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Asociación Española Revista de Psicopatología y Psicología Clínica Vol. 17, N.º 3, pp. 205-217, 2012
de Psicología Clínica Spanish Journal of Clinical Psychology, www.aepcp.net ISSN 1136-5420/12
y Psicopatología
TRANSDIAGNOSTIC GROUP CBT FOR ANXIETY DISORDER:
EFFICACY, ACCEPTABILITY, AND BEYOND
PETER J. NORTON
Anxiety Disorder Clinic, Department of Psychology, University of Houston, USA
Abstract: Interest in transdiagnostic approaches to the cognitive-behavioral treatment (CBT) of
emotional disorders has been increasing over the past decade. The purpose of this paper was to
review the rationale behind transdiagnostic treatment models, describe one such group-based treat-
ment protocol in detail, and report on the building evidence base to date. The evidence suggests that
transdiagnostic CBT for anxiety is associated with symptom improvement, performs better than
waitlist controls, is associated with improvements in comorbid disorders, and performs equiva-
lently to established diagnosis-specific treatments. Transdiagnostic protocols are also associated
with good client satisfaction, high levels of therapeutic alliance and group cohesion, and positive
treatment perceptions during and following treatment. Limitations and directions for future research
are discussed.
Keywords: Transdiagnostic; unified; group treatment; emotional disorders, cognitive behavior
therapy
TCC transdiagnóstica de grupo para los trastornos de ansiedad: Eficacia,
aceptabilidad y otros aspectos
Resumen: Durante la última década se ha venido incrementando el interés por los enfoques del
transdiagnóstico en el tratamiento cognitivo-conductual de los trastornos emocionales. El propósi-
to del presente trabajo consiste en revisar los fundamentos que subyacen a los modelos de trata-
miento transdiagnóstico, describir con detalle un protocolo de tratamiento transdiagnóstico de
grupo, y proporcionar la evidencia aportada hasta la fecha. La evidencia sugiere que la terapia
cognitivo-conductual (TCC) transdiagnóstica de la ansiedad se asocia a mejoría de los síntomas, es
superior al grupo de control de lista de espera, y es similar a los tratamientos diagnóstico-específi-
cos ya establecidos. Los protocolos de transdiagnóstico también se han asociado a buena satisfacción
del cliente, niveles elevados de alianza terapéutica y cohesión grupal, y percepciones positivas del
tratamiento durante el seguimiento. Se discuten las limitaciones y las direcciones para la investiga-
ción futura.
Palabras clave: Transdiagnóstico; tratamiento unificado; tratamiento de grupo; trastornos emocio-
nales; terapia cognitivo-conductual.
1
Interest in transdiagnostic approaches to the (e.g., Fairholme, Boisseau, Ellard, Ehrenreich,
cognitive-behavioral treatment of emotional & Barlow, 2010; Norton, 2009), and books
disorders has been increasing over the past de- (e.g., Barlow, Farchione, et al., 2011; Norton,
cade, with numerous empirical (e.g., Farchione 2012b) being devoted to the topic. At their
et al., 2012; Norton, 2012a) and theoretical heart, transdiagnostic approaches to CBT hold
papers (e.g., Erickson, Janeck, & Tallman, that fi ner clinical distinctions among classes of
2009; Norton, 2006), specials issues (see Man- mental disorders, such as the diagnoses subsu-
sell, 2008; Taylor & Clark, 2009), book chapters med under the classifi cation of Anxiety Disor-
ders or the specifi c Eating Disorder diagnoses,
are of lesser clinical importance than the broa-
Correspondence: Peter J. Norton, Ph.D., Department of der across-diagnosis (or transdiagnostic) fac-
Psychology, 126 Heyne Bldg., University of Houston, tors inherent to all mental disorders within the
Houston, TX, 77204-5022, USA, Phone: 713-743-8675, larger classifi cation (Harvey, Watkins, Mansell,
Fax: 713-743-8633. E-mail: pnorton@uh.edu.
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206 Peter J. Norton
& Shafran, 2004; Norton, 2006). Indeed, as has 1982; Spielberger, 1985), developmental
been argued elsewhere (Norton, 2006), the ex- (Bowlby, 1980; Chorpita & Barlow, 1998;
pansion of Anxiety Disorder diagnoses from Chorpita, Brown, & Barlow, 1998; Rosenbaum,
three in DSM-I (American Psychiatric Associa- 2000; Thompson, 2001), psychopathological
tion [APA], 1952) and DSM-II (APA, 1965) to (Andrews, Stewart, et al., 1990; Brown & Bar-
25 (including subtypes and specifi ers) in DSM- low, 1992; Sanderson, Di Nardo, Rapee, & Bar-
IV-TR (APA, 2000), has not yielded substantia- low, 1990), and interventional research (Norton
lly unique treatments designed to target the & Price, 2007; Hofmann & Smits, 2008) sug-
specifi c features of these diagnoses. Rather, gesting that the commonalities across the anxi-
cognitive-behavioral psychotherapies incorpo- ety disorder diagnoses outweighed the differ-
rating exposure and cognitive techniques, as ences (see Norton, 2009). That is, an individual
well as pharmacological agents impacting the with social anxiety disorder, an individual with
serotonergic system, appear to be similarly effi - agoraphobia, and an individual with a specifi c
cacious across the Anxiety Disorders when ad- phobia of heights, only differ in the specifi c
ministered in similar doses, regardless of spe- phenomenon that elicits their fear and anxiety,
cifi c diagnosis (Norton & Price, 2007; Hofmann while the common factors underlying and main-
& Smits, 2008; AccessPharmacy, accessed taining the fears are the same.
