Application of the unified protocol for transdiagnostic treatment of emotional disorders in post-bariatric surgery patients: aneffectivenessandfeasibilitystudyingroupformat
Abstract
Obesity is a serious health problem with global implications. Bariatric surgery (BS) is the most used and effective treatment, but there are patients who do not lose a substantial amount of weight, a fact that has been related with the presence of emotional eating, anxiety and depression symptoms. The aim of this study is to analyze the effectiveness and feasibility of an emotion regulation-based intervention called Unified Protocol (UP), applied in group format to 6 post-BS patients presenting emotional disorders/symptoms. Results at post-treatment shown high attendance rates and satisfaction with the UP scores and significant improvements on neuroticism, eating disorders symptoms and emotional eating. At 6-month follow-up we found significant reductions on anxiety symptoms, neuroticism, maladjustment and dysregulation (d = 0.83-1.46) and the body mass index remained stable over time. These preliminary results are encouraging about the effectiveness and feasibility of the UP to treat emotional dysregulation in patients after BS.
Downloads
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington: Author.
Arnow, B., Kenardy, J., & Agras, W. (1995). The Emotional Eating Scale: The development of a measure to assess coping with negative affect by eating. International Journal of Eating Disorders, 18(1), 79-90. http://dx.doi.org/10.1002/1098-108X(199507)18:1%3C79::AID-EAT2260180109%3E3.0.CO;2-V
Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., … Cassiello-Robbins, C. (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. https://doi.org/10.1001/jamapsychiatry.2017.2164
Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2015). Protocolo unificado para el tratamiento transdiagnóstico de los trastornos emocionales: Manual del terapeuta y Manual del paciente [Unified protocol for transdiagnostic treatment of emotional disorders: Therapist and patient guide]. Madrid: Alianza Editorial. (Orig., 2011).
Barlow, D. H., Farchione, T. J., Sauer-Zavala, S., Murray-Latin, H., Ellard, K. K., Bullis, J. R., … Cassiello-Robbins, C. (2019). Protocolo Unificado para el tratamiento transdiagnóstico de los trastornos emocionales. Manual del paciente [Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Patient's Guide]. Madrid: Alianza Editorial.
Barlow, D.H., Farchione, T. J., Sauer-Zavala, S., Murray-Latin, H., Ellard, K. K., Bullis, J. R., … Cassiello-Robbins, C. (2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide (2nd ed.). New York, NY: Oxford University Press.
Bean, M. K., Stewart, K., & Olbrisch, M. E. (2008). Obesity in America: Implications for Clinical and Health Psychologists. Journal of Clinical Psychology in Medical Settings, 15(3), 214-224. http://dx.doi.org/10.1007/s10880-008-9124-9
Beck, A. T., & Steer, R. (1993). Beck Anxiety Inventory manual. San Antonio, TX: Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
Bentley, K. H., Gallagher, M. W., Carl, J. R., & Barlow, D. H. (2014). Development and validation of the Overall Depression Severity and Impairment Scale. Psychological Assessment, 26(3), 815-830. https://doi.org/10.1037/a0036216
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. http://dx.doi.org/10.1037/a0016608
Carl, J. R., Gallagher, M. W., Sauer-Zavala, S. E., Bentley, K. H., & Barlow, D. H. (2014). A preliminary investigation of the effects of the unified protocol on temperament. Comprehensive Psychiatry, 55(6), 1426-1434. https://doi.org/10.1016/j.comppsych.2014.04.015
Cassiello-Robbins, C., Southward, M. W., Tirpak, J. W., & Sauer-Zavala, S. (2020). A systematic review of unified protocol applications with adult populations: Facilitating widespread dissemination via adaptability. Clinical Psychology Review, 13(61), 98-99. https://doi.org/10.1016/j.cpr.2020.101852
Cassin, S. E., Sockalingam, S., Du, C., Wnuk, S., Hawa, R., & Parikh, S. V. (2016). A pilot randomized controlled trial of telephone-based cognitive behavioural therapy for pre-operative bariatric surgery patients. Behaviour Research and Therapy, 80,17–22. https://doi.org/http://dx.doi. org/10.1016/j.brat.2016.03.001.
