The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Treatment of Comorbid Psychopathology Accompanying a Generalized Anxiety Disorder

Document Type: Original Article

Authors

1 MSc student of Clinical Psychology, Student of Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran

2 Associate Professor, Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran

3 Assistant Professor, Department of Clinical Psychology, Kermanshah University of Medical Sciences, Kermanshah, Iran

4 MSc of Clinical Psychology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran

Abstract

Abstract

Introduction: Comorbidity among the generalized anxiety disorder is common and may negatively impact treatment outcomes. This study aimed to examine whether the Unified Protocol (UP), a transdiagnostic cognitive-behavioral therapy for emotional disorders (i.e., anxiety, mood, and related disorders), is efficacious in the treatment of co-occurring disorders and symptoms Generalized Anxiety Disorder (GAD).
Method: The research method is semi-empirical pretest-posttest and follow-up plan with a control group. In this randomized clinical trial, 24 GAD patients with comorbid disorders and symptoms of depression, social anxiety and health anxiety have been treated with pharmacotherapy treatment-as-usual or pharmacotherapy treatment-as-usual with 12 sessions of transdiagnostic therapy. Beck Depression Inventory (BDI-II), Social Anxiety Inventory (SIAS) and the Short Form of Health Anxiety (SHAI) were used for assessing comorbidities in pre-test, post-test and 2-month follow-up. Data analysis were done using the SPSS V20.
Results: Significant differences were observed between the two groups. In the treatment group for pharmacotherapy treatment-as-usual and UP, GAD Patients, showed a significant decrease in the comorbid disorders and symptoms of depression, social anxiety and health anxiety compared to the pharmacotherapy treatment-as-usual.
Conclusion: The findings of this study validated the effectiveness of the UP in decreasing comorbid disorders and symptoms of the generalized anxiety disorder. This protocol has a high clinical value in treating emotional disorders and other related disorders.

