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Transdiagnostic mechanisms of change and cognitive-behavioral treatments for PTSD
Accepted Manuscript Title: Transdiagnostic Mechanisms of Change and Cognitive-Behavioral Treatments for PTSDTransdiagnostic Mechanisms of Change in CBT for PTSD–> Author: Matthew W. Gallagher PII: DOI: Reference:
S2352-250X(16)30235-4 http://dx.doi.org/doi:10.1016/j.copsyc.2016.12.002 COPSYC 351
To appear in: Received date: Revised date: Accepted date:
12-9-2016 18-12-2016 19-12-2016
Please cite this article as: Matthew W.Gallagher, Transdiagnostic Mechanisms of Change and Cognitive-Behavioral Treatments for PTSD, http://dx.doi.org/10.1016/j.copsyc.2016.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RUNNING HEAD: Transdiagnostic Mechanisms of Change Transdiagnostic Mechanisms of Change and Cognitive-Behavioral Treatments for PTSD
Matthew W. Gallagher Department of Psychology & Texas Institute for Measurement, Evaluation, and Statistics University of Houston, USA
Corresponding author: Matthew W. Gallagher, Ph.D. Department of Psychology University of Houston Texas Institute for Measurement, Evaluation, and Statistics 4849 Calhoun Rd, Rm 373 Houston, TX 77204-6022 [email protected]
Transdiagnostic Mechanisms of Change 2 Highlights
Identifying mechanisms of change is crucial for understanding recovery from PTSD
Evidence for transdiagnostic mechanisms, such as hope and neuroticism, is reviewed
Current evidence supports the importance of transdiagnostic mechanisms in PTSD
Transdiagnostic treatments are an important future direction for PTSD treatment
Transdiagnostic Mechanisms of Change 3 Abstract This paper reviews the current status of transdiagnostic mechanisms of change targeted in cognitive-behavioral interventions, with a focus on mechanisms that are also relevant to emotional disorders that frequently co-occur with PTSD. First, an overview of the rationale for and key features of identifying mechanisms of change is presented, with a discussion of why it is crucial to examine mechanisms that are relevant across diagnostic boundaries. A review of the current evidence for five promising transdiagnostic mechanisms (hope, neuroticism, emotion regulation, cognitive reappraisal, and anxiety sensitivity) is then provided. Finally, the implications of the increasing evidence of transdiagnostic mechanisms of change are discussed in relation to recently developed transdiagnostic treatment protocols that provide an alternative treatment approach for PTSD.
Transdiagnostic Mechanisms of Change 4 Introduction Tremendous progress has been made in recent decades in developing cognitivebehavioral treatments for individuals with posttraumatic stress disorder (PTSD). Treatments such as cognitive processing therapy (CPT)[1] and prolonged exposure therapy (PE)[2] have been widely supported and recent years have seen the development of new treatments such as written exposure therapy (WET)[3] that also show great promise as alternative treatments for PTSD. Given extensive evidence for the efficacy of CBT for PTSD, the focus of treatment outcome research for PTSD is increasingly shifting towards the examination of the conditions under which treatments are more or less effective (i.e., moderators), and the processes by which treatments promote recovery from PTSD (i.e., mechanisms). There has also been an increasing awareness in recent years of the importance and benefits of examining transdiagnostic mechanisms of change that are relevant not only to PTSD, but to other related emotional disorders. PTSD was removed from the anxiety disorders in the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) [4]). Nevertheless, there is extensive evidence that the majority of individuals who meet diagnostic criteria for PTSD also meet criteria for one or more additional comorbid emotional disorders (i.e., mood, anxiety, and obsessive-compulsive disorders such as panic disorder, major depressive disorder) [5,6], and that common mechanisms may underlie both the development of and recovery from many emotional disorders [7]. Treatments that more intentionally focus on transdiagnostic mechanisms may provide a more efficient and effective alternative to single disorder treatment protocols as they could provide clinicians with a treatment option that could target the full range of comorbid psychiatric conditions that individuals often present with, and could provide a more efficient target for the dissemination of evidenced based treatments.
