptions.
orders.[2,3] Research on outcomes of individual cogni-
tive behavioral therapy (CBT) protocols targeting COMORBIDITY AND OVERLAP AMONG
specific anxiety, mood, and related disorders began to DISORDERS
appear.[4] It soon became apparent that meaningful First, studies of phenomenology and nosology, with a
research studying these new treatments required the particular focus on comorbidity, suggest considerable
generation of detailed individual therapeutic manuals overlap among disorders. At the diagnostic level, this is
necessary to specify and manipulate an independent most evident in high rates of current and lifetime
variable. Psychotherapeutic treatments were thus comorbidity.[17–22] In a study of 1,127 patients pre-
increasingly characterized by individual protocols that senting at our clinic, 55% of patients with a principal
contained specific strategies, such as cognitive restruc- anxiety disorder had at least one additional anxiety or
turing, coping skills, and situational and interoceptive mood disorder at the time of assessment, and this rate
exposure procedures, with each protocol tailored to increased to 76% when lifetime diagnoses were
target specific DSM defined disorders. These treat- considered.[18] Further evidence for the overlap among
ments were then tested empirically and found effica- anxiety and mood disorders emerges from observations
cious in a variety of delivery formats, uses, and that psychological treatments for a given anxiety
settings.[5–11] It is fair to say that these findings have disorder produce improvement, sometimes significant
had a substantial impact in that public health autho- improvement in at least some additional comorbid
rities have allocated billions of dollars for training and anxiety or mood disorders that are not specifically
dissemination of these treatments.[12] addressed, based on the assessment immediately post-
Nevertheless, a number of significant limitations to treatment.[23–26] But these outcomes are uneven and
current treatments exist. There are still a considerable may not be durable in all instances,[24] perhaps because
number of patients who do not respond well to current cross-cutting unified treatment principles were not
psychological treatments, and the reasons for their lack utilized. In any case, whether this broad-based
of response are not yet known. The proliferation of improvement, short term or long term, represents the
manualized treatments has added another layer of generalization of elements of treatment to independent
complexity. Multiple manuals and protocols have been facets of both disorders or a way of effectively
developed for each DSM-IV disorder, many of them addressing ‘‘core’’ features of emotional disorders is
with their own flavors or twists, but most of them not significant to our purpose here. In both cases, the
reflecting the ‘‘copycat’’ phenomena present in phar- efficiency of a unified treatment approach would be
macological development. For example, more than 15 suggested. More importantly, one intriguing explana-
published manuals exist for panic disorder alone, most tion is that this pattern of comorbidity argues for the
with only trivial alterations (and no empirical support existence of what has been called earlier a ‘‘general
justifying these changes), and it is sometimes difficult neurotic syndrome.’’[16,27–30] Under this conceptualiza-
to choose among them. In addition, because the tion, heterogeneity in the expression of emotional
protocols are somewhat complex, dissemination of disorder symptoms (e.g., individual differences in the
even one treatment protocol to providers is an obstacle prominence of social anxiety, panic attacks, anhedonia,
to delivery of evidence-based treatment.[12,13] When a etc.) is regarded as phenotypic variation in the
clinician completes the required months of training, manifestation of a broader syndrome.
they are certified to treat only one diagnostic category
(e.g., PD/A, posttraumatic stress disorder [PTSD])
EVIDENCE OF DISORDER OVERLAP FROM
with uncertain abilities to treat or even address
common patterns of accompanying comorbidity (e.g., AFFECTIVE NEUROSCIENCE
depression, obsessive–compulsive disorder [OCD]). Second, recent research from affective neuroscience
Thus, there are far too many published manuals lends support to the potential existence of a broader
targeting single disorders, no good way to choose based, more fundamental syndrome. Some findings