Keywords


References
1. Brown TA, Barlow DH. Comorbidity among anxiety disorders:
Implications for treatment and DSM-IV. J Consult Clin Psychol.
1992;60(6):835 PMID: 1460147.
2. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR,
Walters EE. Lifetime prevalence and age-of-onset distributions
of DSM-IV disorders in the National Comorbidity Survey
Replication. Arch Gen Psychiatry. 2005;62(6):593-602. DOI:
10.1001/archpsyc.62.6.593
3. Leahy RL, Holland SJ, McGinn LK. Treatment plans and
interventions for depression and anxiety disorders: Guilford
press; 2011.
4. Brown TA, Barlow DH, Liebowitz MR. The empirical basis of
generalized anxiety disorder. The American journal of
psychiatry. 1994.
5. Association AP. Diagnostic and statistical manual of mental
disorders (DSM-5®): American Psychiatric Pub; 2013.
6. Brown TA, Campbell LA, Lehman CL, Grisham JR, Mancill
RB. Current and lifetime comorbidity of the DSM-IV anxiety
and mood disorders in a large clinical sample. J Abnorm Psychol.
2001;110(4):585. PMID: 11727948.
7. Nutt D, Argyropoulos S ,Hood S, Potokar J. Generalized anxiety
disorder: a comorbid disease. Eur Neuropsychopharmacol.
2006;16: 109-18. DOI: 10.1016/j.euroneuro.2006.04.003
8. Covin R, Ouimet AJ, Seeds PM, Dozois DJ. A meta-analysis of
CBT for pathological worry among clients with GAD. J Anxiety
Disord 2008;22(1):108-16. DOI: 10.1016/j.janxdis.2007.01.002
9. Cuijpers P SM, Koole S, Huibers M, Berking M, Andersson G.
Psychological treatment of generalized anxiety disorder: a metaanalysis:
a meta-analysis. Clin Psychol Rev. 2014(34):130-40.
DOI: 10.1016/j.cpr.2014.01.002
10. Hunot V CR, Teixeira V, de Lima MS. Psychological therapies
for generalised anxiety disorder. . Cochrane Database Syst Rev.
2007. DOI: 10.102/14651858.CD001848.pub4.
11. Borkovec T, Abel JL, Newman H. Effects of psychotherapy on
comorbid conditions in generalized anxiety disorder. J Consult
Clin Psychol. 1995;63(3):479.
12. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB,
Pagano M, et al. Influence of psychiatric comorbidity on
recovery and recurrence in generalized anxiety disorder, social
phobia, and panic disorder: a 12-year prospective study. Am J
Psychiatry. 2005;162(6):1179-87. DOI:
10.1176/appi.ajp.162.6.1179.
13. Allen LB, White KS, Barlow DH, Shear MK, Gorman JM,
Woods SW. Cognitive-behavior therapy (CBT) for panic
disorder: Relationship of anxiety and depression comorbidity
with treatment outcome. J Psychopathol Behav Assess.
2010;32(2):185-92. DOI: 10.1007/s10862-009-9151-3
14. Heimberg RG. Cognitive-behavioral therapy for social anxiety
disorder: current status and future directions. Biol Psychiatry.
2002;51(1):101-8.
15. Wilamowska ZA, Thompson‐ Hollands J, Fairholme CP, Ellard
KK, Farchione TJ, Barlow DH. Conceptual background,
development, and preliminary data from the unified protocol for
transdiagnostic treatment of emotional disorders. Depress
Anxiety. 2010;27(10):882-90. DOI: 10.1002/da.20735
16. Krueger RF, Eaton NR. Transdiagnostic factors of mental
disorders. World Psychiatry. 2015;14(1):27-9. DOI:
10.1002/wps.20175
17. Sauer-Zavala S, Wilner JG, Barlow DH. Addressing neuroticism
in psychological treatment. personal disorder. 2017;8(3):191.
18. Clark DA. Cognitive behavioral therapy for anxiety and
depression: possibilities and limitations of a transdiagnostic
perspective. Cogn Behav Ther. 2009;38(S1):29-34.
19. McManus F, Shafran R, Cooper Z. What does a transdiagnostic
approach have to offer the treatment of anxiety disorders? Br J
Clin Psychol. 2010;49(4):491-505. DOI:
10.1348/014466509X476567
20. Riccardi CJ, Korte KJ, Schmidt NB. False safety behavior
elimination therapy: a randomized study of a brief individual
transdiagnostic treatment for anxiety disorders. J Anxiety
Disord. 2017;46:35-45. DOI: 10.1016/j.janxdis.2016.06.003
21. Stice E, Rohde P, Butryn M, Menke KS, Marti CN. Randomized
controlled pilot trial of a novel dissonance-based group treatment
for eating disorders. Behav Res Ther. 2015: (65): 67-75.
DOI: 10.1016/j.brat.2014.12.012
22. Titov N, Dear B, Staples L, Terides M, Karin E, Sheehan J, et al.
