The transdiagnostic approach we recommend rests on solid theoretical ground. Historically, there has been a divide in the classification of psychopathology between those who have aimed to divide pathology into finer slices, resulting in large numbers of separate disorders, each with its putatively specific treatment, and those who argue the merits of identifying and targeting the commonalities shared between disorders. Barlow’s transdiagnostic approach to anxiety and other emotional disorders, as expressed in the UP, is an example of the latter (Barlow & Kennedy, 2016).
Three main observations underpin the rationale for this approach. First, there is a high degree of overlap between emotional disorders, demonstrated by high rates of both current and lifetime comorbidities. Second, a psychological treatment developed specifically for one disorder frequently produces improvements in other comorbid disorders that are not explicitly targeted. Third, affective neuroscience research suggests that a range of emotional disorders share common neurobiological mechanisms (Barlow & Kennedy, 2016).
Barlow proposes a hierarchical structure of emotional disorders, with two core dimensions: neuroticism or adverse effect, and extraversion or positive affect. The balance and interaction of these two dimensions are fundamental in the onset, overlap, and maintenance of a range of anxiety and mood disorders. Significant paths lead from high neuroticism and/or low extraversion to General Anxiety Disorder and many other disorders (Barlow & Kennedy, 2016).
It is important to understand that people with mood disorders do not simply express a higher frequency of negative emotion than people without these disorders. At the core of neuroticism there is also a tendency to react with greater distress to one’s emotional experiences, have more difficulty accepting one’s emotions, and be intolerant of one’s negative feelings (Barlow & Kennedy, 2016). This is expressed through attempts to down-regulate the negative emotions, producing further adverse effects. Many constructs have emerged from research into the neurotic tendency to find emotional experiences aversive. These are experiential avoidance, anxiety sensitivity, deficits in mindfulness, and negative appraisals and attributions that reflect a sense of uncontrollability (Barlow & Kennedy, 2016).
Experiential avoidance is the tendency to escape or avoid uncomfortable thoughts, memories, or emotions and is characterized by emotion-suppression, rumination, and worry. These processes have been shown to have the unintended consequence of exacerbating negative affect, in turn provoking further attempts at avoidance, perpetuating its vicious cycle until, typically, a person engages in avoidant behaviour such as reassurance seeking, substance abuse, or self-harm. Anxiety sensitivity is the tendency to believe that symptoms of anxiety, especially somatic symptoms, will have negative consequences. It is associated with depressive as well as anxiety disorders. Deficits in mindfulness imply a diminished capacity to be aware and accepting of one’s own experience, including unpleasant emotions in the present moment. Finally, negative appraisals and attributions refer to the tendency to make pessimistic, cynical, and highly rigid and automatic interpretations of events and one’s self, with all of these constructs occurring across emotional disorders (Barlow & Kennedy, 2016).
This hierarchy of commonalities in anxiety and emotional disorders provides the theoretical basis for the development of Barlow’s UP, the goal of which is to help clients to recognize and understand their emotions, and to respond to their negative emotions in more adaptive ways. This can lead to a lessening of the severity and frequency of these negative emotional experiences (Barlow & Kennedy, 2016).
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