Targeting Comorbid Anxiety and Depression Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

1 Theoretical and Research Basis for Treatment

Youth mood and anxiety disorders share common risk factors, including genetic, neurobiological, and psychosocial risks (Boomsma, van, Beijsterveldt, & Hudziak, 2005; Eley et al., 2003; Middeldorp, Cath, Dyck, & Boomsma, 2005; Wilamowska et al., 2010). As a partial result of these shared risk factors, emotional disorders tend to exhibit a high rate of co-occurrence. Youth diagnosed with one emotional disorder are likely to also have other mood or anxiety disorders (Angold, Costello, & Erkanli, 1999). Furthermore, youth who experience anxiety symptoms are at an increased risk for future anxiety or mood disorders, in particular (Brady & Kendall, 1992; Cummings, Caporino, & Kendall, 2014; Keenan & Hipwell, 2005).

Barlow, Sauer-Zavala, Carl, Bullis, and Ellard (2014) posit that this high rate of co-occurrence among emotional disorders is also related to a shared underlying core dysfunction known as neuroticism. Neuroticism is considered a temperament-like construct that affects how an individual approaches, experiences, and interprets situations within and outside himself or herself (Barlow et al., 2014). Individuals high in neuroticism tend to experience negative affect, or strong emotions such as fear, sadness, and anxiety, at higher rates or more intensely than those lower in neuroticism. In response to this negative affect, individuals high in neuroticism tend to present with frequent and significant distress and, to relieve this distress, tend to avoid or suppress the uncomfortable feelings that they perceive as intolerable. Because avoidant behaviors function to quickly relieve distress, they are negatively reinforced over time. However, these behaviors also function to maintain symptoms of emotional disorders when individuals fail to learn adaptive or more helpful ways of coping with their strong emotions (Barlow et al., 2014). Preliminary work investigating neuroticism in anxious and depressed adolescents shows that youth with anxiety and depression display similar patterns of the features (i.e., high negative affect, low distress tolerance, and high experiential avoidance) that underlie the construct of neuroticism in adults. Furthermore, neuroticism in adolescents is positively associated with self-reported anxiety and depressive symptoms (Tonarely, Sherman, & Ehrenreich-May, 2017).

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al., 2010) is an emotion-focused, evidence-based treatment that targets this core dysfunction of neuroticism in adults (Marchette & Weisz, 2017). It has also been adapted to address emotional disorders in youth with the development of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C and UP-A, respectively; Ehrenreich-May et al., 2017). These protocols bring together cognitive-behavioral techniques, such as cognitive reappraisal, problem solving, and opposite action strategies, including a variety of exposure paradigms and behavioral activation, as well as mindfulness techniques, into a single treatment. The UP (Barlow et al., 2010) for adults has been shown to lead to significant improvements at posttreatment (Farchione et al., 2012), as well as maintenance of gains at follow-up time points (Bullis, Fortune, Farchione, & Barlow, 2014). Furthermore, one recent randomized-controlled trial of the UP has shown that the UP produces equivalent remission rates for adults with anxiety compared with multiple different diagnosis-specific protocols (Barlow et al., 2017).

These results suggest that this transdiagnostic treatment may serve as the optimal choice for treating individuals with multiple comorbid anxiety disorders, rather than attempting to target each individual anxiety disorder with disorder-specific protocols (Barlow et al., 2017).

The UP-C and UP-A present the same skills as the UP; however, the skills have been adapted to be developmentally sensitive in their presentation, as well as in their delivery. Furthermore, the UP-C and UP-A also target core emotional parenting behaviors that are common across emotional disorders in youth, including high levels of criticism, overcontrol/overprotection, inconsistency, and modeling of avoidance (Ehrenreich-May et al., 2017). Research has provided support for the efficacy and feasibility of the UP, UP-A, and UP-C for individuals with mood, anxiety, and other emotional disorders. The UP-A appears to significantly improve symptoms of emotional disorders in adolescents. Results from multiple baseline, open-trial and initial wait-list controlled trial studies showed that adolescents evidenced significant improvement in their symptoms after receiving 16 sessions of treatment using the UP-A and gains were maintained at follow-up time points (Ehrenreich, Goldstein, Wright, & Barlow, 2009; Ehrenreich-May et al., 2017; Ehrenreich-May, Queen, Bilek, Remmes, & Marciel, 2014). The UP-C is a group version of the UP-A, with concurrent child and parent group content. Preliminary evidence suggests the UP-C may be similarly effective to leading cognitive-behavioral therapy (CBT) approaches to childhood anxiety, with potential benefits for those youth with higher levels of parent-reported sadness dysregulation or depressive symptoms (Kennedy, Bilek, & Ehrenreich-May, under review).