Transdiagnostic Mechanisms of Change 5 Multiple transdiagnostic CBT protocols have been developed in recent years that are designed to target emotional disorders and PTSD. To date, there is not yet a transdiagnostic treatment that has accumulated sufficient evidence to be considered an empirically supported treatment for PTSD. The goal of this article is not to compare and contrast various transdiagnostic interventions, and the present article does not represent an exhaustive list of potential transdiagnostic mechanisms of change. The goal is to provide an introduction and brief overview of current knowledge regarding transdiagnostic mechanisms of change by highlighting certain mechanisms of change that have transdiagnostic relevance and that are therefore relevant to current and future cognitive-behavioral treatments for PTSD. Defining and Identifying Mechanisms of Change A mechanism of change is a process or psychological construct that causes and explains how an intervention ultimately results in change in the outcome of interest [8]. With the increasing recognition of the importance of studying mechanisms of change for PTSD and other psychological disorders, significant progress has been made in identifying the methodological features of a study that are necessary to identify mechanisms of change [9]. A compelling theoretical rationale for why a construct could function as a mechanism of one or more treatments is the first requirement. It is then necessary to demonstrate that the mechanism is associated with PTSD symptoms, that the potential mechanism changes as a function of treatment, and that changes in the mechanism predict changes in PTSD symptoms. Appropriate methods of data-analysis must be used both for the disentangling of intraindividual change processes [10] and for the testing of mediation [11]. It is also crucial that the mechanism be shown to change prior to change in symptoms. Without the demonstration of temporal precedence, it is impossible to determine whether a construct is truly a mechanism rather than
Transdiagnostic Mechanisms of Change 6 merely a correlate or consequence of change in symptoms. The failure to demonstrate temporal precedence of change remains the primary limitation of much of the research in this area, but recent research is increasingly using appropriate designs and assessment methods that allow for the demonstration of temporal precedence. The present article does not provide a detailed critique of the methodological features used for each mechanism discussed. The mechanisms discussed do not all meet the full criteria that have been suggested as necessary for establishing a mechanism of change [8,9]. It is worth noting that the methods used in this research area and the strengths of the potential conclusions regarding mechanisms of CBT for PTSD are rapidly improving. Transdiagnostic Mechanisms and PTSD The present review focuses on a select number of mechanisms with promising empirical support and a compelling theoretical rationale for considering the mechanism to be of transdiagnostic importance and also relevant to PTSD. The mechanisms discussed in the present article include hope, neuroticism, emotion regulation, anxiety sensitivity, and cognitive changes. These five mechanisms have all been demonstrated to predict symptomatology across diagnostic boundaries and were chosen to provide coverage of mechanisms that are currently commonly studied within CBT for PTSD (i.e., cognitions and emotion regulation), mechanisms that are increasingly studied within transdiagnostic CBT treatments (i.e., anxiety sensitivity and neuroticism), and a mechanism that has for decades been suggested to be common across therapeutic modalities (i.e., hope). Other promising potential mechanisms that are not discussed here but that are relevant to PTSD and for which promising evidence exists regarding a potential mechanistic role include experiential avoidance [12], mindfulness [13], and emotional acceptance/distress tolerance [14]. For each mechanism discussed a basic definition and
Transdiagnostic Mechanisms of Change 7 theoretical overview is first presented, followed by a review of the research demonstrating the relationship of the mechanism with symptoms of PTSD and the evidence that the mechanism is relevant to recovery from PTSD and related disorders. Hope. The most widely researched model of hope defines hope as a cognitive-motivational construct that consists of pathways thinking, the ability to identify strategies or methods for pursuing and achieving goals, and agency thinking, the motivation to implement the identified pathways and persevere when confronted with obstacles [15]. Hope has been shown to be an important predictor of a broad range of psychological outcomes, including symptoms of PTSD [16,17]. For decades, it has been argued that the promotion of hope during psychotherapy may be an important common factor that is relevant across a broad range of psychotherapy interventions [18]. More recently, it has been argued that the common and core elements of CBT interventions may have a consistent effect on promoting hope, regardless of the specific disorder that is being targeted [19]. Current evidence supports this contention and indicates that that hope plays an important role as a mechanism of change of both CPT and PE. Hope has been shown to increase as a result of both treatments and to predict changes in symptoms of PTSD, with some evidence that the more cognitively focused treatment (i.e., CPT) has a greater influence on hope than PE [20]. Furthermore, it has been demonstrated that hope at the midpoint of treatment is a better predictor of subsequent changes in PTSD than PTSD is a predictor of subsequent changes in hope, which provides strong evidence regarding temporal precedence of change [21]. Hope therefore appears to be a promising mechanism of change of current gold standard treatments for PTSD. Neuroticism. Neuroticism represents the temperamental disposition to frequently experience and respond negatively to negative emotions. Most commonly studied within the context of
Transdiagnostic Mechanisms of Change 8 personality psychology, recent years have seen an increased focus on identifying the role of neuroticism in conferring vulnerability to a broad range of emotional disorders [22], and explaining the associations between emotional disorders [23]. There is clear evidence now that neuroticism plays an important role in predicting emotional disorder symptomatology beyond disorder specific dimensions of vulnerability [24]. Meta-analytic reviews also demonstrate the transdiagnostic importance of neuroticism to PTSD and indicate that the influence of neuroticism may be particularly strong on PTSD [25]. The potential for neuroticism to function as a key transdiagnostic mechanism of change has resulted in neuroticism being a primary target in recently developed transdiagnostic interventions for emotional disorders [26], and there is increasing evidence supporting the impact that transdiagnostic CBT protocols have on neuroticism and responses to negative affect [27,28]. Few studies have specifically examined the role of neuroticism as a mechanism of change within the treatment of PTSD, but there are multiple well designed longitudinal studies that demonstrate the role of neuroticism in increasing the risk for developing PTSD across varying lengths of time and above and beyond other factors [29,30,31]. Neuroticism is therefore one of the most promising future directions for identifying potential transdiagnostic mechanisms of change relevant to PTSD and related disorders [7]. Emotion Regulation. Emotion regulation is an umbrella term used to capture a variety of strategies that individuals may use to engage with and respond to emotional experiences [32]. Given the primacy of emotion regulation in daily functioning, and its relevance to a broad range of psychological disorders, it is not surprising that various facets of emotion regulation are increasingly being considered as transdiagnostic dimensions of both vulnerability to and recovery from PTSD and related emotional disorders [33,34]. Meta-analytic reviews have demonstrated the robust influence that deficits in emotion regulation can have on both