Disorder-specific versus transdiagnostic and clinician-guided
versus self-guided treatment for major depressive disorder and
comorbid anxiety disorders: a randomized controlled trial. J
Anxiety Disord. 2015;35:88-102. DOI:
10.1016/j.janxdis.2015.08.002
23. Palermo TM, Bromberg MH, Beals-Erickson S, Law EF, Durkin
L, Noel M, et al. Development and initial feasibility testing of
brief cognitive-behavioral therapy for insomnia in adolescents
with comorbid conditions. Clin Pract Pediatr Psychol.
2016;4(2):214.
24. Milosevic I, Chudzik SM, Boyd S, McCabe RE. Evaluation of
an integrated group cognitive-behavioral treatment for comorbid
mood, anxiety, and substance use disorders: A pilot study. J
Anxiety Disord. 2017;46:85-100. DOI:
10.1016/j.janxdis.2016.08.002.
25. Barlow DH, Farchione TJ, Sauer-Zavala S, Latin HM, Ellard
KK, Bullis JR, et al. Unified protocol for transdiagnostic
treatment of emotional disorders: Therapist guide: Oxford
University Press; 2017.
26. Barlow DH EK, Fairholme CP. Unified protocol for
transdiagnostic treatment of emotional disorders: Workbook:
Oxford University Press; 2010.
27. Farchione TJ, Fairholme CP, Ellard KK, Boisseau CL,
Thompson-Hollands J, Carl JR, et al. Unified protocol for
transdiagnostic treatment of emotional disorders: a randomized
Mohammadpour et al.
131 Int J Behav Sci Vol.12, No.3, Autumn 2018
controlled trial. Behav Ther. 2012;43(3):666-78. DOI:
10.1016/j.beth.2012.01.001
28. de Ornelas Maia ACC, Nardi AE, Cardoso A. The utilization of
unified protocols in behavioral cognitive therapy in
transdiagnostic group subjects: A clinical trial. J Affect Disord.
2015;172:179-83. DOI: 10.1016/j.jad.2014.09.023
29. Steele SJ, Farchione TJ, Cassiello-Robbins C, Ametaj A, Sbi S,
Sauer-Zavala S, et al. Efficacy of the Unified Protocol for
transdiagnostic treatment of comorbid psychopathology
accompanying emotional disorders compared to treatments
targeting single disorders. J Psychiatr Res. 2018;104:211-6.
DOI: 10.1016/j.jpsychires.2018.08.005
30. Brown TA, Barlow DH, DiNardo PA. Anxiety Disorders
Interview Schedule for DSM-IV (ADIS-IV): Client Interview
Schedule: Graywind Publications Incorporated; 1994.
31. Mohammadi A, Birashk B, Gharraee B. Comparison of the
Effect of Group Transdiagnostic Treatment and Group Cognitive
Therapy on Emotion Regulation. Iranian Journal of Psychiatry
& Clinical Psychology. 2013;19 (3): 187-94. (in persian)
32. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure
for assessing generalized anxiety disorder: the GAD-7. Arch
Intern Med. 2006;166(10):1092-7. DOI:
10.1001/archinte.166.10.1092
33. Zargar F. Comparing the effectiveness of acceptance-based
behavior therapy to applied relaxation on worry and generalized
anxiety disorder symptoms. J Res Med Sci. 2014;17(1):26-30.
(in persian)
34. Beck AT, Steer RA, Brown GK. Beck depression inventory-II.
San Antonio. 1996;78(2):490-8.
35. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani
N. Psychometric properties of a Persian‐ language version of the
Beck Depression Inventory‐ Second edition: BDI‐ IIPERSIAN.
Depress Anxiety. 2005;21(4):185-92. DOI:
10.1002/da.20070. (in persian)
36. Heimberg RG, Mueller GP, Holt CS, Hope DA, Liebowitz MR.
Assessment of anxiety in social interaction and being observed
by others: The Social Interaction Anxiety Scale and the Social
Phobia Scale. Behav Ther. 1992;23(1):53-73.
37. Tavoli A, Allahyari A, Azadfallah P, Fathi Ashtiani A ,Melyani
M, Sahragard M. Validity and reliability of the farsi version of
social interaction anxiety scale (sias). Iranian Journal of
Psychiatry and Clinical Psychology. 2012;18(3):227-32. (in
persian)
38. Abramowitz JS, Olatunji BO, Deacon BJ. Health anxiety,
hypochondriasis, and the anxiety disorders. Behav
Ther. 2007;38(1):86-94. DOI: 10.1016/j.beth.2006.05.001.
39. Salkovskis PM, Rimes KA, Warwick H, Clark D. The Health
Anxiety Inventory: development and validation of scales for the
measurement of health anxiety and hypochondriasis. Psychol
Med. 2002;32(5):843-53.
40. Panahi Saeid aM, shoeiri Mohmmadreza, Eghtedarnezhad
Somayeh. Investigating factor structure and psychometric