Depression and Anxiety
884 Wilamowska et al.

from this literature suggest hyperexcitability of limbic time.[61–63] Whereas neuroticism/negative affect is
structures, coupled with disrupted or limited inhibitory relevant to the full range of emotional disorders,
control by cortical structures, may distinguish indivi- the contribution of extraversion/positive affect seems
duals with anxiety and mood disorders from healthy to be more specific to unipolar depression, SAD,
controls, and may be one possible explanation for the agoraphobia, and mania, with depression, SAD, and
increased intensity and frequency of negative emotional agoraphobia associated with low extraversion/positive
experience among individuals with anxiety and mood affect and mania with high extraversion/positive
disorders.[31–34] Several recent studies seem to support affect.[15,29,63–66] Although the theoretical frameworks
the idea that increased ‘‘bottom up’’ processing through were developed independently (cf. references[67,68]),
amygdala overactivation, coupled with dysregulation of neuroticism/negative affect and extraversion/positive
cortical inhibition of amygdala responses, may be affect are closely related to Gray’s[69] constructs of
characteristic across these disorders, as evidenced in behavioral inhibition and behavioral activation, res-
studies of social anxiety disorder (SAD),[35–37] post- pectively, at both the conceptual and empirical
traumatic stress disorder (PTSD),[38] generalized anxi- levels.[62,70–72] A substantial literature underscores the
ety disorder (GAD),[39,40] specific phobia,[41,42] and roles of these constructs in accounting for the onset,
depression.[43,44] In addition, increased amygdala acti- overlap, and maintenance of anxiety and depres-
vation has been found to distinguish individuals high in sion.[15,29,62,73] For instance, in a large sample of
the personality dimension of neuroticism,[45] which outpatients, Brown et al.[29] found that virtually all
may represent a unifying diathesis for anxiety and the considerable covariance among latent variables
mood disorders (see below). Exaggerated amygdala corresponding to the DSM-IV constructs of unipolar
responses have also been linked to a functional depression (DEP), SAD, GAD, OCD, and PD/A was
polymorphism in the promoter region of the serotonin explained by the higher order dimensions of negative
transporter gene (5HTTPR), linking the presence of affect and positive affect (bipolar depression was not
the s/s genotype (presence of two short alleles) to included). Although the results were consistent with
greater magnitude of amygdala responses to emotional the notion of neuroticism/negative affect as a broadly
stimuli,[46,47] and reductions in positive connectivity relevant dimension of vulnerability, results indicated
between the amygdala and ventromedial prefrontal the DSM-IV disorders were differentially related to
cortex.[48] This suggests more intense limbic responses negative affect, with DEP and GAD evidencing the
and less efficient regulatory feedback between cortical strongest associations.[15,29] In accord with a reformu-
and limbic structures. Further, the presence of this s/s lated hierarchical model of anxiety and depression,[29]
allele functional polymorphism has been found to be and consistent with the results reported above, positive
associated with neuroticism and trait anxiety.[49] Time affect was predictive of DEP and SAD only. These
will tell whether these commonalities better account findings have recently been extended by our research
for the nature of emotional disorders than unique team, but require further extension to emotional
neurobiological factors associated with single DSM disorders comorbid with psychotic or externalizing
diagnoses.[50] disorders.[15,16,74]

LATENT STRUCTURE OF EMOTIONAL ETIOLOGY

DISORDERS Fourth, current conceptual models assert that
Third, another thread of evidence emerges from dimensions of temperament do not act alone in
quantitative approaches using structural equation determining the etiology, course, and complications
modeling to examine the full range of anxiety and of emotional disorders.[14,65,75,76] For instance,
mood disorders without the constraints of artificial we[14,77,78] have formulated a triple vulnerability model
categories, given their strong relationship and potential of emotional disorders, which draws from and inte-
overlap.[29,51–53] We have been studying this question grates the rich literatures of genetics, personality,
for the last 10 years[15,16,29,54] and have confirmed, with cognitive science, neuroscience, and emotion and
some modifications, the tripartite model of emotional learning theories. This model specifies the existence
disorders first proposed by Clark and Watson,[52] of a generalized biological vulnerability to experience
which places emphasis on dimensions corresponding anxiety consisting of a well-established genetic con-
to broader biologically and environmentally based tribution to this diathesis accounting for approximately
constructs of temperament and personality (e.g., 30–50% of the variance. In addition, a generalized
neuroticism/negative affectivity).[55] psychological vulnerability emerges from early child-
Two genetically based core dimensions of tempera- hood experience characterized by a stressful unpredict-
ment have been posited as instrumental in the etiology able environment and/or the influence of specific
and course of the emotional disorders: neuroticism/ parenting styles described in detail in the attachment
negative affectivity and extraversion/positive affectivity. theory literature that inhibit the development of
Extensive evidence indicates these constructs are effective coping procedures and the emergence of
strongly heritable[56–60] and relatively stable over self-efficacy.
