Emotion regulation as the mediator of reductions in anxiety and depression in the Unified Protocol (UP) for transdiagnostic treatment of emotional disorders: double-blind randomized clinical trial

Khakpoor, Sahel; Saed, Omid; Armani Kian, Alireza

doi:10.1590/2237-6089-2018-0074

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Original Articles • Trends Psychiatry Psychother. 41 (3) • Jul-Sep 2019 • https://doi.org/10.1590/2237-6089-2018-0074 copy

Emotion regulation as the mediator of reductions in anxiety and depression in the Unified Protocol (UP) for transdiagnostic treatment of emotional disorders: double-blind randomized clinical trial

Regulação emocional como mediadora de reduções em ansiedade e depressão no Protocolo Unificado para o tratamento transdiagnóstico de transtornos psicológicos: ensaio clínico randomizado duplo-cego

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

An important subject in evaluation of the efficacy of treatments is to examine how the intervention is effective and to identify the consequences of that treatment. In this regard, the current study investigates the role of emotion regulation as the mediator of the treatment outcomes of therapy using the Unified Protocol (UP) for transdiagnostic treatment of emotional disorders.

Method:

This article describes a double-blind randomized clinical trial. A sample of 26 individuals was selected based on cut-off scores for the Beck Depression Inventory and Beck Anxiety Inventory and their final diagnoses were confirmed with the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). The sample was randomly divided into two groups: control and treatment (13 patients each). The treatment group received 20 one-hour UP sessions. The Beck Depression Inventory, the Beck Anxiety Inventory, and the Difficulties in Emotion Regulation Scale were administered at two stages, pre-treatment and post-treatment.

Results:

The UP reduced anxiety and depression in patients through improvement in emotion regulation. Furthermore, the results showed that the difficulty engaging in goal-directed behavior and non-acceptance of emotional response subscales were capable of predicting 62% of variance in anxiety scores. In turn, two subscales, difficulty engaging in goal-directed behavior and lack of emotional clarity, predicted 72% of variance in depression scores.

Conclusion:

Emotion regulation can be considered as a potential mediating factor and as predictive of outcomes of transdiagnostic treatment based on the UP.

Clinical trial registration:

Iranian Registry of Clinical Trials, IRCT2017072335245N1.

Keywords:
Emotion regulation; mediator; treatment outcomes; unified protocol; randomized clinical trial

Modules	Session	Intervention
Module 1. Motivational enhancement	1	This module helped patients to assess the advantages and disadvantages of changing their behavior or staying the same. Also, patients were asked to set more objective goals.

Module 2. Psychoeducation	2	In this module, the adaptive nature of the emotions and the main components of emotional experience were taught to patients.

Module 3. Present-focused, nonjudgmental awareness	3-5	During this module, patients were helped to understand how to observe and react to their emotions and practice present-focused awareness using mindfulness exercises.

Module 4. Increasing cognitive flexibility	6-8	In this module, patients are asked to identify their common thinking traps, learn how to modulate maladaptive thinking patterns, and increase their flexibility in assessing different situations.

Module 5. Identification and prevention of emotional and behavioral avoidance	9-11	This module generally focused on the behavioral components of emotional experience and helped patients to identify emotional avoidance and emotion-driven behaviors (EDBs) and work on current patterns of emotional responses.

Module 6. Increasing the awareness and tolerance of physical sensations	12-14	During this module, patients were encouraged to increase their tolerance to physical sensations. The therapist performed exercises to stimulate body sensations similar to those associated with anxiety and discomfort.

Module 7. Situational emotion exposures	15-19	During this module, the therapist helped patients to plan and then confront an emotional avoidance hierarchy. In these exposures, emphasis is on emotional experience.

Module 8. Relapse prevention	20	This module includes an overview of the treatment content and patient progress. The therapist helped patients to identify ways in which treatment advantages maintain and predict future difficulties.

	Treatment group (n = 12)			Control group (n = 12)
	M ± SD	M ± SD	M ± SD	M ± SD	M ± SD	M ± SD
Variable	Pre-test	Post-test	Change score	Pre-test	Post-test	Change score
BAI	19.33±11.38	8.92±6.24	10.42±10.8	20±12.79	21.25±11.77	-1.25±5.26
BDI	18.5±11.16	8.33±12.21	10.17±5.67	19.67±10.13	21.92±11.28	-2.25±7.63
DERS	98.33±21.22	70.83±14.12	27.5±17.17	107.4±22.6	109±21.57	-1.58±15.55

Dependent variable		Post-test adjusted means
		Treatment	Control
		M ± SD	M ± SD	df	MS	f	p	η² or Eta
Pre-test
	BAI	9.1±1.95	21.06±1.95	1	857.85	18.89	0.0001	0.474
	BDI	8.86±1.97	21.39±1.97	1	937.83	20.23	0.0001	0.491

Pre-test and DERS
	BAI	11.43±2.29	18.74±2.29	1	158.83	3.82	0.065	0.161
	BDI	12.04±2.05	18.21±2.05	1	121.38	3.47	0.077	0.148

Variable	2	3	4	5	6	7	8	9
1. BAI	0.694^* * p < 0.05,	0.726^† † p < 0.01.	0.731^† † p < 0.01.	0.689^† † p < 0.01.	0.167	0.590^† † p < 0.01.	0.514^† † p < 0.01.	0.732^† † p < 0.01.
2. BDI	1	0.519^† † p < 0.01.	0.813^† † p < 0.01.	0.645^† † p < 0.01.	0.284	0.733^† † p < 0.01.	0.539^† † p < 0.01.	0764^† † p < 0.01.

DERS
3. Nonaccept		1	0.813^† † p < 0.01.	0.540^† † p < 0.01.	0.340	0.508^† † p < 0.01.	0.478^* * p < 0.05,	0.765^† † p < 0.01.
4. Goals			1	0.757^† † p < 0.01.	0.299	0.676^† † p < 0.01.	0.638^† † p < 0.01.	0.877^† † p < 0.01.
5. Impulse				1	0.151	0.682^† † p < 0.01.	0.481^† † p < 0.01.	0.676^† † p < 0.01.
6. Awareness					1	0.183	0.563^† † p < 0.01.	0.522^† † p < 0.01.
7. Strategies						1	0.529^† † p < 0.01.	0.824^† † p < 0.01.
8. Clarity							1	0.793^† † p < 0.01.
9. Total score								1

Dependent variable/model/predictive variable			R	R²2. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-25.	F	p of F	Beta	t	p
BAI
	Model 1
		Goals	0.731	0.531	24.03	0.0001	0.731	4.9	0.0001
	Model 2
		Goals	0.787	0.620	16.028	0.0001	0.433	2.2	0.40
		Nonaccept	0.787	0.620	16.028	0.0001	0.418	2.13	0.046

BDI
	Model 1
		Goals	0.813	0.660	40.8	0.0001	0.813	6.39	0.0001
	Model 2
		Goals	0.850	0.723	26.04	0.0001	0.584	3.65	0.002
		Clarity	0.850	0.723	26.04	0.0001	0.338	2.11	0.047

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E-mail: trends@aprs.org.br

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[1] Correspondence: Omid Saed, Department of Clinical Psychology, Faculty of Medicine, Zanjan University of Medical Sciences Zanjan, Iran Tel.: + 98 24 33534500, Fax: + 98 24 33534500 E-mail: o.saed@zums.ac.ir