Transdiagnostic Mechanisms of Change 9 vulnerability to and maintenance of PTSD and related disorders [35]. There is also increasing evidence regarding the role of emotion regulation as a general mechanism of CBT interventions [36], which is not surprising given that the manner in which individuals approach, experience, and respond to their emotions should impact the course of symptoms across diagnostic boundaries. Within the context of CBT interventions for PTSD, there is evidence that deficits in emotion regulation are an important predictor of treatment outcome in both youth with PTSD [37] and adults with PTSD and comorbid emotional disorders [38]. The examination of the influence of emotion regulation deficits in influencing the course of psychopathology is a promising and popular current area of study, and it is likely that evidence for the transdiagnostic influence of emotion regulation will increase in the coming years. Cognitions and Cognitive Reappraisal. One of the most common features of individuals with PTSD is negative posttraumatic cognitions that develop in the aftermath of trauma and are believed to play an important role in the maintenance of PTSD symptoms[39].The capacity to adaptively engage in cognitive reappraisal is often discussed as a core emotion regulation skill with transdiagnostic relevance [32]. Current theoretical models of emotion regulation highlight how the capacity to modify or alter one’s cognitions as emotions unfold is broadly relevant across contexts [32], and meta-analytic reviews have demonstrated that individual differences in cognitive reappraisal predict symptoms across diagnostic boundaries [35]. Negative cognitions and cognitive reappraisal skills are therefore one of the most commonly targeted and studied potential mechanisms of change of PTSD treatments. The mechanistic role of promoting more adaptive cognitions during CBT for PTSD has been examined both in terms of the role of general cognitive reappraisal skills and specific reductions in negative posttraumatic cognitions that are prominent in PTSD. Research has demonstrated that the promotion of more adaptive cognitive
Transdiagnostic Mechanisms of Change 10 reappraisal skills are an important mechanism of both CPT [40] and PE [41]. There is also robust evidence regarding the role of posttraumatic cognitions as a mechanism of CPT [42], PE [43,44], cognitive therapy [45], and more generalized CBT [46] for PTSD. The importance of posttraumatic cognitions in promoting recovery from PTSD is also supported by dismantling studies that have demonstrated that just the cognitive components of one of the most widely studied interventions for PTSD (CPT) are efficacious in promoting recovery from PTSD [47] Anxiety Sensitivity. Anxiety sensitivity represents a fear of anxiety related bodily sensations [48]. Although anxiety sensitivity was initially conceptualized and primarily examined as a mechanism that may be particularly relevant to the development of and recovery from panic disorder, there is increasing evidence of the transdiagnostic relevance of anxiety sensitivity. Meta-analytic reviews have demonstrated that elevated anxiety sensitivity is broadly relevant to emotional disorders and that PTSD is one of the disorders with the strongest relationship with anxiety sensitivity [49]. There is also increasing evidence demonstrating that anxiety sensitivity may be an important pathway by which emotional disorders cascade into the development of other comorbid conditions. For example, heightened anxiety sensitivity in individuals with emotional disorders appears to predict the development and severity of substance use disorders, which may reflect a maladaptive attempt to regulate the distress caused by anxiety sensitivity and related symptoms [50]. Anxiety sensitivity has not been examined extensively within the context of CPT or PE, but multiple studies have demonstrated that interventions that specifically target anxiety sensitivity can have a robust effect on PTSD outcomes and that changes in anxiety sensitivity are an important predictor of recovery from PTSD [51,52,53]. Although there is limited evidence regarding the role of anxiety sensitivity within the context of current gold standard treatments for PTSD, there is robust evidence regarding the mechanistic role of anxiety
Transdiagnostic Mechanisms of Change 11 sensitivity in diagnosis-specific [54] and transdiagnostic [55] interventions, suggesting that decreasing anxiety sensitivity is likely to be an important factor in CBT interventions for PTSD given the prominent role of hyperarousal symptoms in PTSD. Conclusions There is promising and rapidly increasing evidence regarding the role that transdiagnostic mechanisms play in promoting recovery from PTSD in empirically supported treatments for PTSD and newer treatments that show great promise. The statistical and methodological features of these studies are also rapidly improving, which strengthens conclusions regarding exactly when and how these constructs function as mechanisms of change. The current evidence suggests that many of the key mechanisms of CBT for PTSD are quite similar to the mechanisms that have been demonstrated for the emotional disorders that most commonly occur with PTSD. This evidence also suggests that the examination of transdiagnostic treatments such as the Unified Protocol [29], Acceptance and Commitment Therapy [56], Group Cognitive-Behavioral Therapy of Anxiety [57] and Transdiagnostic Behavior Therapy [58], represent an important future direction for PTSD. These transdiagnostic interventions were developed to more intentionally target transdiagnostic mechanisms than traditional CBT for PTSD, and there is promising evidence demonstrating that transdiagnostic interventions have robust effects on the mechanisms reviewed (e.g., neuroticism in the Unified Protocol [27]). Transdiagnostic interventions generally seem to be a promising direction of treatment for individuals suffering in the aftermath of trauma, and recent reviews provide an overview of different transdiagnostic treatments and how they may be applied to PTSD [59]. Although there is currently more evidence for these transdiagnostic treatments for other emotional disorders than for PTSD, there is increasing evidence for the role of these interventions as a treatment for PTSD and conditions
Transdiagnostic Mechanisms of Change 12 that are frequently comorbid with PTSD [58,60,61]. The results of the present review provide promising evidence that targeting transdiagnostic mechanisms of change may ultimately represent an efficient and efficacious means of promoting recovery from PTSD and comorbid emotional disorders such as depression that often manifest in the aftermath of trauma.