Depression and Anxiety
 Review: Conceptual Basis of the Unified Protocol 885

These early experiences lead to a general sense of traditional empirically supported CBT treat-
unpredictability and uncontrollability over life events ments,[1,2,79] integrated with the advances in research
that, along with elevated sympathetic nervous system on emotion regulation and dysregulation.[80–84] It is
arousal, form the core of the process of anxiety.[14] If important to note that the UP continues to emphasize
these two generalized or diatheses line up, the the fundamental principles of traditional CBT as
individual is at increased risk for experiencing general- applied to emotional disorders, such as extinction
ized anxiety and/or depression in the context of learning, through the prevention of cognitive and
triggering stressful events.[51,78] But a third diatheses, behavioral avoidance strategies, behavioral, emotional
referred to as a specific psychological vulnerability, and interoceptive exposure, and the identification and
comes into play in the form of learning a particular modification of maladaptive cognitions.
focus for anxiety, or learning that some situations, Although it has roots in traditional cognitive
objects, or internal somatic states are potentially behavioral principles, the UP is unique in the particular
dangerous even if objectively they are not. These early emphasis placed on the way individuals with emotional
learning experiences can be as straightforward as disorders experience and respond to their emotions.
watching parents model severe fears of specific objects For example, the UP expands on the traditional
or situations, such as small animals (e.g., as in specific practices used for patients with panic disorder via
phobia), or more subtle, such as experiencing heigh- interoceptive exposure,[77,84] to include exposure to and
tened attention from caregivers to the potential danger confrontation of the somatic aspects of uncomfortable
of experiencing unexplained somatic sensations (e.g., as emotions and teaches patients to respond to those
in PD/A or hypochondriasis). We have proposed that emotions more adaptively. This is done in addition to
these specific foci of anxiety represent the disorder- traditional strategies focusing on external contextual
specific symptoms that may be trivial variations in the cues associated with the emotional disorder (e.g.,
manifestation of a broader underlying syndrome. performance demands in SAD, worry triggers in
One may notice that the two generalized vulnerabil- GAD). By focusing on the patient’s particular emo-
ities, biological and psychological, describe a more tional experience, the UP emphasizes the adaptive
stable disposition to experience anxiety, and thus could functional nature of emotions, facilitates greater
be considered more accurately as a temperament. tolerance of intense emotions, and seeks to identify
Indeed, we consider anxiety in this regard as simply and correct maladaptive attempts to regulate emotional
the expression of the temperament of neuroticism/ experiences.