2 Case Introduction

Tony, a pseudonym, is a 15-year-old White Hispanic male who presented to a University-based, specialty clinic. Tony split his time, living half of the week with his mother, stepfather, younger sister (aged 13 years), and stepsister (aged 15 years) and his remaining time living with his biological father and younger half sisters. His mother had recently remarried (just prior to the start of treatment) and Tony noted concerns about his relationship with his stepfather, describing his stepfather as very different from himself.

3 Presenting Complaints

At the time of intake, Tony reported difficulty with anxiety in social situations and excessive worrying. Socially, Tony and his parents noted that he had very limited social contact and had no friends. Tony and his mother reported that his fear of negative evaluation was affecting his performance in school, in sports, and with peers. In addition to his fear of negative evaluation, Tony also reported increased feelings of sadness, leading to low motivation to interact with peers, further limiting his self-efficacy in social situations. Finally, Tony reported high levels of worry in other domains, including his future and his family, as well as high levels of perfectionism. At intake, Tony reportedly engaged in few to no pleasurable activities, had low energy, flat affect, and experienced persistent and distressing levels of worry. Tony did note high motivation to address his difficulties and to learn new ways to cope with his intense emotions of anxiety and sadness.

4 History

At intake, Tony was in the 10th grade at a private high school in a metropolitan area. He was reportedly receiving above average grades in most academic areas although he had always struggled some in math due to the fact that he often “blanked out” on tests and was on his high school’s football team. Tony’s mother denied any family history of emotional disorders or any treatment history for Tony’s emotional concerns. Although this was the first time that Tony would be receiving treatment for his emotional concerns, Tony and his mother agreed that Tony had always been a worrier, concerning himself with “adult” worries, such as finances and his parents’ health from a very young age.

5 Assessment

Prior to treatment initiation, Tony and his parents were administered several diagnostic tools and symptom measures. To assess his symptoms of depression, anxiety, and related problems, Tony was administered the Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000). The RCADS is a 47-item, self-report measure of anxiety and depressive symptoms. The RCADS contains six distinct subscales based upon Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) criteria: separation anxiety, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and major depressive disorder (MDD). The conversion from raw scores to T-scores allows for interpretation of clinical significance, with T-scores of 65 or greater indicating borderline levels of clinical severity, and T-scores of 70 and above representing clinically significant elevations (UCLA Department of Psychology). The RCADS Total Anxiety Subscale was used as a measure of Tony’s general anxiety symptoms, the RCADS Social Phobia Subscale was used as a measure of social anxiety symptoms specifically, and the RCADS MDD Subscale was used as a measure of Tony’s depressive symptoms. At intake, Tony reported clinically elevated symptoms of depression (MDD T-score = 76; clinically significant), symptoms of overall anxiety (Total Anxiety T-score = >80; clinically significant), and of social anxiety (Social Phobia T-score = >80; clinically significant). This measure was also used at posttreatment to examine change in self-reported symptoms from pre- to posttreatment (see “Outcomes” section).

To assess the core features of neuroticism, Tony was administered three measures at intake, as well as at posttreatment to examine treatment-based change in these features from pre- to posttreatment (see “Outcomes” section). The Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) was administered to assess Tony’s level of negative affect. The PANAS is a 26-item self-report measure that contains two mood-related subscales: Negative Affect (NA) and Positive Affect (PA). Each item consists of a single adjective. Items within the NA subscale include distressed, irritable, upset, hostile, scared, afraid, ashamed, guilty, nervous, and jittery. Items within the PA subscale include interested, excited, enthusiastic, attentive, alert, inspired, proud, determined, and active. Individuals are asked to rate the extent to which they have experienced each emotion within the previous week. Psychometrically, the PANAS has demonstrated good internal consistency and construct validity among an adolescent sample (ages 12-18; Huebner & Dew, 1995). At intake, Tony endorsed elevated levels of negative affect (NA = 51) and low levels of positive affect (PA = 30).

The Emotional Avoidance Strategy Inventory for Adolescents (EASI-A; Kennedy & Ehrenreich-May, 2016) was administered to assess Tony’s level of experiential avoidance. The EASI-A is a 17-item adaptation of a self-report measure of emotional avoidance. The 17-item version of the EASI-A is shown to have good reliability and predictive validity in school-based samples of child and adolescent youth (Kennedy & Ehrenreich-May, 2016). At intake, Tony endorsed elevated levels of experiential avoidance (EASI-A = 51).