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Transdiagnostic Mechanisms of Change 17 than was previously believed, and that changes in temperament are an important marker of recovery. 28. Sauer-Zavala S, Boswell JF, Gallagher MW, Bentley KH, Ametaj A, Barlow DH. The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the transdiagnostic treatment of emotional disorders. Behaviour research and therapy. 2012 Sep 30;50(9):551-7. 29. *Sadeh N, Miller MW, Wolf EJ, Harkness KL. Negative emotionality and disconstraint influence PTSD symptom course via exposure to new major adverse life events. Journal of anxiety disorders. 2015 Apr 30;31:20-7. a. This longitudinal study examined the links between personality and PTSD symptom severity in trauma-exposed veterans across a four year period. Results indicated that personality predicted subsequent levels of PTSD, and that this effect may partially occur due to an increase in stressful life events that individuals with greater neuroticism experience. These finding provide support for neuroticism as a transdiagnostic factor that is relevant to the longitudinal course of PTSD. 30. Breslau N, Schultz L. Neuroticism and post-traumatic stress disorder: a prospective investigation. Psychological medicine. 2013 Aug 1;43(08):1697-702. 31. Lawrence JW, Fauerbach JA. Personality, coping, chronic stress, social support and PTSD symptoms among adult burn survivors: a path analysis. Journal of Burn Care & Research. 2003 Jan 1;24(1):63-72. 32. Gross JJ, editor. Handbook of emotion regulation. Guilford publications; 2013 Dec 17.
Transdiagnostic Mechanisms of Change 18 33. Campbell-Sills L, Ellard KK, Barlow DH. Emotion regulation in anxiety disorders. Handbook of emotion regulation. 2013. 34. Kring AM, Sloan DM, editors. Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment. Guilford Press; 2009 Nov 4. 35. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review. 2010 Mar 31;30(2):217-37. 36. *Gratz KL, Weiss NH, Tull MT. Examining emotion regulation as an outcome, mechanism, or target of psychological treatments. Current opinion in psychology. 2015 Jun 30;3:85-90. a. This manuscript provides a conceptual overview of how various emotion regulation strategies influence PTSD and related disorders, and reviews current evidence demonstrating emotion regulation to be a transdiagnostic mechanism of change in CBT. The review demonstrates the importance of emotion regulation in predicting recovery both in interventions that explicitly target emotion regulation and in interventions that do not. 37. Sharma-Patel K, Brown EJ. Emotion Regulation and Self Blame as Mediators and Moderators of Trauma-Specific Treatment. 38. Hinton DE, Hofmann SG, Pollack MH, Otto MW. Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: Improvement in emotion regulation and orthostatic blood pressure response. CNS neuroscience & therapeutics. 2009 Sep 1;15(3):255-63. 39. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behaviour research and therapy. 2000 Apr 30;38(4):319-45.
Transdiagnostic Mechanisms of Change 19 40. Boden MT, Westermann S, McRae K, Kuo J, Alvarez J, Kulkarni MR, Gross JJ, Bonn-Miller MO. Emotion regulation and posttraumatic stress disorder: A prospective investigation. Journal of Social and Clinical Psychology. 2013 Mar 1;32(3):296. 41. Zalta AK, Gillihan SJ, Fisher AJ, Mintz J, McLean CP, Yehuda R, Foa EB. Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of consulting and clinical psychology. 2014 Feb;82(1):171. 42. *Schumm JA, Dickstein BD, Walter KH, Owens GP, Chard KM. Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy. Journal of Consulting and Clinical Psychology. 2015 Dec;83(6):1161. a. This study examined mechanisms of change in cognitive processing therapy in a sample of 195 veterans with PTSD. Results were consistent with the theoretical model of cognitive processing therapy in that changes in trauma-related cognitions predicted changes in symptoms of PTSD. Most importantly, results demonstrated that changes in trauma-related cognitions temporally preceded changes in PTSD symptoms, which is a crucial step for demonstrating mechanisms of change. 43. Kumpula MJ, Pentel KZ, Foa EB, LeBlanc NJ, Bui E, McSweeney LB, Knowles K, Bosley H, Simon NM, Rauch SA. Temporal Sequencing of Change in Posttraumatic Cognitions and PTSD Symptom Reduction During Prolonged Exposure Therapy. Behavior Therapy. 2016 Mar 3. 44. McLean CP, Yeh R, Rosenfield D, Foa EB. Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents. Behaviour research and therapy. 2015 May 31;68:64-9.