behavioral inhibition (N/BI) with the addition, in many
cases, of a specific focus (or several specific foci)
dictated by the learning experiences that comprise the COMPONENTS OF TREATMENT
third vulnerability. Evidence for this relationship,
presented in detail elsewhere, provides somewhat less Currently, the UP consists of eight modules with five
support at present for the third (specific) vulnerability of these modules forming the core components of
than for the two generalized vulnerabilities.[14,78] If this treatment (see Table 1). The modular focus allows
is the case, a unified treatment approach that moves various portions of the treatment to be expanded or
beyond disorder-specific symptoms and targets com- shortened as appropriate for a given patient. The
mon underlying vulnerabilities may lead to more following is a basic description of the modules:
enduring treatment effects. The first treatment module, Motivation Enhancement,
In summary, the considerable overlap among anxiety focuses on increasing the patient’s readiness and
and mood disorders, as evidenced by high rates of motivation for behavior change and fostering the
diagnostic comorbidity, some generalization of treat- patient’s self-efficacy or belief in his or her ability to
ment response, common patterns of neural activation, successfully achieve change. Patients complete a
quantitative approaches highlighting temperamental ‘‘Decisional Balance’’ exercise weighing the pros and
dimensions, and similar etiological processes suggests
that commonalities among anxiety and mood disorders TABLE 1. Modules of the unified protocol for
may supercede differences.[14,78] If this is the case, then transdiagnostic treatment of emotional disorders
a unified treatment protocol cutting across current Module Title
diagnostic categories to address core features of the
anxiety disorders and mood disorders could be a more 1 Motivation Enhancement
parsimonious and, perhaps, powerful option than 2 Psychoeducation and Treatment Rationale
current single diagnosis treatment protocols. 3 Emotion Awareness Traininga
4 Cognitive Reappraisala
5 Emotion Driven Behaviors and Emotional Avoidancea
PROTOCOL DEVELOPMENT 6 Awareness and Tolerance of Physical Sensationsa
7 Interoceptive and Situational Exposurea
The development of the Unified Protocol for 8 Relapse Prevention
Transdiagnostic Treatment of Emotional Disorders
a
(UP) began with the distillation of key principles from Indicates core UP module.

Depression and Anxiety

886 Wilamowska et al.

cons of changing versus staying the same. Patients also thoughts, feelings, and behaviors that arise in reaction
articulate goals for treatment, with a focus on making to their emotions, and encourage patients to allow
goals more concrete, and identify possible steps for these emotional reactions to occur (accept them)
achieving their treatment goals. This module was without ascribing judgmental attributions (e.g., ‘‘This
incorporated into the UP based on research conducted makes me feel uncomfortable’’).
by Westra et al., illustrating the efficacy of such In the fourth module, and second core module,
techniques as an adjunct in the treatment of anxiety Cognitive Reappraisal, patients develop an under-
disorders,[85] and is based heavily in the principles and standing of how they interpret or appraise situations
techniques used in Motivational Interviewing.[86] and how their appraisals influence patterns of emo-
Although the UP typically dedicates one session to tional responding, with an emphasis on the ways in
motivation enhancement, therapists continue to use these which cognitions interact with behaviors and physio-
strategies throughout the course of treatment as neces- logical sensations in ongoing emotional experiences.
sary in order to maintain motivation for behavior change. The aim of this module is to foster flexible thinking by
The second module, Psychoeducation and Treatment teaching patients to generate numerous alternative
Rationale, focuses on educating patients about the attributions and appraisals when faced with intense
adaptive nature of emotions and the main components emotional experiences. The concepts of appraisal and
of an emotional experience (physiological, cognitive, reappraisal are introduced in session, by having the
and behavioral), with a specific focus on why the full patient describe the actions depicted in a scene from an
range of negative and positive emotions are both ambiguous picture. Although the patient’s initial
necessary and functional. In addition, an introduction interpretation is often negative, more flexible alter-
to the concept of Emotion Driven Behaviors (EDBs) native appraisals are subsequently elicited with the goal
(i.e., action tendencies or motivated behavioral of highlighting that generating different ‘‘takes’’ on a
responses that are an integral part of the emotion situation is always possible. Over the course of
(e.g., fear–escape; anxiety–vigilance)) is provided, high- treatment, appraisals are elicited and reappraisal is
lighting their adaptive function. Finally, patients are practiced by reviewing the patient’s self-monitoring
introduced to monitoring their emotional experiences forms in session.