Tony was administered the Distress Tolerance Scale (DTS; Leyro, Bernstein, Vujanovic, McLeish, & Zvolensky, 2011; Simons & Gaher, 2005) to measure his ability to handle uncomfortable emotions. The DTS is a 15-item, self-report measure of distress tolerance. Although psychometrics were originally obtained in adult samples (Leyro et al., 2011; Simons & Gaher, 2005), recent preliminary psychometric analyses suggest that its factor structure is similar in children and adolescents (Tonarely, Kennedy, & Ehrenreich-May, 2016). However, in youth, preliminary work has suggested that the global distress tolerance (GDT) scale score, comprised of a subset of items on the DTS, serves as the most valid measure of overall distress tolerance. On this scale, lower scores represent lower levels of distress tolerance. At intake, Tony endorsed low levels of distress tolerance (GDT = 14).

Finally, Tony and his parents were administered the Anxiety Disorders Interview Schedule (ADIS) for the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013), Child and Parent Versions (ADIS-5 C/P; Silverman & Albano, manuscript in preparation). The ADIS-5-C/P is a downward extension of the Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014) for adults. It is a semistructured interview commonly used to assist trained clinicians in the diagnosis of DSM-5 anxiety disorders, mood disorders, and externalizing disorders in children and adolescents. The ADIS-IV-C/P has demonstrated adequate validity (Lyneham, Abbott, & Rapee, 2007; Wood, Piacentini, Bergman, McCracken, & Barrios, 2002) and Silverman, Saavedra, and Pina (2001) demonstrated excellent test–retest reliability on anxiety disorders symptoms scales. Psychometrics on the ADIS-5-C/P are currently being investigated, but the measure’s structure and components mirror those of the ADIS-IV-C/P. The ADIS-5-C/P also allows for the assessment of Clinical Severity Ratings (CSR) for each diagnosis, with scores ranging from 0 to 8, with scores greater than or equal to 4 indicating clinical levels of disorder-relevant impairment. In Tony’s case, a trained and reliable (i.e., clinician who matched on assigned diagnosis and severity scores with a previously trained clinician on the ADIS-5-C/P) clinician administered the ADIS-5-C/P to determine emotional disorder diagnoses and severity at pre- and posttreatment assessment points. Following this diagnostic interview, Tony’s Clinical Global Impairment–Severity (CGI-S; Guy, 1976), a psychometrically validated measure of overall impairment from psychological distress, was assessed by his interviewer on a scale from 0 (not at all impaired) to 7 (extremely impaired) and was rated at a 6. Following treatment, Tony’s CGI-S and Clinical Global Impairment–Improvement (CGI-I) rating were also obtained.

6 Case Conceptualization

Following administration of the ADIS-5-C/P, Tony was assigned social anxiety disorder (DSM-5: 300.23) to account for his anxiety around social situations. This diagnosis was given a CSR rating of a 6. Specifically, Tony reported avoiding trying to make friends at school because he worried he would run out of things to say or would say something wrong. Resultantly, Tony did not make any friends at school and spent most weekends in his room playing videogames or watching television. Tony and his mother also reported that his fear of negative evaluation also affected his performance in football. When Tony became worried about his football performance, he would typically feign an injury and sit out of practice or tie his shoes for a long period of time to miss drills. He also tended to pass the ball to his teammates to avoid being the center of attention during games. Notably, these behaviors prevented him from being viewed accurately by his coaches and coaches visiting from local colleges to recruit players. Prior to treatment initiation, both Tony and his mother stated that these symptoms had been present more days than not and were reportedly causing significant functional impairment at home, school, and social settings.

An additional diagnosis of generalized anxiety disorder (DSM-5: 300.02) was assigned to account for Tony’s general worries. This diagnosis was given a CSR of a 5 at pretreatment. He and his mother endorsed worries in multiple domains, including worries about performing well in school, making friends, the future, his family’s health, his family’s finances, and his own safety. Tony reported that he experienced significant distress related to his worries regarding his football performance and its potential impact on his future (e.g., whether he would be recruited for college). Tony and his mother agreed that these worries frequently affected his ability to concentrate and made it difficult to fall asleep.

Tony also indicated clinically elevated symptoms of depression, overall anxiety, and social anxiety on the RCADS. Furthermore, he endorsed elevated levels of the core features of neuroticism, including (a) high negative perceptions of the experience of emotions (i.e., low distress tolerance), (b) frequent and intense negative affect, and (c) a high degree of experiential avoidance in response to these frequent and intense emotional experiences, as assessed via self-report measures.