Cassin, S. E., Sockalingam, S., Wnuk, S., Strimas, R., Royal, S., Hawa, R., & Parikh, S. V. (2013). Cognitive-behavioral therapy for bariatric surgery patients: Preliminary evidence for feasibility, acceptability, and effectiveness. Cognitive and Behavioral Practice, 20(4), 529–543. https://doi.org/10.1016/j.cbpra.2012.10.002
Castaneda, D., Popov, V. B., Wander, P., & Thompson, C. C. (2019). Risk of suicide and self-harm is increased after bariatric surgery—a systematic review and meta-analysis. Obesity Surgery, 29(1), 322–333. http://dx.doi.org/10.1007/s11695-018-3493-4
Cohen, J. (1960). A coefficient of agreement for nominal scales. Educational and Psychological Measurement, 20, 37-46. http://dx.doi.org/10.1177/001316446002000104
Cooper, P. J., Taylor, M. J., Cooper, Z., & Fairburn, C. G. (1987). The development and validation of the Body Shape Questionnaire. International Journal of Eating Disorders, 6, 485-494. http://dx.doi.org/10.1002/1098-108X(198707)6:4%3C485::AID-EAT2260060405%3E3.0.CO;2-O
Costa, P. T., & McCrae, R. R. (1999). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI). Madrid: TEA Ediciones.
De Andrés Pizarro, J. (2000). El análisis de estudios cualitativo [Qualitative study analysis]. Atención Primaria [Primary Care], 25(1), 42-46.
Echeburúa, E., Corral, P., & Fernández-Montalvo, J. (2000). Maladjustment Inventory (MI): Psychometric properties in clinical contexts. Análisis y Modificación de Conducta [Analysis and Behavioral Modification], 26(107), 325-340.
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, 88-101. http://dx.doi.org/10.1016/j.cbpra.2009.06.002
Ferrando, L., Bobes, J., Gibert, J., Soto, M., & Soto, O. (2000). MINI entrevista neuropsiquiátrica internacional [MINI international neuropsychiatric interview]. Madrid: Instituto IAP.
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. http://dx.doi.org/10.1007/s10862-008-9102-4
Henderson, M., & Freeman, C. P. L. (1987). A self-rating scale for bulimia: The ‘BITE’. The British Journal of Psychiatry, 150 (1), 18-24. http://dx.doi.org/10.1192/bjp.150.1.18
Hernáez, A., Zomeño, M. D., Dégano, I. R., Pérez-Fernández, S., Goday, A., Vila, J., … Marrugat, J. (2019). Exceso de peso en España: situacioón actual, proyecciones para 2030 y sobrecoste directo estimado para el Sistema Nacional de Salud [Excess weight in Spain: Current situation, projections for 2030, and estimated direct extra cost for the Spanish Health System. Revista Española de Cardiología [Spanish Journal of Cardiology], 72(11), 916-924. https://doi.org/10.1016/j.recesp.2018.07.009
Hervás, G., & Jódar, R. (2008). The Spanish version of the Difficulties in Emotion Regulation Scale. Clinica y Salud [Clinical and Health], 19(2), 139-156.
Hjelmesæth, J., Rosenvinge, J. H., Gade, H., & Friborg, O. (2019). Effects of cognitive-behavioral therapy on eating behaviors, affective symptoms, and weight loss after bariatric surgery: A randomized clinical trial. Obesity Surgery, 29(1), 61-69. https://doi.org/10.1007/s11695-018-3471-x
IBM Corp. (2013). IBM SPSS Statistics for Windows, Version 22.0. New York: IBM.
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.
Jumbe, S., Hamlet, C., & Meyrick, J. (2017). Psychological aspects of bariatric surgery as a treatment for obesity. Current Obesity Reports, 6(1), 71-78. https://doi.org/10.1007/s13679-017-0242-2
Kalarchian, M. A., & Marcus, M. D. (2003). Management of the bariatric surgery patient: Is there a role for the cognitive-behavior therapist? Cognitive and Behavioral Practice, 10(2), 112-119. https://doi.org/10.1016/S1077-7229(03)80019-6
Lahey, B. B. (2009). Public health significance of neuroticism. American Psychologist, 64(4), 241-256. https://doi.org/10.1038/jid.2014.371
Larsen, D., Attkisson, C., Hargreaves, W., & Nguyen, T. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2, 197–207.
Lauren, A. D., Sijercic, I., & Cassin, S. E. (2020). Preoperative and post-operative psychosocial interventions for bariatric surgery patients: A systematic review. Obesity Reviews, 1-23. https://doi.org/10.1111/obr.12926
Magán, I., Sanz, J., & García-Vera, M. P. (2008). Psychometric properties of a Spanish version of the Beck Anxiety Inventory (BAI) in general population. The Spanish Journal of Psychology, 11(2), 626–640. https://doi.org/10.1017/S1138741600004637
Martín, E., Ruiz-Tovar, J., & Sánchez, R. (2017). Vía clínica de cirugía bariátrica 2017 [Clinical pathway of bariatric surgery 2017]. Albacete: Inm3diA comunicación.