by identifying antecedents; cognitive, behavioral, and In the fifth module, and third core module, Emotion
physiological responses; and short- and long-term Driven Behaviors and Emotion Avoidance, the goal is to
consequences of these responses. The aim of this identify specific behaviors that prevent full exposure to
module is to help foster a greater acceptance of the (and processing of) strong emotions. Emotion avoid-
adaptive, functional nature of emotions and increase ance can occur through subtle behavioral avoidance
the patient’s awareness of their own patterns of (e.g., procrastination), cognitive avoidance (e.g., day-
emotional responding. dreaming or tuning out), or by use of safety signals
In the third module, and the first core module, (something that a patient may keep with them at all
Emotion Awareness Training, the focus is on helping times that confers an irrational sense of safety during
patients develop a greater objective awareness of their intense emotional experiences). Emotion driven beha-
emotional experiences through monitoring the inter- viors (EDBs) are the behavioral components of an
action between thoughts, feelings, and behaviors while emotion that can be adaptive (e.g., flight/fight response
anchoring this awareness within the current context in in life-threatening situations), but can easily become
which their emotions occur. Placing unfolding emo- maladaptive when they occur indiscriminately or are
tional experiences, within the context of present- employed in inappropriate circumstances (e.g., flight/
moment experiences, allows patients to identify fight response in social situations). As such, another
patterns of responses and/or emotion regulation important goal of this phase is to aid patients in
strategies being employed that are inconsistent or identifying maladaptive EDBs and teaching them to
incompatible with ongoing situational or motivational develop more adaptive behavioral responses to intense
demands. This is often difficult for patients initially, emotions.
because many are distracted by past experiences or In the sixth module, and fourth core module,
potential upcoming stressors. Therefore, in order to Awareness and Tolerance of Physical Sensations, all patients
foster emotion awareness, the UP utilizes an adaptation engage in a series of interoceptive exercises designed to
of mindfulness exercises from Segal et al.[87] as well as evoke physical sensations analogous to those typically
brief, daily exercises designed to condition present- associated with anxiety and distress. Interoceptive
focused awareness. In addition, consistent with the UPs exposures are applied across diagnoses, whether or
focus on emotional responding, idiosyncratic emotion not physical sensations represent a specific focus of the
induction exercises (such as playing meaningful music patient’s anxiety, as a way to increase the patient’s
in session or viewing personal emotive photographs) awareness of the role of physical sensations as a core
are used with the intention of practicing present- component of emotional experiences, as well as
focused awareness in the context of an ongoing increase tolerance of these sensations. Through these
emotional experience. During these emotion expo- exercises, patients begin to recognize the ways in which
sures, the therapist works with the patient to identify somatic sensations might influence thoughts and
Depression and Anxiety
 Review: Conceptual Basis of the Unified Protocol 887

behaviors, as well as how thoughts and behaviors can diagnoses. At 6-month follow-up, 92% had achieved
serve to intensify these sensations. significant RCI scores on principal diagnoses (N 5 13)
In the seventh module, and the final core module, and 80% showed significant RCI scores on comorbid
Interoceptive and Situational Exposure, patients increase diagnoses (N 5 11). Additionally, 62% of the 13
their tolerance of intense or uncomfortable emotions individuals, for whom follow-up data were available,
through exposure to both internal and external emo- demonstrated additional gains over the period between
tional triggers. Continued engagement in interoceptive posttreatment and follow-up, with 23% evidencing
exposure allows patients to identify and tolerate significant RCI scores between posttreatment and
uncomfortable physiological sensations that often follow-up. Finally, analyses of the effect of treatment
accompany and can serve as internal triggers for on negative affect, as assessed by the negative affect
emotional experiences. Through situational exposures, subscale of the Positive and Negative Affect
patients are gradually introduced to situations and Schedule[91] revealed that by posttreatment 67% of
experiences that they had been avoiding earlier and that patients had achieved scores within a normal range, as
serve as external triggers for emotional experiences. In compared to only 27% at pretreatment. By 6-month
this sense, exposure to situational experiences serves as follow-up, 82% of patients achieved scores within a
an external context to provoke intense emotional normal range.