properties of the Persian version of the short form of health
anxiety questionnaire in a non-clinical sample. Educational
Measurement. 2011:21-46. (in persian)
41. Vickers AJ. Parametric versus non-parametric statistics in the
analysis of randomized trials with non-normally distributed data.
BMC Med Res Methodol. 2005;5(1):35. DOI: 10.1186/1471-
2288-5-35
42. Vickers AJ. Analysis of variance is easily misapplied in the
analysis of randomized trials: a critique and discussion of
alternative statistical approaches. Psychosom Med.
2005;67(4):652-5. DOI; 10.1097/01.psy.0000172624.52957.a8
43. Barlow DH, Farchione TJ, Bullis JR, Gallagher MW, Murray-
Latin H, Sauer-Zavala S ,et al. The unified protocol for
transdiagnostic treatment of emotional disorders compared with
diagnosis-specific protocols for anxiety disorders: a randomized
clinical trial. JAMA psychiatry. 2017;74(9):875-84. DOI:
10.1001/jamapsychiatry.2017.2164
44. Newby JM, McKinnon A, Kuyken W, Gilbody S, Dalgleish T.
Systematic review and meta-analysis of transdiagnostic
psychological treatments for anxiety and depressive disorders in
adulthood. Clin Psychol Rev. 2015;40:91-110. DOI:
10.1016/j.cpr.2015.06.002
45. Ito M, Okumura Y, Horikoshi M, Kato N, Oe Y, Miyamae M, et
al. Japan Unified Protocol Clinical Trial for Depressive and
Anxiety Disorders (JUNP study): study protocol for a
randomized controlled trial. BMC psychiatry. 2016;16(1):71.
DOI: 10.1186/s12888-016-0779-8.
46. Cassiello-Robbins C, Sauer-Zavala S, Wilner JG, Bentley KH,
Conklin LR, Farchione TJ, et al. A Preliminary Examination of
the Effects of Transdiagnostic Versus Single Diagnosis
Protocols on Anger During the Treatment of Anxiety Disorders.
J Nerv Ment Dis. 2018;206(7):549-54. DOI:
10.1097/NMD.0000000000000834
47. Westra HA, Arkowitz H, Dozois DJ. Adding a motivational
interviewing pretreatment to cognitive behavioral therapy for
generalized anxiety disorder: A preliminary randomized
controlled trial. J Anxiety Disord. 2009;23(8):1106-17. DOI:
10.1016/j.janxdis.2009.07.014
48. Forsyth JP, Barrios V, Acheson DT .Exposure therapy and
cognitive interventions for the anxiety disorders: overview and
newer third-generation perspectives. Handbook of exposure
therapies: Elsevier; 2007. 61-108.
49. Gross JJ. Emotion regulation: Conceptual and empirical
foundations. 2014.
50. Johnston L, Titov N, Andrews G, Spence J, Dear BF. A RCT of
a transdiagnostic internet-delivered treatment for three anxiety
disorders: examination of support roles and disorder-specific
outcomes. PloS one. 2011;6(11): 28079. DOI:
http://doi.org/10.1371/journal.pone.0028079
51. Tolin DF. Is cognitive–behavioral therapy more effective than
other therapies?: A meta-analytic review. Clin Psychol
Rev. 2010;30(6):710-20. DOI: 10.1016/j.cpr.2010.05.003
52. Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L.
Brief psychological therapies for anxiety and depression in
primary care: meta-analysis and meta-regression. BMC Med.
2010;8(1):38. DOI: 10.1186/1741-7015-8-38
53. Donker T, Griffiths KM, Cuijpers P, Christensen H.
Psychoeducation for depression, anxiety and psychological
distress: a meta-analysis. BMC Med. 2009;7(1):79.
54. Ejeby K, Savitskij R, Öst L-G, Ekbom A, Brandt L, Ramnerö J,
et al. Randomized controlled trial of transdiagnostic group
treatments for primary care patients with common mental
disorders. Fam Pract. 2014;31(3):273-80. DOI:
10.1093/fampra/cmu006
55. Mohajerin B, Bakhtiyar M, Olesnycky OS, Dolatshahi B, Motabi
F. Application of a transdiagnostic treatment for emotional
disorders to body dysmorphic disorder: A randomized controlled
trial. J Affect Disord. 2019;245:637-44. DOI;
10.1016/j.jad.2018.11.058. (in persian)
56. Abdi R, Bakhshi A, MAHMOUD AM. Efficacy of unified
transdiagnostic treatment on reduction of transdiagnostic factors
and symptoms severity in emotional disorders. 2013. (in persian)
57. Bullis JR, Fortune MR, Farchione TJ, Barlow DH. A preliminary
investigation of the long-term outcome of the Unified Protocol
for Transdiagnostic Treatment of Emotional Disorders. Compr
Psychiatry. 2014;55(8):1920-7. DOI:
10.1016/j.comppsych.2014.07.016