Transdiagnostic Mechanisms of Change 20 45. Kleim B, Grey N, Wild J, Nussbeck FW, Stott R, Hackmann A, Clark DM, Ehlers A. Cognitive change predicts symptom reduction with cognitive therapy for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 2013 Jun;81(3):383. 46. Mueser KT, Rosenberg SD, Xie H, Jankowski MK, Bolton EE, Lu W, Hamblen JL, Rosenberg HJ, McHugo GJ, Wolfe R. A randomized controlled trial of cognitivebehavioral treatment for posttraumatic stress disorder in severe mental illness. Journal of consulting and clinical psychology. 2008 Apr;76(2):259. 47. Resick PA, Galovski TE, Uhlmansiek MO, Scher CD, Clum GA, Young-Xu Y. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of consulting and clinical psychology. 2008 Apr;76(2):243. 48. Taylor S. Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety. Routledge; 2014 May 12. 49. Naragon-Gainey K. Meta-analysis of the relations of anxiety sensitivity to the depressive and anxiety disorders. Psychological bulletin. 2010 Jan;136(1):128. 50. Zvolensky MJ, Farris SG, Leventhal AM, Schmidt NB. Anxiety sensitivity mediates relations between emotional disorders and smoking. Psychology of Addictive Behaviors. 2014 Sep;28(3):912. 51. *Allan NP, Short NA, Albanese BJ, Keough ME, Schmidt NB. Direct and mediating effects of an anxiety sensitivity intervention on posttraumatic stress disorder symptoms in trauma-exposed individuals. Cognitive behaviour therapy. 2015 Nov 2;44(6):512-24.
Transdiagnostic Mechanisms of Change 21 52. Vujanovic AA, Bernstein A, Berenz EC, Zvolensky MJ. Single-session anxiety sensitivity reduction program for trauma-exposed adults: A case series documenting feasibility and initial efficacy. Behavior therapy. 2012 Sep 30;43(3):482-91. 53. Fetzner MG, Asmundson GJ. Aerobic exercise reduces symptoms of posttraumatic stress disorder: a randomized controlled trial. Cognitive behaviour therapy. 2015 Jul 4;44(4):301-13. 54. Gallagher MW, Payne LA, White KS, Shear KM, Woods SW, Gorman JM, Barlow DH. Mechanisms of change in cognitive behavioral therapy for panic disorder: the unique effects of self-efficacy and anxiety sensitivity. Behaviour research and therapy. 2013 Nov 30;51(11):767-77. 55. Boswell JF, Farchione TJ, Sauer-Zavala S, Murray HW, Fortune MR, Barlow DH. Anxiety sensitivity and interoceptive exposure: a transdiagnostic construct and change strategy. Behavior therapy. 2013 Sep 30;44(3):417-31. 56. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: Model, processes and outcomes. Behaviour research and therapy. 2006 Jan 31;44(1):1-25. 57. Norton PJ Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. 2012. Guilford Press. 58. Gros, D. F. (2014). Development and initial evaluation of Transdiagnostic Behavior Therapy (TBT) for veterans with affective disorders. Psychiatry Research, 220, 275-282. 59. Gutner, CA, Galovski, T, Bovin, MJ and Schnurr, PP, Emergence of Transdiagnostic Treatments for PTSD and Posttraumatic Distress. Current psychiatry reports, 2016 18(10), p.95.
