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Transdiagnostic Treatment of Anxiety Disorders in a Group Format Based on the Principles of the Unified Protocol: a Preliminary Intensive Measurement Examination of Process and Outcome

  • Yogev KivityEmail author
  • Mirit Shani Sela
  • Anat Yariv
  • May Koubi
  • Amit Saad
  • Shmuel Fennig
  • Yuval Bloch
Article
  • 11 Downloads

Abstract

We describe a transdiagnostic treatment for anxiety disorders in community mental health centers (CMHCs), based on the Unified Protocol (Barlow et al. 2011), and adapted to a group format (UP-G). Participants were 13 CMHC patients in an intensive measurement design. Participants were interviewed for anxiety severity at pre- and post-treatment and completed weekly self-reports of distress, emotion dysregulation, valued living, fear of bodily sensations, and therapeutic alliance. We observed significant improvements in all measures except for valued living. Improvements in emotion regulation preceded and predicted subsequent reductions in distress as well as the other way around. Improvements in alliance co-occurred with reductions in distress. The UP-G is a flexible intervention that is suitable for CMHCs and may assist in reducing the burden of anxiety disorders and improving dissemination. These preliminary findings suggest that improvements in emotion regulation may play an important role in facilitating change in the UP-G.

Keywords

Cognitive-behavioral therapy Unified protocol Anxiety disorders Group therapy Transdiagnostic protocol 

Notes

Acknowledgments

The authors would like to thank Michal Master-Barak for conducting clinical assessments for the study.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