Overall, at the time of intake, Tony was struggling with high levels of negative affect, including frequent and intense experiences of anxiety and increased sadness and withdrawal. Tony reportedly interpreted these strong emotional experiences as intolerable, which led him to engage in behaviors to suppress or escape from these emotional experiences. His attempts to suppress or get rid of these strong emotions reportedly included avoiding social interactions, withdrawing from activities, and excessive worrying, among others. These behaviors, in turn, helped to maintain his emotional disorder symptoms over time by contributing to a learned negative reinforcement cycle. Specifically, Tony learned over time that isolating himself from social situations ameliorated his anxiety and avoiding activity was easier than pushing himself to remain active when sad, albeit maintaining his avoidance and his anxiety and depressive symptoms long term.

7 Course of Treatment and Assessment of Progress

Tony completed a full course of UP-A, including utilization of all eight of the core modules. Given the flexible and semimodular nature of this treatment, the duration spent on each module was dictated by clinical judgment regarding the efficacy of each technique in targeting Tony’s emotional disorder symptoms. Specifically, relatively more time was spent on Modules 3 and 7, which were most effective in addressing Tony’s symptoms of social anxiety and depressive symptoms. See below for a breakdown of content covered throughout Tony’s UP-A treatment sessions. Core Module 8, which focuses on relapse prevention and maintaining gains, looks similar to relapse prevention and treatment maintenance components in other CBT packages, and therefore is not discussed in detail.

Course of Treatment

Core Module 1: Building and keeping motivation (one session)

As mentioned previously, the goals of this module include providing an explanation of the structure and course of therapy, identification of the adolescent’s, as well as the parent(s)’ main reasons for seeking treatment, and to address motivation for change. Tony noted three Top Problems (Weisz et al., 2011) during this first session. The Top Problems were as follows: (a) avoidance of fun things and interacting with others when he is sad, (b) avoidance of social gatherings and situations due to feeling anxious about the potential judgments of others, and (c) spending a great deal of time worrying about a lot of different situations (e.g., school, his room being neat, his future). These top problems were given severity ratings from 0 (not at all a problem) to 8 (extreme problem). At Session 1, Top Problem 1 was given a severity rating of 8, Top Problem 2 a severity rating of 6, and Top Problem 3 a severity rating of 8. Tony was also asked to identify SMART (specific, measurable, attainable, reasonable, time-limited) goals for treatment. His goals included doing fun things even when he is sad, approaching and getting used to social situations, and spending less time worrying. Overall, Tony and his parents indicated little concerns regarding their motivation for treatment.

Core Module 2: Getting to know your emotions and behaviors (two sessions)

During these psychoeducation sessions, Tony was first introduced to the concept of emotions as normal, natural, and harmless components of the human experience. He and his therapist also discussed the function of emotions and identified the helpful and unhelpful ways that emotions influence behavior, using examples from Tony’s own experiences. Then, Tony learned about the three parts of an emotional experience (i.e., the thoughts, physical sensations, and behaviors) and worked with his therapist to break down personal examples of anxiety (e.g., when anticipating having a conversation with someone new) and sadness (e.g., in the evening after football practice when thinking about his performance and anticipating doing homework) into their three parts. During these sessions, Tony also learned about the concept of a trigger to one’s emotional experience and worked with his therapist to identify the trigger to the examples delineated above. Tony and his therapist also discussed the short- and long-term consequences of engaging in certain emotional behaviors with a focus on the cycle of avoidance. As home learning, Tony began tracking the before (i.e., trigger), during (i.e., thoughts, physical sensations, and emotional behaviors), and after (i.e., short- and long-term consequences of emotional behaviors) of his intense emotional experiences to begin to recognize the unique parts of his emotional experience, as well as to identify his own cycle of avoidance. This was an especially important part of treatment for Tony, as an increased awareness about his emotions would allow him to recognize and effectively use coping skills to target intense emotional experiences later in treatment.

Core Module 3: Introduction to emotion-focused behavioral experiments (one session and ongoing opposite action for duration of treatment)

As mentioned previously, the goal of this module is to encourage the adolescent to engage in opposite actions from his or her less helpful emotional behaviors. In the UP-A, opposite action serves as a means for changing or deescalating emotional experiences. For Tony, learning about and engaging in opposite actions for his emotional experiences were most impactful in helping Tony decrease the frequency of his use of maladaptive emotional behaviors in response to sadness (i.e., withdrawal) and anxiety in social situations (i.e., avoidance), thereby decreasing the intensity and frequency of his experience of sadness and social anxiety in the long term. During this session, Tony’s therapist introduced him to the connection between emotions and activity levels. This conversation was made more relevant to Tony with the use of personal examples. Tony and his therapist then identified activities that Tony liked to do. Given Tony’s significantly low activation, this activity was a challenge. Tony’s therapist worked with him to identify small steps that Tony could take to increase his activity. As home learning practice following this session, Tony was instructed to track his emotion and activity levels daily. He was also encouraged to engage in an emotion-focused behavioral experiment when he experienced high levels of sadness or down mood. Although Tony seemed hesitant to try to engage in many activities during the initial week in which these behavioral experiments were introduced, he did successfully monitor his emotion and activity levels and attempted at least two different activities during the initial week of activity planning (i.e., journaling about current events, taking shorter naps, watching funny YouTube videos).

