2. An online transdiagnostic treatment for affective and mood disorders
Bogdan Tudor Tulbure
Nastasia Sălăgean
Andrei Rusu
Silvia Măgurean
Florin Alin Sava
West University of Timișoara, Romania

3. Main objectives To start a conversation about
a broader conceptualization of psychological treatments
what are he core transdiagnostic processes?
what are effective ways to personalize treatments?
will transdiagnostic processes be present in the near future?
what are the future avenues for the development of CBT?
To present the results of a transdiagnostic RCT we recently conducted in Romania

4. What are transdiagnostic treatments
McEvoy, Nathan & Norton (2009)
Unified (or transdiagnostic) treatments are those that apply the same underlying treatment principles across mental disorders without tailoring the protocol to specific diagnoses
treatment focus is not limited to specific diagnoses, they are applied to individuals who may meet criteria for one/more clinical diagnoses
the emphasis is on functional links between components of the transdiagnostic formulation (e.g., thoughts, behaviors, physiology, and emotions), which is then individualized during therapy

5. Trasransdiagnostic approaches
Three classes of treatment approaches (Sauer-Zavala et al., 2017)
universally applied therapeutic principles
represent a “top-down” approach where general intervention techniques are used across disorders
in the cognitive therapy (CT) framework patients are encouraged to identify cognitive distortions and reevaluate experiences in a more realistic fashion,
in the acceptance and commitment therapy (ACT) framework patients are encouraged to be more accepting, to cultivate cognitive defusion, mindfulness and to pursue their life values
empirically-based modular strategies
relevant intervention strategies are used to address each problem presented by an individual patient regardless of his diagnostic
shared mechanism approach
interventions address the common underlying mechanism according to theoretical models of psychopathology
use a “bottom-up” approach by identifying the core vulnerabilities that contribute to the development and maintenance of multiple disorders, and then design strategies to target them.

6. Mansell & McEvoy (2017)
aimed to identify a core process in a large treatment-seeking sample (N=313) of participants with anxiety or depression
Affect Control Scale (Williams et al., 1997) fear of emotions
Penn State Worry Questionnaire (PSWQ, Meyer et al., 1990)
Ruminative Responses Questionnaire (RRS, Treynorm et al., 2003)
Repetitive Thinking Questionnaire (RTQ-10, McEvoy et al., 2014)
The Acceptance, Safety behaviors, Escape and Avoidance Scale (AcSEAS, pronounced “Axes”; McEvoy et al., in preparation)
Beck Depression Inventory-II (BDI-II) & Beck Anxiety Inventory (BAI)
Principal component analyses - Found a single factor (54 items) accounted for the largest proportion of the variance & correlated with symptoms of anxiety and depression
Could not name it!

7. Transdiagnostic approach rationale
Common etiology for multiple psychological disorders
Triple vulnerability model (Barlow 2000, 2002)
Biological vulnerability
Neuroticism/Negative affectivity
Behavioral inhibition
General psychological vulnerability
Life experiences that lead to the conclusion that negative life events are unpredictibile and uncontrollable
No / weak coping mechanisms
Specific psychological vulnerability
Life experiences where certain aspects (ex: somatic senzations, intrusive thoughts, social evaluation) are seen as dangerous
+ Stressful life events

8. Transdiagnostic approach rationale
High comorbidity for various psychogical disorders
Current assessment – 55% of Ps with one anxiety disorder have a second anxious or affective disorder
Life span assessment – 76% of Ps have more than one clinical diagnostic (Brown et al. 2001, Kessler et al , 1998, Roy-Brine et al. 2006, Tsao et al. 2002, 2005)
Perfectionism was proven a transdiagnostic factor (Egan, Wade & Shafran 2011, Maricutoiu, Magurean, Tulbure – under review).

9. Are transdiagnostic treatments for anxiety and affective disorder effective?
Reinholt and Krogh (2014)
11 studies where transdiagnostic interventions for anxiety disorders were compared to WLCG/TAU
moderate ES at post-treatment (d = .68) maintained at FU
Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, (2015)
50 studies of transdiagnostic packages for anxiety and affective disorders
large pre- to post ES for depression (Hedges g = .91), and anxiety (g = .86), and moderate ES quality of life (g = .69)
guided internet/computerized transdiagnostic treatments showed superior results in reducing anxiety when compared to face-to-face group CBT, and also in reducing depression when compared to individual face-to-face treatments

10. Are transdiagnostic treatments for anxiety and affective disorder effective?
Newby, Twomey, Li, & Andrews (2016)
17 studies that compared computerized/internet delivered transdiagnostic interventions with WLCG on anxiety, depression and quality of life
large post-treatment ES for depression (g = .84),
med. post-treatemnt ES for anxiety (g=.78) & QOLI (g=.48)
Pearl & Norton (2017)
Compared transdiagnostic and diagnostic-specific interventions for anxiety disorders (67 studies)
g = (95% CI: 0.874–1.027) for diagnostic-specific
g = (95% CI: 0.876–1.242) for transdiagnositic
large ES and overlapping confidence intervals
the new generation of transdiagnostic programs is at least as efficacious as the classical disorder-specific CBT

11. Study Objective
To test the efficacy (how it works in well-controlled conditions) of the PsychoTherapy for Anxiety & Depression (PsiTAD) in Romania