experiences. Through repeated exposure to both
internal and external cues, patients ultimately increase
their tolerance for intense and uncomfortable emo-
SUMMARY AND CONCLUSIONS
tional experiences. Several converging factors underscore the promise of
In the last module, Relapse Prevention, treatment a unified transdiagnostic approach to the treatment of
principles are reviewed, and it is emphasized that the anxiety and mood disorders.
return of anxiety and mood disturbances does not mean
the patient has relapsed. Instead, patients are reminded
(1) Extant treatment protocols for the full range of
of the natural vacillation of emotions and how they can
employ the skills learned in therapy to navigate anxiety disorders contain a common set of proce-
dures, such as cognitive reappraisal, prevention of
through these experiences in an adaptive way.
avoidance, and exposure-based procedures, which
differ only in the situations, cognitions, and
PRELIMINARY DATA behaviors that provide the context for the applica-
tion of the procedures.[92,93]
The latest iteration of the UP was pilot tested in an
(2) Extensive comorbidity among anxiety and mood
open trial of 15 patients with heterogeneous anxiety
disorders might be better addressed through a
and mood disorders, seeking treatment at our center.
treatment protocol that targets multiple disorders
Outcomes of this trial are detailed in Ellard et al.[88]
simultaneously, as well as anxiety disorder ‘‘not
To determine the clinical significance of outcomes in
otherwise specified’’ (NOS) and subdefinitional
this trial, we examined the proportion of individuals
threshold variations, by focusing on common
meeting criteria for treatment responder status and
underlying factors across the disorders.
high end-state functioning, using a conservative
adaptation of algorithms reported in other similar (3) A unified transdiagnostic treatment approach
would facilitate dissemination and training by
trials of CBT for anxiety.[88,89] Using this algorithm,
providing a single set of therapeutic principles
73% of patients achieved responder status, and 60% of
rather than numerous diverse protocols. Such an
patients achieved high end-state functioning. The
approach would be more cost effective and may
response for comorbid disorders was also promising
help to increase the availability of evidence-
(N 5 11), with 64% of patients attaining both respon-
based treatments for anxiety and mood disorders,
der and high end-state functioning status. Data were
meeting a significant public health need.
available for 13 individuals at 6-month follow-up. Of
(4) The presence of considerable overlap and common
these individuals, 85% achieved responder status and
factors among disorders, as evidenced through
69% achieved high end-state functioning on principal
diagnoses (defined as the most interfering current generalized treatment responses, common patterns
of neural activation, the latent structure of anxiety
diagnosis). Follow-up data for comorbid diagnoses
and mood disorders, and common etiological
(N 5 11) indicated 80% achieved responder status, with
variables, suggest common unifying factors present
more than half achieving high end-state functioning on
across the emotional disorders that may be amen-
comorbid disorders. Further examination of clinically
able to a single set of therapeutic principles.
significant change using the reliable change index
(RCI) approach[90] applied to measures in the same Others have noted the value of distilling transdiag-
manner as our conservative algorithm[88] revealed nostic approaches to psychopathology. In addition to
that 93% had achieved significant RCI scores at our own efforts,[92] Fairburn pioneered the concept of
acute posttreatment on principal diagnoses, and 56% transdiagnostic protocols and developed a transdiag-
had achieved significant RCI scores on comorbid nostic protocol for eating disorders to address the fact
Depression and Anxiety
888 Wilamowska et al.

that a particularly large number of those patients meet 13. Barlow DH, Levitt JT, Bufka LF. The dissemination of
NOS criteria.[94,95] Norton has proposed a somewhat empirically supported treatments: a view to the future. Behav
similar set of transdiagnostic therapeutic principles to Res Ther 1999;37:S147–S162.
ours for the anxiety disorders.[96] Some investigators 14. Barlow DH. Anxiety and its Disorders: The Nature and
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