During the subsequent session, Tony and his therapist reviewed his emotion and activity level tracker. Tony was able to recognize how his emotion and activity levels were connected. Furthermore, he was able to see that engaging in behavioral experiments tended to de-intensify his experience of sadness.

As Tony presented at intake with high levels of withdrawal and social avoidance, the use of emotion-focused behavioral experiments for sadness and social anxiety continued throughout treatment. Therefore, Tony and his therapist completed weekly opposite action planning throughout treatment. Throughout treatment, Tony became increasingly excited about and more motivated to complete the activities planned for the coming week and was able to generalize these opposite action goals to unplanned activities (i.e., participating in conversations with his peers at school and football practice, going to parties). For Tony, this module was extremely important, as its core targets are anhedonia, low mood, and avoidance, which were three of Tony’s most impairing issues.

Core Module 4: Awareness of physical sensations (one session)

During this session, Tony learned about the connection between physical sensations and emotions and reviewed the function of physical sensations during an emotional experience. Tony noted that he often experienced uncomfortable physical sensations in social situations and especially in crowded places. Tony completed a body drawing exercise in which he noted the physical sensations he experienced when he was anxious (i.e., heart beating fast, sweating, out of breath) and sad (i.e., heavy, brain full of thoughts). When Tony was challenged with completing sensational exposures (i.e., running in place, hyperventilating, shaking head back and forth), he was successfully able to track the emotions, thoughts, and urges to perform avoidance behaviors associated with each activity and to notice these feelings without doing anything to make them go away using a body-scanning activity. As a result, he was able to recognize that physical sensations in response to these activities lessened in severity and duration with practice. However, Tony did react strongly to these sensational exposures, noting a desire to stop the exercise and connecting these sensations to those he experiences when in a crowd. Therefore, he was asked to complete two trials of the head-shaking exposure for home learning. Later in treatment, the idea of pairing sensational exposures with social exposures proved a useful way to intensify the challenge of social exposures as they became easier for Tony (i.e., engaging in sensational exposure just prior to a social exposure to intensify the activity). As Tony’s avoidance of social situations was in part influenced by his intolerance of these physical sensations, exposing him to these feelings and allowing him to realize that they are harmless may have helped to reduce his avoidance of social situations.

Core Module 5: Being flexible in your thinking (four sessions)

During the first session of the module, Tony was introduced to the concept of thinking traps and flexible thinking. Tony was able to relate thinking traps to his own experience and successfully identified several thinking traps into which he fell most often (i.e., thinking the worst, ignoring the positive, black and white thinking). During the second session of the module, Tony was introduced to the skill of detective thinking and practiced this skill using personally relevant examples. While Tony was able to successfully grasp these concepts and identify thinking traps, he demonstrated significant difficulty using detective thinking independently to think more flexibly and often struggled to identify alternative thoughts to his original thinking trap thoughts. To troubleshoot this issue, Tony and his therapist decided to have Tony type his most common thinking trap thoughts into his phone with the name of the thinking trap and evidence to support an alternate thought, to increase his ability to practice thinking more flexibly with greater automaticity (e.g., “if I do not get a football scholarship, I will never get into college”; “thinking the worst”; “even if I do not get a football scholarship, I may get into college due to my grades and other qualifications”). This strategy proved helpful to Tony and over time, he was able to utilize detective thinking without the aid of his phone.

In the fourth session of this module, problem solving was introduced and practiced in session. These problem-solving steps were useful for Tony throughout treatment when dealing with conflict in particular, especially relating to arguments with his stepfather over topics including Tony spending time one-on-one with his stepfather, who he did not feel completely comfortable with. Tony successfully utilized his problem-solving steps to identify steps to addressing conflicts with family members. Tony worked with his therapist to come up with solutions, evaluate the positives and negatives of each solution, and choose the best solution to try.