12. West University of Timisoara, RO
The PsiTAD Team
West University of Timisoara, RO
Bogdan Tudor Tulbure
Florin Alin Sava
Andrei Rusu
Silvia Magurean
Nastasia Salagean
Daniela Moza
Graduate students
Axente Valentina
Farcaș Mihaela Anca
Ghinea Roxana
Giuris Larisa Roxana
Lațcu Neli Anca
Măroiu Cristina
Telbisz Sergiu
Trică Ștefana Ioana

13. PsiTAD study design

14. PsiTAD main study measures
Primary outcome measures:
Depression – Beck Depression Inventory-II (BDI-II)
GAD – Penn State Worry Questionnaire (PSWQ)
SOC – Social Phobia Inventory (SPIN)
OCD – Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
PAD – Panic Disorder Severity Scale - Self Report (PDSS-SR)
PTSD – PTSD Checklist for DSM-5 (PCL-5)
Additional measures:
Perfectionism – Almost Perfect Scale–Revised (APS-R)
Quality of life – Quality of Life Inventory (QOLI)
Symptom interference – Work and Social Adjustment Scale (WSAS)
Neuroticism – IPIP (neuroticism items)
Emotion Regulation – Emotion Regulation Questionnaire (ERQ)
Anxiety Sensitivity Index (ASI)

15. PsiTAD Study inclusion criteria:
be fluent in Romanian,
be at least 18 years of age,
have at least one selt-report score above the cut-off (ex: SPIN>19, BDI>14)
have a current diagnosis of an anxiety disorder or major depression/ dysthymia on SCID-I (RV)
have no suicidal ideation (i.e., not exceed a score of 2 on the BDI-II suicide item and not report parasuicidal behavior on the Screening Questionnaire of the SCID-I)
take no medication, or have an unchanged dosage during last month
take part in no other treatment programs,
have no obstacle to participation (i.e., have Internet acces, have no long travel plans during the treatment etc.);
have no bipolar disorder and no psychosis (according to medication status)

16. Study Diagram

17. PsiTAD treatment & delivery
We used a treatment manual (based on Barlow’s transdiagnostic intervention ) and we additionally included a perfectionism component
The treatment consists of 9 modules adapted for the online environment
Psychology master students offered weekly feedback for homework assignments and answer participant’s questions on an online platform

18. M2. Understanding and tracking emotions
Emotions are adaptive
All emotions (+ & - ) are important and adaptative at their core
No emotions are ”bad” or ”dangerus”
Adaptive functions of emotions
They get us ready to react to external stimuli
They motivate us engage in behaviors (Emotion Driven Behaviors EDB), that are often automatic and adaptive
Could you please offer an exemple when the so called ”negative” emotions were useful or adaptive?
Adaptive nature of fear, sadness, anger

19. M2. Understanding and tracking emotions

20. M3. Observing your emotions and your reactions to your emotions

21. M4. Understanding your thoughts (cognitive component)

22. M5. Emotonal avoidance & perfectionism
Timp de un minut gândiți-vă cum arată un urs polar. Pur și simplu luați-vă un minut pentru a vă gândi la un urs polar, vizualizând cum arată blana lui, cum se mișcă etc. Ați reușit să vă imaginați acest lucru?
Wegner & Schneider

24. M8. Understanding and confronting physical sensations
Hiperventilația
Timp de 60’ respirați adânc și rapid pe gură cu multă forță => amețeală și senzația de irealitate.
Respirați printr-un pai subțire.
Timp de 120’ respirați printr-un pai subțire ținându-vă de nas, ca să nu intre aer decât prin gaura paiului.
=> dificultatea de a respira/lipsa de aer, anxietate.
Învârtiți-vă pe loc
Timp de 60’ învârtiți-vă repede (o rotație la fiecare trei secunde) cu ochii închiși. Puteti folosi un scaun rotativ.
=> amețeală și dezorientare.
Alergați pe loc
Alergați pe loc un min. ridicându-vă genunchii cât mai sus =>creșterea ritmului cardiac, respirații scurte, obraji înroșiți, creșterea temperaturii corporale

25. PsiTAD data analysis
Linear mixed models were used to estimates the effects of the program on primary and secondary outcome measures
Effect sizes were calculated using Cohen’s d

26. Results Primary outcome measures

27. Depression (BDI-II)
Socia Anxiety (SPIN)

28. Results Secondary outcome measures

29. Symptom interference (WSAS)

30. Results (ES) Primary outcome

31. Results (ES) Secondary outcomes

32. Recovery Rates

33. Advantages of transdiagnostic interventions
Common conceptualization for more than one disorder
One (unified) intervention can simultaneously address several problems
Ease of implementation
Reduce the needs for training in multiple protocols
Effectively address comorbidity
Improve the dissemination of evidence-based CBT
Lower economic costs

34. Future directions
Run comparative RCT for the three transdiagnostic models?
universally applied therapeutic principles
empirically-based modular strategies
shared mechanism approach
Challenge the current disorder classification system?
Look for a limited set of underlying mechanism and related therapeutic processes or accept that there is more than one effective strategy for the same problem?

35. www.e-CBT.ro/en Email: bogdan.tulbure@e-cbt.ro