08/10/2011). Second, they found that their ability to pro-
As a result, and in response to constraints vide timely clinical services was impaired by
imposed in attempting to train and deliver mul- an unusual conundrum: patient fl ow was too
tiple CBT treatment programs for specifi c di- high to provide immediate individual CBT to
agnoses, several investigators (Barlow, Far- all clients with an anxiety disorder who re-
chione, et al., 2011; Erickson, Janeck, & quested treatment, but patient fl ow with any
Tallman, 2007; Norton, 2012b; Schmidt, Buck- specifi c anxiety disorder diagnosis was too slow
ner, Pusser, Woolaway-Bickel, & Preston, 2012) to provide timely group CBT for those diagno-
have developed transdiagnostic CBT programs ses. Indeed, as noted by Norton and Hope
in order to minimize training demands and (2008), «assuming that all new intakes had an
maximize treatment accessibility for individuals anxiety disorder, it would still require (based on
with anxiety disorders. The current paper will National Comorbidity Survey prevalence esti-
discuss in detail the development and evaluation mates) an average 21 intakes before one would
of one of the most thoroughly studied transdi- expect to have recruited 6 individuals with a
agnostic treatments for anxiety disorders. primary diagnosis of specifi c phobia to form the
group. It would require 25 intakes for a six-
person social phobia group, 31 intakes for a
TRANSDIAGNOSTIC GROUP CBT FOR panic/agoraphobia group, 50 intakes for a PTSD
ANXIETY DISORDER: DESCRIPTION OF group, 53 intakes for a GAD group, and 199
THE PROGRAM intakes for an OCD group» (p. 14). In contrast,
a transdiagnostic group CBT approach would
In 2002, Norton and Hope (unpublished allow for groups to begin as soon as a suffi cient
draft; now published as Norton, 2012b) began number of patients with any anxiety disorder
developing a transdiagnostic group CBT pro- (e.g., 2 patients with panic disorder, 2 with so-
gram in response to two emerging factors. First, cial anxiety disorder, 2 with generalized anxiety
considerable data had been mounting from ge- disorder, 1 with OCD, and 1 with PTSD).
netic (Andrews, 1991; Andrews, Stewart, Allen, The transdiagnostic group CBT program
& Henderson, 1990; Andrews, Stewart, Morris- (Norton, 2012b; for a group case study, see
Yates, Holt, & Henderson, 1990; Jang, 2005; Norton & Hope, 2008) consists of 12 weekly
Jardin, Martin, & Henderson, 1984; Kendler, 2-hour group sessions incorporating six to
Heath, Martin, & Eaves, 1987; Kendler, Neale, eight individuals with any anxiety disorder
Kessler, Heath, & Eaves, 1992), personality diagnosis. Groups are typically led by two
(Clark & Watson, 1991; Eysenck, 1957; Gray, therapists, although they have been success-
Revista de Psicopatología y Psicología Clínica 2012, Vol. 17 (3), 205-217 © Asociación Española de Psicología Clínica y Psicopatología
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Transdiagnostic CBT for anxiety disorder 207
fully implemented by one experienced thera- threat may differ. The group treatment incor-
pist on several occasions, and emphasize an porates psychoeducation into the development
overarching philosophy that clients have an and maintenance of anxiety, cognitive restruc-
excessive or irrational fear of a particular turing of excessive or irrational thoughts un-
thing (e.g., heights, negative evaluation) as derlying the anxiety disorder, graduated expo-
opposed to having diagnoses of panic disorder, sure and response prevention, cognitive
OCD, etc. In this way, all clients are seen as restructuring of core beliefs underlying anxi-
sharing the same basic pathology, even though ety, and termination and relapse prevention
the specifi c stimuli that trigger the anxiety and skills (see Table 1).
the behavioral responses to reduce danger or
Table 1. Session-by-session overview of the Transdiagnostic Group CBT program.