Transdiagnostic Mechanisms of Change 22 60. Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL, Thompson-Hollands J, Carl JR, Gallagher MW, Barlow DH. Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behavior therapy. 2012 Sep 30;43(3):666-78. 61. Gallagher MW. The Unified Protocol for the Treatment of Posttraumatic Stress Disorder. Unified Protocol Clinical Applications. Barlow DH & Farchione, TJ Editors, 2017. New York: Oxford University Press
S2352-250X(16)30235-4 http://dx.doi.org/doi:10.1016/j.copsyc.2016.12.002 COPSYC 351
To appear in: Received date: Revised date: Accepted date:
12-9-2016 18-12-2016 19-12-2016
Please cite this article as: Matthew W.Gallagher, Transdiagnostic Mechanisms of Change and Cognitive-Behavioral Treatments for PTSD, http://dx.doi.org/10.1016/j.copsyc.2016.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RUNNING HEAD: Transdiagnostic Mechanisms of Change Transdiagnostic Mechanisms of Change and Cognitive-Behavioral Treatments for PTSD
Matthew W. Gallagher Department of Psychology & Texas Institute for Measurement, Evaluation, and Statistics University of Houston, USA
Corresponding author: Matthew W. Gallagher, Ph.D. Department of Psychology University of Houston Texas Institute for Measurement, Evaluation, and Statistics 4849 Calhoun Rd, Rm 373 Houston, TX 77204-6022 [email protected]
Transdiagnostic Mechanisms of Change 2 Highlights
Identifying mechanisms of change is crucial for understanding recovery from PTSD
Evidence for transdiagnostic mechanisms, such as hope and neuroticism, is reviewed
Current evidence supports the importance of transdiagnostic mechanisms in PTSD
Transdiagnostic treatments are an important future direction for PTSD treatment
Transdiagnostic Mechanisms of Change 3 Abstract This paper reviews the current status of transdiagnostic mechanisms of change targeted in cognitive-behavioral interventions, with a focus on mechanisms that are also relevant to emotional disorders that frequently co-occur with PTSD. First, an overview of the rationale for and key features of identifying mechanisms of change is presented, with a discussion of why it is crucial to examine mechanisms that are relevant across diagnostic boundaries. A review of the current evidence for five promising transdiagnostic mechanisms (hope, neuroticism, emotion regulation, cognitive reappraisal, and anxiety sensitivity) is then provided. Finally, the implications of the increasing evidence of transdiagnostic mechanisms of change are discussed in relation to recently developed transdiagnostic treatment protocols that provide an alternative treatment approach for PTSD.
Transdiagnostic Mechanisms of Change 4 Introduction Tremendous progress has been made in recent decades in developing cognitivebehavioral treatments for individuals with posttraumatic stress disorder (PTSD). Treatments such as cognitive processing therapy (CPT)[1] and prolonged exposure therapy (PE)[2] have been widely supported and recent years have seen the development of new treatments such as written exposure therapy (WET)[3] that also show great promise as alternative treatments for PTSD. Given extensive evidence for the efficacy of CBT for PTSD, the focus of treatment outcome research for PTSD is increasingly shifting towards the examination of the conditions under which treatments are more or less effective (i.e., moderators), and the processes by which treatments promote recovery from PTSD (i.e., mechanisms). There has also been an increasing awareness in recent years of the importance and benefits of examining transdiagnostic mechanisms of change that are relevant not only to PTSD, but to other related emotional disorders. PTSD was removed from the anxiety disorders in the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) [4]). Nevertheless, there is extensive evidence that the majority of individuals who meet diagnostic criteria for PTSD also meet criteria for one or more additional comorbid emotional disorders (i.e., mood, anxiety, and obsessive-compulsive disorders such as panic disorder, major depressive disorder) [5,6], and that common mechanisms may underlie both the development of and recovery from many emotional disorders [7]. Treatments that more intentionally focus on transdiagnostic mechanisms may provide a more efficient and effective alternative to single disorder treatment protocols as they could provide clinicians with a treatment option that could target the full range of comorbid psychiatric conditions that individuals often present with, and could provide a more efficient target for the dissemination of evidenced based treatments.
Transdiagnostic Mechanisms of Change 5 Multiple transdiagnostic CBT protocols have been developed in recent years that are designed to target emotional disorders and PTSD. To date, there is not yet a transdiagnostic treatment that has accumulated sufficient evidence to be considered an empirically supported treatment for PTSD. The goal of this article is not to compare and contrast various transdiagnostic interventions, and the present article does not represent an exhaustive list of potential transdiagnostic mechanisms of change. The goal is to provide an introduction and brief overview of current knowledge regarding transdiagnostic mechanisms of change by highlighting certain mechanisms of change that have transdiagnostic relevance and that are therefore relevant to current and future cognitive-behavioral treatments for PTSD. Defining and Identifying Mechanisms of Change A mechanism of change is a process or psychological construct that causes and explains how an intervention ultimately results in change in the outcome of interest [8]. With the increasing recognition of the importance of studying mechanisms of change for PTSD and other psychological disorders, significant progress has been made in identifying the methodological features of a study that are necessary to identify mechanisms of change [9]. A compelling theoretical rationale for why a construct could function as a mechanism of one or more treatments is the first requirement. It is then necessary to demonstrate that the mechanism is associated with PTSD symptoms, that the potential mechanism changes as a function of treatment, and that changes in the mechanism predict changes in PTSD symptoms. Appropriate methods of data-analysis must be used both for the disentangling of intraindividual change processes [10] and for the testing of mediation [11]. It is also crucial that the mechanism be shown to change prior to change in symptoms. Without the demonstration of temporal precedence, it is impossible to determine whether a construct is truly a mechanism rather than