Core Module 6: Awareness of emotional experiences (two sessions)

During these sessions, Tony was introduced to the concept of present-moment and nonjudgmental awareness. For Tony, these awareness strategies were most helpful during social interactions and during times of worry. Prior to learning these skills, Tony typically found himself overanalyzing his behaviors during social interactions, making it difficult to remain engaged in the present. In addition, Tony would engage in unhelpful and intense worry regarding his future, particularly before bed. Tony was introduced to the idea that this judgmental focus on his thoughts and behaviors, as well as this future-oriented worry behavior during these situations only helped to increase the intensity of his emotional experience. As a tool for acting opposite to this, Tony was introduced to many different present-moment and nonjudgmental awareness strategies that he was encouraged to use during these situations. For Tony, the “sportscasting” present-moment awareness exercise (i.e., narrating what is happening in the moment for himself) as well as the “thoughts on a stream” nonjudgmental awareness activity (i.e., placing all parts of one’s emotional experience on a stream and letting thoughts flow in and out, attempting to avoid getting stuck on or judging emotions) helped him to stay calm and remain focused on the present in social situations, as well as when beginning to worry. Throughout the remainder of treatment, Tony was encouraged to employ awareness exercises during social and worry-related exposures to stay focused on the present and also to prevent himself from engaging in future-related worry and postevent rumination regarding his social skills and performance during the social exposures.

Core Module 7: Situational emotion exposure (five sessions)

During these sessions, Tony was introduced to the rationale for situational emotion exposures, worked with his therapist to build a hierarchy to engage in exposures gradually, and finally completed exposures both in-session, as well as at home. Along with Core Module 3, Core Module 7 led to the greatest improvements in emotional disorder symptoms for Tony. When Tony was initially tasked with building an exposure hierarchy, Tony indicated hesitation to face these difficult emotions. Tony noted that he was afraid that social exposures, in particular, would be difficult. However, with use of motivational interviewing techniques taken from Module 1, his therapist was able to work with Tony to agree on exposure plans that involved taking “baby steps” toward his ultimate goals. Throughout this discussion, Tony became visibly more comfortable looking at the hierarchy, and this exercise was used as an example of how exposures get easier with practice.

During the remaining sessions of this module, Tony’s therapist would generally begin by reviewing Tony’s ongoing opposite action home learning practice and work with Tony to create a new calendar for the coming week. Then, the therapist typically worked with Tony to complete exposures on his hierarchy. Prior to each exposure, Tony was asked to rate his discomfort on a scale from 0 (no discomfort) to 8 (extreme discomfort). The therapist and Tony worked together to apply detective thinking prior to each exposure, to rerate his distress several times during each exercise, and then to use nonjudgmental awareness exercises during and after each exposure. This latter strategy was particularly helpful for Tony who tended to ruminate about his performance after each exposure. Due to observed difficulties with social skills, social scripts and role-plays were often incorporated into exposure sessions as well. Throughout these exposure sessions, Tony was able to complete situational exposures targeting both his social avoidance, as well as his perfectionistic worries. See Figure 1, which outlines Tony’s hierarchy for additional information regarding exposure goals.

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Figure 1.

Tony’s hierarchy.

Module P: Parenting the emotional adolescent

As mentioned, this module is to be utilized as needed throughout treatment. Tony’s therapist met with Tony’s mother to check-in regarding Tony’s progress for a portion of the time during each session. During these meetings with Tony’s mother, the therapist briefly reviewed the emotional parenting behaviors and their opposite parenting behaviors. Tony’s therapist focused on the emotional parenting behavior of criticism, as well as overcontrol. Tony’s mother indicated frustration regarding Tony’s avoidance and worry. His therapist not only empathized with her, but also framed Tony’s behaviors within the cycle of avoidance. In addition, Tony’s therapist tasked his mother with practicing the skill of increasing empathy throughout treatment.

Outcomes

Treatment-based change in symptoms (RCADS), disorder severity (ADIS-5-C/P)

Tony completed the RCADS, at pre- and posttreatment to measure treatment-based changes in anxiety and depressive symptoms. At pretreatment, Tony endorsed clinically elevated symptoms of overall anxiety (T-score = >80), social anxiety (T-score = >80), and depressive symptoms (T-score = 76). Following treatment, Tony was re-administered the RCADS. After 16 weeks comprising 16 sessions of therapy using the UP-A, Tony evidenced significantly lower symptoms across all three areas assessed. Tony’s overall symptoms of anxiety at posttreatment had decreased significantly and fell at a borderline clinical level (T-score = 68). Tony’s symptoms of depression decreased and were within the borderline clinical range as well (T-score = 68). His symptoms of social anxiety had also decreased, but remained within the clinical level (T-score = 71; just meeting clinically significance). In sum, at posttreatment, Tony no longer indicated clinically elevated symptoms of depression and overall anxiety. Additional social anxiety exposure and generalization of such experiences were recommended for Tony to continue to improve within this area. Outcomes are presented in Table 1.

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Table 1.

Pre- to Posttreatment Change.