Session Session Content Assigned Homework
1 Psychoeducation and group socialization Self-monitoring of anxiety (ongoing)
2 Psychoeducation and introduction of Monitoring of anxious thoughts
cognitive restructuring
3 Cognitive restructuring Challenging anxious thoughts (ongoing)
4 Graduated in-session exposure and response preven- Self-directed exposure and response
tion prevention
5 Graduated in-session exposure and response preven- Self-directed exposure and response
tion prevention
6 Graduated in-session exposure and response preven- Self-directed exposure and response
tion prevention
7 Graduated in-session exposure and response preven- Self-directed exposure and response
tion prevention
8 Graduated in-session exposure and response preven- Self-directed exposure and response
tion prevention
9 Graduated in-session exposure and response preven- Self-directed exposure and response
tion prevention
10 Cognitive restructuring of core beliefs Monitoring negative-mood inducing core
beliefs
11 Cognitive restructuring of core beliefs Challenging negative mood-inducing core
beliefs
12 Termination and relapse prevention Implementing post-treatment self-therapy plan (on-
going)
Prior to Session 1 comorbid anxiety diagnoses. For example, if
an individual presented with a principal diag-
Before initiating treatment, patients are nosis of social phobia and a comorbid diagno-
asked to develop a Fear Hierarchy with a ther- sis of OCD, his or her hierarchy might consist
apist to help guide the treatment. The Fear Hi- of items addressing public speaking and as-
erarchy is a simple list of up to ten situations sertiveness (social phobia) as well as contami-
or stimuli that provoke their anxiety. Hierar- nation and washing (OCD). If possible, varia-
chies should ideally comprise a range of situ- tions that make each situation or stimuli more
ations and stimuli ideographic to that individ- or less anxiety provoking, such as going to a
ual, and should address not only situations or crowded versus relatively deserted mall, should
stimuli associated with the principal diagnoses be included.
but also situations or stimuli associated with
© Asociación Española de Psicología Clínica y Psicopatología Revista de Psicopatología y Psicología Clínica 2012, Vol. 17 (3), 205-217
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208 Peter J. Norton
Session 1 to be utilized during the introduction to cogni-
tive restructuring in the second session.
The fi rst session, which is typically more
didactic in structure than the subsequent ses- Cognitive
sions, is designed to socialize clients to the
group format and allow clients to feel more Attention shift to
comfortable sharing their personal diffi culties. perceived dangers
Activation of threat-
Issues such as attendance, homework comple- relevant memories
tion, confi dentiality, and respecting the group
members and process (e.g., allowing everyone
to contribute) are emphasized. Much of the rest
of the session focuses on providing education
about the nature of anxiety and anxiety disor-
der; the cognitive, behavioral, and physiological
components of anxiety. An emphasis is placed Physiological Behavioral
on normalizing the experience of anxiety, in that Motivation to escape
anxiety disorders are not a «malfunctioning» of Increased heart rate, or avoid the perceived
the anxiety and fear systems, but rather their muscle tension, threat, behavioral
respiration, sweating, rituals to minimize
inappropriate activation to stimuli that are either etc. danger
not dangerous or much less dangerous than the
individual feels. The three components of anx- Figure 1. Model of the interaction between cognitions,
iety-physiological activation, cognitive shifts behaviors, and physiological responses.
toward evidence of danger or threat, and behav-
ioral escape/avoidance motivations-are de-
scribed to assist the clients in becoming impar- Session 2
tial observers of their own anxiety (see Figure 1).
Clients are encouraged to describe their own The second session focuses primarily on the
experiences of anxiety, including the triggers cognitive component of anxiety. A model is
that provoke their fears, in an effort to highlight presented that highlights the fact that it is not
the commonalities and differences in the group’s the stimulus that provokes anxiety, but rather
experience of anxiety and to promote group the individual’s interpretation of the stimulus as
cohesion. Finally, therapists briefl y describe the dangerous or threatening. An example of a
components of treatment: Education/Self-Mon- household smoke detector is often a good anal-
itoring, Specifi c Cognitive Restructuring, Grad- ogy. Should a smoke detector sound its alarm
uated Exposure, and Generalized Cognitive when, for example, someone is cooking bacon,
Restructuring, emphasizing that each compo- the smoke detector is functioning properly but
nent of treatment will require work both in ses- simply alerting the homeowner of danger when
sion and at home. Daily self-monitoring of the actual threat is low. This idea is used to in-
anxiety levels and monitoring the three compo- troduce the concept of automatic thoughts—
nents of anxiety during a specifi c anxiety-pro- over-exaggerated or irrational thoughts of dan-
voking episode are assigned as homework. ger or threat that seem to arise automatically
Daily self-monitoring is assigned to (a) provide when encountering or anticipating the stimuli
ongoing evaluation of progress throughout or situation that a client fears. An example of a
treatment, (b) potentially identify previously hypothetical client is typically provided (e.g., a
unknown variables that may exacerbate or mit- client with health anxiety concerns that a head-
igate each client’s anxiety, and (c) help the cli- ache is a sign of a potential stroke) to help cli-
ents become an observer, rather than just an ents understand that although the threat feels
experiencer, of their anxiety. Monitoring the likely to the individual, there are many more
three components during an episode of anxiety likely interpretations (e.g., the headache could
is assigned to provide specifi c client examples be due to stress, poor sleep, a hangover, etc.).
Revista de Psicopatología y Psicología Clínica 2012, Vol. 17 (3), 205-217 © Asociación Española de Psicología Clínica y Psicopatología
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