Transdiagnostic Mechanisms of Change 6 merely a correlate or consequence of change in symptoms. The failure to demonstrate temporal precedence of change remains the primary limitation of much of the research in this area, but recent research is increasingly using appropriate designs and assessment methods that allow for the demonstration of temporal precedence. The present article does not provide a detailed critique of the methodological features used for each mechanism discussed. The mechanisms discussed do not all meet the full criteria that have been suggested as necessary for establishing a mechanism of change [8,9]. It is worth noting that the methods used in this research area and the strengths of the potential conclusions regarding mechanisms of CBT for PTSD are rapidly improving. Transdiagnostic Mechanisms and PTSD The present review focuses on a select number of mechanisms with promising empirical support and a compelling theoretical rationale for considering the mechanism to be of transdiagnostic importance and also relevant to PTSD. The mechanisms discussed in the present article include hope, neuroticism, emotion regulation, anxiety sensitivity, and cognitive changes. These five mechanisms have all been demonstrated to predict symptomatology across diagnostic boundaries and were chosen to provide coverage of mechanisms that are currently commonly studied within CBT for PTSD (i.e., cognitions and emotion regulation), mechanisms that are increasingly studied within transdiagnostic CBT treatments (i.e., anxiety sensitivity and neuroticism), and a mechanism that has for decades been suggested to be common across therapeutic modalities (i.e., hope). Other promising potential mechanisms that are not discussed here but that are relevant to PTSD and for which promising evidence exists regarding a potential mechanistic role include experiential avoidance [12], mindfulness [13], and emotional acceptance/distress tolerance [14]. For each mechanism discussed a basic definition and
Transdiagnostic Mechanisms of Change 7 theoretical overview is first presented, followed by a review of the research demonstrating the relationship of the mechanism with symptoms of PTSD and the evidence that the mechanism is relevant to recovery from PTSD and related disorders. Hope. The most widely researched model of hope defines hope as a cognitive-motivational construct that consists of pathways thinking, the ability to identify strategies or methods for pursuing and achieving goals, and agency thinking, the motivation to implement the identified pathways and persevere when confronted with obstacles [15]. Hope has been shown to be an important predictor of a broad range of psychological outcomes, including symptoms of PTSD [16,17]. For decades, it has been argued that the promotion of hope during psychotherapy may be an important common factor that is relevant across a broad range of psychotherapy interventions [18]. More recently, it has been argued that the common and core elements of CBT interventions may have a consistent effect on promoting hope, regardless of the specific disorder that is being targeted [19]. Current evidence supports this contention and indicates that that hope plays an important role as a mechanism of change of both CPT and PE. Hope has been shown to increase as a result of both treatments and to predict changes in symptoms of PTSD, with some evidence that the more cognitively focused treatment (i.e., CPT) has a greater influence on hope than PE [20]. Furthermore, it has been demonstrated that hope at the midpoint of treatment is a better predictor of subsequent changes in PTSD than PTSD is a predictor of subsequent changes in hope, which provides strong evidence regarding temporal precedence of change [21]. Hope therefore appears to be a promising mechanism of change of current gold standard treatments for PTSD. Neuroticism. Neuroticism represents the temperamental disposition to frequently experience and respond negatively to negative emotions. Most commonly studied within the context of
Transdiagnostic Mechanisms of Change 8 personality psychology, recent years have seen an increased focus on identifying the role of neuroticism in conferring vulnerability to a broad range of emotional disorders [22], and explaining the associations between emotional disorders [23]. There is clear evidence now that neuroticism plays an important role in predicting emotional disorder symptomatology beyond disorder specific dimensions of vulnerability [24]. Meta-analytic reviews also demonstrate the transdiagnostic importance of neuroticism to PTSD and indicate that the influence of neuroticism may be particularly strong on PTSD [25]. The potential for neuroticism to function as a key transdiagnostic mechanism of change has resulted in neuroticism being a primary target in recently developed transdiagnostic interventions for emotional disorders [26], and there is increasing evidence supporting the impact that transdiagnostic CBT protocols have on neuroticism and responses to negative affect [27,28]. Few studies have specifically examined the role of neuroticism as a mechanism of change within the treatment of PTSD, but there are multiple well designed longitudinal studies that demonstrate the role of neuroticism in increasing the risk for developing PTSD across varying lengths of time and above and beyond other factors [29,30,31]. Neuroticism is therefore one of the most promising future directions for identifying potential transdiagnostic mechanisms of change relevant to PTSD and related disorders [7]. Emotion Regulation. Emotion regulation is an umbrella term used to capture a variety of strategies that individuals may use to engage with and respond to emotional experiences [32]. Given the primacy of emotion regulation in daily functioning, and its relevance to a broad range of psychological disorders, it is not surprising that various facets of emotion regulation are increasingly being considered as transdiagnostic dimensions of both vulnerability to and recovery from PTSD and related emotional disorders [33,34]. Meta-analytic reviews have demonstrated the robust influence that deficits in emotion regulation can have on both