	Pretreatment	Posttreatment
Total anxiety T-score	>80	68
Social anxiety T-score	>80	71
Depression T-score	76	68
Distress tolerance (GDT)	14	30
Avoidance (EASI-A)	51	37
Negative affect (PANAS-NA)	51	53

Note. Symptoms T-scores measured using the RCADS. GDT = global distress tolerance; EASI-A = Emotional Avoidance Strategy Inventory for Adolescents; PANAS-NA = Positive and Negative Affect Schedule–Negative Affect; RCADS = Revised Children’s Anxiety and Depression Scale.

Tony and his mother were also re-administered the ADIS-5-C/P following treatment. As a result of this interview, Tony was found to have improved significantly overall. At pretreatment, Tony was given CSRs of 6 for social anxiety disorder, as well as a CSR of a 5 for generalized anxiety disorder. At posttreatment, Tony’s symptoms of social anxiety significantly improved with this CSR decreasing to a 3. In addition, Tony’s symptoms of generalized anxiety disorder decreased, but remained at a clinical level with a CSR of a 4. Clinician rated global improvement (CGI-I; Guy, 1976) was assigned a 2, suggesting that Tony’s overall clinical impairment was much improved following treatment. Furthermore, at his final session, Tony rated the severity of Top Problem 1 at 3, Top Problem 2 at 2, and Top Problem 3 a severity rating of 4. See Figure 2 for a session-by-session graphical representation of Tony’s change in top problem ratings throughout treatment.

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Figure 2.

Tony’s top problems.

Treatment-based functional change

In addition to significant symptom change, Tony also experienced significant functional changes throughout UP-A treatment. Notably, by engaging in additional pleasant activities throughout treatment following the introduction to opposite action, Tony began to find himself enjoying more activities, broadening his interests, and becoming more involved with peers and meeting with college football coaches. In addition, toward the end of treatment, Tony was able to make new friends, which improved his mood as well as his confidence. This increase in social functioning might be attributed to several factors, including decreased withdrawal and increased social opportunity as well as increased social confidence following extensive social exposure practice during session. Whereas Tony’s social anxiety was negatively affecting his performance in football, toward the beginning of therapy, increased approach behaviors following a reduction in his perfectionism worries and social anxiety resulted in significantly improved performance in football, as well as increased willingness to be a full participant in practices. By the end of treatment, Tony presented as a happier, more confident teenager with particular talents in writing, football, and academics. His mother described him as more sociable than they had ever imagined him becoming and noted a substantial increase in his overall mood, problem-solving abilities, and overall well-being.

Report on pre-post change in transdiagnostic factors

In addition to understanding treatment-based changes in symptoms, an examination of treatment-based changes in the core features of neuroticism is indicated. At pretreatment, Tony completed the PANAS (negative affect), the EASI-A (experiential avoidance), and the DTS (distress tolerance) and exhibited patterns consistent with high levels of neuroticism. Specifically, at pretreatment Tony indicated high levels of negative affect (NA = 51), high levels of experiential avoidance (EASI-A = 51), and low levels of distress tolerance (GDT = 14). Following treatment, Tony was re-administered these three measures and he continued to report high levels of negative affect (NA = 53). However, he reported reduced levels of experiential avoidance (EASI-A = 37), and greater distress tolerance (GDT = 30).Through exposure sessions and consistent opposite action practice, Tony was able to increase his ability to tolerate aversive emotions, including anxiety and sadness elicited by either unhelpful thoughts or particular situations. As a result, he was able to practice developing and utilizing more appropriate coping skills within these situations (e.g., nonjudgmental awareness, detective thinking). Naturally, this increase in distress tolerance was associated with a decrease in Tony’s use of avoidance in social situations and withdrawal in response to sadness. Outcomes are presented in Table 1.

This case illustration of Tony, a 15-year-old adolescent with significant anxiety and depression, provides important information about how the UP-A effectively targets both anxiety and depression in youth suffering from these commonly comorbid conditions. In addition, the evaluation of pre- to posttreatment change in Tony’s self-reported core features of neuroticism suggests that the UP-A effectively targets and addresses these core features that underlie emotional disorders in youth.

8 Complicating Factors

For Tony, the major complicating factors interfering with his ability to obtain and generalize the skills learned in session included his social skills difficulty, as well as increased conflict with his stepfather. With regard to social skills deficits, it appeared that Tony was not only anxious in social situations but also often had difficulty carrying on conversations with others and remembering the different components of a social interaction. During UP-A sessions, Tony’s therapist was able to review and role-play social interactions with Tony prior to initiating different social exposures, which, together with repeated practice of in-session social exposures, appeared to help reduce social awkwardness and allowed Tony to feel more comfortable and confident in social interactions outside of session. Persistent conflict at home affected Tony’s mood as well as the focus of certain UP-A sessions. Tony and his therapist worked together using the problem-solving steps throughout treatment to identify potential solutions to address this conflict at home. Tony successfully attempted the solutions that were decided on in session; however, this conflict remained a significant stressor for Tony throughout treatment.