References

  1. Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176–181.CrossRefGoogle Scholar
  2. Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., et al. (2017). The Unified Protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: a randomized clinical trial. JAMA Psychiatry, 74(9), 875–884.PubMedPubMedCentralCrossRefGoogle Scholar
  3. Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2011). The unified protocol for transdiagnostic treatment of emotional disorders: therapist guide. New York: Oxford University Press.Google Scholar
  4. Bolger, N., & Laurenceau, J. P. (2013). Intensive longitudinal methods: an introduction to diary and experience sampling research. New York, NY: Guilford.Google Scholar
  5. Boswell, J. F., Farchione, T. J., Sauer-Zavala, S., Murray, H. W., Fortune, M. R., & Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A transdiagnostic construct and change strategy. Behavior Therapy, 44(3), 417–431.PubMedPubMedCentralCrossRefGoogle Scholar
  6. Brown, T. A., Antony, M. M., & Barlow, D. H. (1995). Diagnostic comorbidity in panic disorder: Effect on treatment outcome and course of comorbid diagnoses following treatment. Journal of Consulting and Clinical Psychology, 63(3), 408–418.PubMedCrossRefGoogle Scholar
  7. Brown, T. A., & Barlow, D. H. (2009). A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: implications for assessment and treatment. Psychological Assessment, 21(3), 256–271.PubMedPubMedCentralCrossRefGoogle Scholar
  8. Bullis, J. R., Fortune, M. R., Farchione, T. J., & Barlow, D. H. (2014). A preliminary investigation of the long-term outcome of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. Comprehensive Psychiatry, 55(8), 1920–1927.PubMedPubMedCentralCrossRefGoogle Scholar
  9. Bullis, J. R., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Carl, J. R., & Barlow, D. H. (2015). The unified protocol for transdiagnostic treatment of emotional disorders: Preliminary exploration of effectiveness for group delivery. Behavior Modification, 39(2), 295–321.PubMedCrossRefGoogle Scholar
  10. Burlingame, G. M., Seebeck, J. D., Janis, R. A., Whitcomb, K. E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53(4), 446–461.PubMedCrossRefGoogle Scholar
  11. Carmody, J., & Baer, R. A. (2008). Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Journal of Behavioral Medicine, 31(1), 23–33.PubMedCrossRefGoogle Scholar
  12. Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514.PubMedPubMedCentralCrossRefGoogle Scholar
  13. Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52(6), 1090–1097.PubMedCrossRefGoogle Scholar
  14. Clark, D. A. (2009). Cognitive behavioral therapy for anxiety and depression: Possibilities and limitations of a transdiagnostic perspective. Cognitive Behaviour Therapy, 38(S1), 29–34.PubMedCrossRefGoogle Scholar
  15. de Ornelas Maia, A. C. C., Braga, A. A., Nunes, C. A., Nardi, A. E., & Silva, A. C. (2013). Transdiagnostic treatment using a unified protocol: application for patients with a range of comorbid mood and anxiety disorders. Trends in Psychiatry and Psychotherapy, 35(2), 134–140.CrossRefGoogle Scholar
  16. de Ornelas Maia, A. C. C., Nardi, A. E., & Cardoso, A. (2015). The utilization of unified protocols in behavioral cognitive therapy in transdiagnostic group subjects: A clinical trial. Journal of Affective Disorders, 172, 179–183.PubMedCrossRefPubMedCentralGoogle Scholar
  17. Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010). Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice, 17(1), 88–101.CrossRefGoogle Scholar
  18. Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J., Carl, J. R., et al. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behavior Therapy, 43(3), 666–678.PubMedPubMedCentralCrossRefGoogle Scholar
  19. Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2017). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52–60.PubMedPubMedCentralCrossRefGoogle Scholar
  20. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54.CrossRefGoogle Scholar
  21. Hamilton, M. A. X. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32(1), 50–55.PubMedCrossRefGoogle Scholar
  22. Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16(1), 12–25.CrossRefGoogle Scholar
  23. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.PubMedPubMedCentralCrossRefGoogle Scholar
  24. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.PubMedCrossRefGoogle Scholar
  25. Jaeger, B. (2016). r2glmm: Computes R squared for mixed (multilevel) models, R package version 0.1.2 [Computer software]. Retrieved from https://cran.r-project.org/package=r2glmm.
  26. Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21–37.PubMedCrossRefGoogle Scholar
  27. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.PubMedPubMedCentralCrossRefGoogle Scholar
  28. Kroenke, K., Spitzer, R. L., Williams, J. B., Monahan, P. O., & Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Annals of Internal Medicine, 146(5), 317–325.PubMedCrossRefGoogle Scholar
  29. Lane, S. P., & Hennes, E. P. (2018). Power struggles: Estimating sample size for multilevel relationships research. Journal of Social and Personal Relationships, 35(1), 7–31.CrossRefGoogle Scholar
  30. Laposa, J. M., Mancuso, E., Abraham, G., & Loli-Dano, L. (2017). Unified protocol transdiagnostic treatment in group format: A preliminary investigation with anxious individuals. Behavior Modification, 41(2), 253–268.PubMedCrossRefGoogle Scholar
  31. Matza, L. S., Morlock, R., Sexton, C., Malley, K., & Feltner, D. (2010). Identifying HAM-A cutoffs for mild, moderate, and severe generalized anxiety disorder. International Journal of Methods in Psychiatric Research, 19(4), 223–232.PubMedCrossRefGoogle Scholar
  32. Nakagawa, S., & Schielzeth, H. (2013). A general and simple method for obtaining R2 from generalized linear mixed-effects models. Methods in Ecology and Evolution, 4(2), 133–142.CrossRefGoogle Scholar
  33. Norton, P. J., & Paulus, D. J. (2017). Transdiagnostic models of anxiety disorder: Theoretical and empirical underpinnings. Clinical Psychology Review, 56, 122–137.PubMedCrossRefGoogle Scholar
  34. Osma, J., Castellano, C., Crespo, E., & García-Palacios, A. (2015). The unified protocol for transdiagnostic treatment of emotional disorders in group format in a Spanish public mental health setting. Behavioral Psychology, 23(3), 447–466.Google Scholar
  35. Pinheiro, J., Bates, D., DebRoy, S., Sarkar, D., & R Core Team. (2016). nlme: Linear and nonlinear mixed effects models, R package version 3.1-128 [Computer software]. Retrieved from http://CRAN.R-project.org/package=nlme.
  36. Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data analysis methods (2nd ed.). Thousand Oaks: Sage Publications, Inc..Google Scholar
  37. Reinholt, N., Aharoni, R., Winding, C., Rosenberg, N., Rosenbaum, B., & Arnfred, S. (2017). Transdiagnostic group CBT for anxiety disorders: The unified protocol in mental health services. Cognitive Behaviour Therapy, 46(1), 29–43.PubMedCrossRefGoogle Scholar
  38. Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow, D. H. (2012). The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the transdiagnostic treatment of emotional disorders. Behaviour Research and Therapy, 50(9), 551–557.PubMedPubMedCentralCrossRefGoogle Scholar
  39. Shear, M. K., Vander Bilt, J., Rucci, P., Endicott, J., Lydiard, B., Otto, M. W., et al. (2001). Reliability and validity of a structured interview guide for the Hamilton Anxiety Rating Scale (SIGH-A). Depression and Anxiety, 13, 166–178.PubMedCrossRefPubMedCentralGoogle Scholar
  40. Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33.PubMedGoogle Scholar
  41. Stein, M. B., Roy-Byrne, P. P., Craske, M. G., Campbell-Sills, L., Lang, A. J., Golinelli, D., et al. (2011). Quality of and patient satisfaction with primary health care for anxiety disorders. The Journal of Clinical Psychiatry, 72(7), 970–976.PubMedPubMedCentralCrossRefGoogle Scholar
  42. Suárez, L., Bennett, S., Goldstein, C., & Barlow, D. H. (2009). Understanding anxiety disorders from a “triple vulnerability” framework. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 153–172). New York: Oxford University Press.Google Scholar
  43. Wang, L., & Maxwell, S. (2015). On disaggregating between-person and within-person effects with longitudinal data using multilevel models. Psychological Methods, 20(1), 63–83.PubMedCrossRefGoogle Scholar
  44. Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. (2011). The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. The Psychological Record, 60(2), 249–272.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Bar Ilan UniversityRamat Gan,Israel
  2. 2.Shalvata Mental Health CenterHod HaSharonIsrael
  3. 3.Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael

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