Transdiagnostic Therapy for Anxiety

March 22, 2019
Clinical psychology is starting to use transdiagnostic therapy to treat multiple problems with the same strategy. Keep reading to find out about Norton's work on the treatment of anxiety disorders.

In the last decade, clinical psychology has seen numerous advances in the types of treatments available to help patients. One of them is transdiagnostic therapy.

Usually, therapists learn to use a specific treatment for each psychopathology. However, some studies have shown that using the same therapy for a whole category of disorders could be more effective and also more efficient. This concept is called transdiagnostic therapy.

Transdiagnostic therapy focuses on the common thread that runs through different disorders. For example, panic, phobias, and general anxiety share a set of traits common in all anxiety disorders. These might be distressing or negative thoughts, physiological hyperactivation, avoidance, or safety behaviors.

Does it make sense, then, to use one cognitive behavioral therapy (CBT) for each specific disorder? According to the Norton group at the University of Houston (Norton, Hayes, and Hope 2004; Norton and Hope, 2005), the answer is no.

The researchers did randomized clinical trials using transdiagnostic cognitive-behavioral group therapy on a set of patients with different depression and anxiety disorders. They found that not only did anxiety symptoms improve, but so did the comorbid secondary diagnosis that wasn’t related to anxiety (depression, for example). 

“The combination was more effective than CBT combined with other types of anxiety disorder treatments, like relaxation training, according to Peter Norton, associate professor in clinical psychology and director of the Anxiety Disorder Clinic at the University of Houston (UH).”

A woman who needs transdiagnostic therapy.

What does transdiagnostic therapy for anxiety look like?

The key for transdiagnostic therapy is a therapist who is able to find the common thread that runs through different anxiety disorders.

It doesn’t matter if you suffer from panic attacks, arachnophobia, or even obsessive-compulsive disorder. In transdiagnostic therapy, you forget about the specific labels and just say that the patients suffer from anxiety. The particular manifestation of the anxiety doesn’t matter.

This common nuclear pathology from Norton is basically determined by the structure of the tripartite model of anxiety and depression (Clark and Watson, 1991).

For Clark and Watson, the tripartite model of anxiety and depression suggests that depression and anxiety have shared components (generalized negative affect) and unique components (anhedonia and physiological hyperactivation).

Norton used these references and assumed that negative affect could be considered a central psychopathological component of both anxiety and depression. In accordance with this theoretical model, the processes and components of treatment are the same for different and unique manifestations of anxiety.

The common ingredients in transdiagnostic CBT were:

Psychoeducation

The therapist teaches the patient about anxiety in general: what it looks like, why it happens, and why it persists. Following the tripartite model, the therapist also provides information about negative affect, which is common in anxiety and depression.

Mental health professionals should understand that if they manage emotionality and move away from artificial distinctions, the comorbidities of each patient will improve.

Comorbitities are pathologies that often go along with the primary problem. Anxiety and depression are examples of that. In fact, in most cases, they’re so alike that you almost can’t tell them apart. One way to reconcile that is to look at them on the basis of negative affect.

Cognitive restructuring

We know that most patients with anxiety suffer from distressing or negative thought patterns. We also know that anxiety is a response to a feeling of potential danger.

Studies show that for patients with anxiety, the intuitive response to danger doesn’t work properly. Their thoughts are exaggerated and out of touch with reality. Proper training in cognitive restructuring can help patients identify and modify their distressing thoughts. They can use Socratic dialogue to replace their negative thoughts with more realistic ones.

For example, when someone is panicking, they often think things such as “Am I going to have a panic attack?” or “Am I going crazy?” Someone with general anxiety disorder may think: “What if my daughter gets raped when she goes out tonight?”

The goal is for the patient to focus on reality and the facts that exist at the moment, instead of imagining things that haven’t happened yet. Even if the things that the patient imagines happen, they’re unlikely to happen just how the patient imagined.

A sad guy leaning on a wall.

Exposure and response prevention

This strategy is useful to expose the patient to the things that they’re afraid of. Exposure can be real, imaginary, or interoceptive. The idea is to use exposure to help panic disorder patients learn to deal with the emotions that often arise.

Exposure helps with the physiological habituation of anxiety, as well as anxiety triggers. The other outcome is that patients can learn to stop using avoidance coping. Coping methods might include the thoughts or acts of obsessive-compulsive disorder, generalized anxiety disorder behaviors, or taking a tranquilizer for a panic disorder.

Conclusions about transdiagnostic therapy

Transdiagnostic therapy is yielding great results. According to Norton, patients see more improvement with transdiagnostic therapy than with standard therapy. They also see a positive impact on secondary diagnoses. Two-thirds of comorbidities cleared, compared to 40% success rate when treating the specific disorder.

You can see that transdiagnostic therapy may be more efficient for patients overall. It can more efficient for the therapist as well, who can treat a group of people with the same diagnosis all at the same time.

The transdiagnostic psychopathological perspective makes it possible to look at mental disorders from a broader standpoint. Seeing them from the convergance of different psychological processes common to sets of disorders makes the treatment more holistic and effective.

We can also conclude that scientists have underestimated the importance of other emotions such as disgust. Recent studies have shown that anhedonia and fear also play an important role in some anxiety disorders, especially phobias and OCD.

Although researchers haven’t figured out how much disgust plays a part in the general negative affect disorder, everything seems to indicate that it could be a generic transdiagnostic dimension of sensitivity to disgust, which could be etiologically implied in some group or groups of mental disorders.

Logically, CBT should include modifying said construct in new transdiagnostic protocols. Nevertheless, the results are very promising so far. Not only is transdiagnostic therapy effective for adults, but also for kids and teens, who are usually harder to diagnose.

  • Norton, P. J. (2012). Group cognitive-behavioral therapy of anxiety: A transdiagnostic treatment manual. New York: Guilford.
  • Sandín, B.; Chorot, P.; Valiente, R. (2012). Transdiagnostico: Nueva frontera en psicología clínica. Revista de Psicopatología y Psicología Clínica. Vol. 17, N.º 3, pp. 185-203.