Transdiagnostic Mechanisms of Change 9 vulnerability to and maintenance of PTSD and related disorders [35]. There is also increasing evidence regarding the role of emotion regulation as a general mechanism of CBT interventions [36], which is not surprising given that the manner in which individuals approach, experience, and respond to their emotions should impact the course of symptoms across diagnostic boundaries. Within the context of CBT interventions for PTSD, there is evidence that deficits in emotion regulation are an important predictor of treatment outcome in both youth with PTSD [37] and adults with PTSD and comorbid emotional disorders [38]. The examination of the influence of emotion regulation deficits in influencing the course of psychopathology is a promising and popular current area of study, and it is likely that evidence for the transdiagnostic influence of emotion regulation will increase in the coming years. Cognitions and Cognitive Reappraisal. One of the most common features of individuals with PTSD is negative posttraumatic cognitions that develop in the aftermath of trauma and are believed to play an important role in the maintenance of PTSD symptoms[39].The capacity to adaptively engage in cognitive reappraisal is often discussed as a core emotion regulation skill with transdiagnostic relevance [32]. Current theoretical models of emotion regulation highlight how the capacity to modify or alter one’s cognitions as emotions unfold is broadly relevant across contexts [32], and meta-analytic reviews have demonstrated that individual differences in cognitive reappraisal predict symptoms across diagnostic boundaries [35]. Negative cognitions and cognitive reappraisal skills are therefore one of the most commonly targeted and studied potential mechanisms of change of PTSD treatments. The mechanistic role of promoting more adaptive cognitions during CBT for PTSD has been examined both in terms of the role of general cognitive reappraisal skills and specific reductions in negative posttraumatic cognitions that are prominent in PTSD. Research has demonstrated that the promotion of more adaptive cognitive
Transdiagnostic Mechanisms of Change 10 reappraisal skills are an important mechanism of both CPT [40] and PE [41]. There is also robust evidence regarding the role of posttraumatic cognitions as a mechanism of CPT [42], PE [43,44], cognitive therapy [45], and more generalized CBT [46] for PTSD. The importance of posttraumatic cognitions in promoting recovery from PTSD is also supported by dismantling studies that have demonstrated that just the cognitive components of one of the most widely studied interventions for PTSD (CPT) are efficacious in promoting recovery from PTSD [47] Anxiety Sensitivity. Anxiety sensitivity represents a fear of anxiety related bodily sensations [48]. Although anxiety sensitivity was initially conceptualized and primarily examined as a mechanism that may be particularly relevant to the development of and recovery from panic disorder, there is increasing evidence of the transdiagnostic relevance of anxiety sensitivity. Meta-analytic reviews have demonstrated that elevated anxiety sensitivity is broadly relevant to emotional disorders and that PTSD is one of the disorders with the strongest relationship with anxiety sensitivity [49]. There is also increasing evidence demonstrating that anxiety sensitivity may be an important pathway by which emotional disorders cascade into the development of other comorbid conditions. For example, heightened anxiety sensitivity in individuals with emotional disorders appears to predict the development and severity of substance use disorders, which may reflect a maladaptive attempt to regulate the distress caused by anxiety sensitivity and related symptoms [50]. Anxiety sensitivity has not been examined extensively within the context of CPT or PE, but multiple studies have demonstrated that interventions that specifically target anxiety sensitivity can have a robust effect on PTSD outcomes and that changes in anxiety sensitivity are an important predictor of recovery from PTSD [51,52,53]. Although there is limited evidence regarding the role of anxiety sensitivity within the context of current gold standard treatments for PTSD, there is robust evidence regarding the mechanistic role of anxiety
Transdiagnostic Mechanisms of Change 11 sensitivity in diagnosis-specific [54] and transdiagnostic [55] interventions, suggesting that decreasing anxiety sensitivity is likely to be an important factor in CBT interventions for PTSD given the prominent role of hyperarousal symptoms in PTSD. Conclusions There is promising and rapidly increasing evidence regarding the role that transdiagnostic mechanisms play in promoting recovery from PTSD in empirically supported treatments for PTSD and newer treatments that show great promise. The statistical and methodological features of these studies are also rapidly improving, which strengthens conclusions regarding exactly when and how these constructs function as mechanisms of change. The current evidence suggests that many of the key mechanisms of CBT for PTSD are quite similar to the mechanisms that have been demonstrated for the emotional disorders that most commonly occur with PTSD. This evidence also suggests that the examination of transdiagnostic treatments such as the Unified Protocol [29], Acceptance and Commitment Therapy [56], Group Cognitive-Behavioral Therapy of Anxiety [57] and Transdiagnostic Behavior Therapy [58], represent an important future direction for PTSD. These transdiagnostic interventions were developed to more intentionally target transdiagnostic mechanisms than traditional CBT for PTSD, and there is promising evidence demonstrating that transdiagnostic interventions have robust effects on the mechanisms reviewed (e.g., neuroticism in the Unified Protocol [27]). Transdiagnostic interventions generally seem to be a promising direction of treatment for individuals suffering in the aftermath of trauma, and recent reviews provide an overview of different transdiagnostic treatments and how they may be applied to PTSD [59]. Although there is currently more evidence for these transdiagnostic treatments for other emotional disorders than for PTSD, there is increasing evidence for the role of these interventions as a treatment for PTSD and conditions
Transdiagnostic Mechanisms of Change 12 that are frequently comorbid with PTSD [58,60,61]. The results of the present review provide promising evidence that targeting transdiagnostic mechanisms of change may ultimately represent an efficient and efficacious means of promoting recovery from PTSD and comorbid emotional disorders such as depression that often manifest in the aftermath of trauma.
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