9 Access and Barriers to Care

It is important to note that Tony received this transdiagnostic treatment at a training clinic within a university setting. As a result, Tony was able to receive evidence-supported treatment at a low cost. If it were not for the clinic’s ability to provide services at a low cost to families in need, Tony may not have received evidence-based treatment.

10 Follow-Up

Following completion of UP-A sessions outlined above, Tony returned for several booster sessions. During booster sessions, Tony and his therapist reviewed his progress and problem-solved any barriers to his continued completion of exposure exercises in school, with peers, and at home. In addition, during such sessions, Tony and his therapist worked together to complete additional social exposures and to use cognitive restructuring techniques to continue to target his worries. Finally, during booster sessions, Tony was able to report on his continued progress with engagement in pleasant activities.

11 Treatment Implications of the Case

There is a great deal of inherent overlap between emotional disorders due to shared risk factors, as well as to the common underlying factor of neuroticism (Barlow et al., 2014; Tonarely et al., 2017). Illustrated by this case report outlining Tony’s treatment, both qualitative and quantitative data support the usefulness of the UP-A in addressing not only symptom reduction, but also improvements in neuroticism more broadly. Notably, Tony was a client who had clinically interfering levels of both anxiety and subclinical levels of depression. Although the UP-A is comprised of many of the same active treatment components of other CBT models for youth (Kendall, 2011; Kendall et al., 2010), it targets both anxiety and depressive disorders at once through the targeting of underlying features common across both disorders (i.e., negative affect/low mood, low distress tolerance, and high avoidance). Namely, according to UP-A theoretical underpinnings (Barlow et al., 2014; Tonarely et al., 2017), several core factors underlying anxiety, depression, and related disorders allow for transdiagnostic treatments to effectively treat multiple related disorders under one unifying protocol (Bilek & Ehrenreich-May, 2012; Ehrenreich et al., 2009; Ehrenreich-May et al., 2017; Farchione et al., 2012; Queen, Barlow, & Ehrenreich-May, 2014). These transdiagnostic approaches work well for adolescents with anxiety and/or depressive disorders, but are especially useful for those with co-occurring anxiety and depressive disorders, as well as heightened neuroticism, an underlying temperament factor of emotional disorders more broadly, as is the case for Tony.

12 Recommendations to Clinicians and Students

As mentioned previously, the utilization of the UP-A has many benefits, including the ability to address more than one disorder using one protocol. When using the UP-A, it is important to always keep the case conceptualization at the forefront to make sure the material is tailored to the individual client. While the order of modules is flexible, it is recommended that the order presented in the manual be used when using this protocol for the first one or two clients, as the content presented later builds on previously presented material to a certain extent. While this was not the case for Tony, many adolescents with emotional disorders respond to strong emotional experiences with aggressive or angry behaviors in addition to avoidance. It is possible to conceptualize these behaviors within the cycle of angry behaviors discussed in the protocol.

One suggested future direction for clinicians and researchers might be investigating the role that culture plays in the implementation and acceptance of the UP-A as a treatment for emotional disorders in youth. The current case paper outlines the use of the UP-A with a White Hispanic male. However, limited work has been done to investigate cultural differences in individuals’ responses to the UP-A. Assessing culturally relevant factors and using the resultant cultural insight to tailor the treatment could help enhance the utility of the UP-A content for adolescents from ethnic minority groups. Perhaps this could be done by utilizing an instrument similar to the one used by Zigarelli, Jones, Palomino, and Kawamura (2016) in a recent case paper outlining the importance of integration of cultural factors while delivering an evidence-based (CBT) treatment to an African American male. This future investigation could help elucidate cultural factors relevant to transdiagnostic treatment of adolescents with emotional disorders and paint a clearer picture of how to best tailor this treatment to the needs of ethnic minority groups.

Finally, as is the case when using most other manualized, empirically supported treatments, therapist training is required for the UP-A. Due to the directive and specific nature of the UP-A therapist guide and workbook (Ehrenreich-May et al., 2017), therapist training is generally straightforward, typically consisting of completion of a 1- to 2-day training as well as consultation calls or adherence coding of treatment tapes throughout a therapist’s first case with a UP-A trainer. As the UP-A targets many different emotional disorders via one transdiagnostic protocol, this treatment may be an ideal option for community mental health providers, who see many clients with various presentations.