Martínez-Borba, V., Osma, J., Crespo-Delgado, E., Andreu-Pejo, L., & Monferrer-Serrano, A. (2022). Prevention of Emotional Disorders and Symptoms Under Health Conditions: A Pilot Study using the Unified Protocol in a Fertility Unit. Anales de Psicología / Annals of Psychology, 38(1), 25–35. https://doi.org/10.6018/analesps.462331
Mezzich, J. E., Ruipérez, M. A., Pérez, C., Yoon, G., Liu, J., & Mahmud, S. (2000). The Spanish version of the Quality of Life Index. The Journal of Nervous and Mental Disease, 188(5), 301-305. http://dx.doi.org/10.1097/00005053-200005000-00008
Moya, T. R., Bersabé, R., & Jiménez, M. (2004). Fiabilidad y validez del test de investigación bulímica de Edimburgo (BITE) en una muestra de adolescentes españoles [Reliability and validity of the Bulimic Investigatory Test Edinburgh (BITE) in a sample of Spanish adolescents]. Psicología Conductual [Conductual Psychology], 12, 447-461.
National Health and Medical Research Council. (2013). Clinical practice guidelines for the management of overweight and obesity in children and adolescents. Canberra: National Health and Medical Research Council.
Norman, S. B., Allard, C. B., Trim, R. S., Thorp, S. R., Behrooznia, M., Masino, T. T., & Stein, M. B. (2013). Psychometrics of the Overall Anxiety Severity and Impairment Scale (OASIS) in a sample of women with and without trauma histories. Archives of Women’s Mental Health, 16(2), 123–129. https://doi.org/10.1007/s00737-012-0325-8
OECD (2019). The heavy burden of obesity: The economics of prevention, OECD Health Policy Studies. Paris: OECD Publishing. https://doi.org/10.1787/b53ed5f9-fr
Oltmanns, J. R., Rivera, J., Cole, J., Merchant, A., & Steiner, J. P. (2020). Personality psychopathology: Longitudinal prediction of change in body mass index and weight post-bariatric surgery. Health Psychology, 39(3), 245–254. https://doi.org/10.1037/hea0000842
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.
Osma, J., Martínez-García, L.; Quilez-Orden, A.; Peris-Baquero, Ó. (2021). Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Medical Conditions: A Systematic Review. International Journal of Environmental Research and Public Health, 18, 5077. https://doi.org/10.3390/ ijerph18105077
Osma, J., Quilez-Orden, A., Suso-Ribera, C., Peris-Baquero, O., Norman, S. B., Bentley, K. H., & Sauer-Zavala, S. (2019). Psychometric properties and validation of the Spanish versions of the Overall Anxiety and Depression Severity and Impairment Scales. Journal of Affective Disorders, 252. https://doi.org/10.1016/j.jad.2019.03.063
Osma, J., Sánchez-Gómez, A., & Peris-Baquero, Ó. (2018). Applying the unified protocol to a single case of major depression with schizoid and depressive personality traits. Psicothema, 30(4), 364-369. https://doi.org/10.7334/psicothema2018.41
Perpiñá, C., Cebolla, A., Botella, C., Lurbe, E., & Torró, M. (2011). Emotional Eating Scale for Children and Adolescents: Psychometric characteristics in a Spanish sample. Journal of Clinical Child & Adolescent Psychology, 40(3), 424-433. http://dx.doi.org/10.1080/15374416.2011.563468
Qualtrics. (2017). Qualtrics (version 2.16) [computer program]. Provo, UT: Qualtrics.
Raich, R. M., Mora, M., Soler, A., Avila, C., Clos, I., & Zapater, L. (1996). Adaptación de un instrumento de evaluación de la insatisfacción corporal [Adaptation of a body dissatisfaction assessment instrument]. Clínica y Salud [Clinical and Health], 7, 51-66.
Sanz, J., García-Vera, M. P., & Fortún, M. (2012). El Inventario de ansiedad de Beck“ (BAI): propiedades psicométricas de la versión española en pacientes con trastornos psicológicos [The Beck Anxiety Inventory (BAI): psychometric properties of the Spanish version in patients with psychological disorders]. Psicología Conductual [Behavioral Psychology], 20(3), 563.
Sanz, J., García-Vera, M., Espinosa, R., Fortún, M., & Vázquez, C. (2005). Adaptación española del Inventario para la depresión de Beck-II (BDI-II): Propiedades psicométricas en pacientes con trastornos psicológicos [Spanish adaptation of the Beck Depression Inventory-II (BDI-II): Psychometric properties in patients with psychological disorders]. Clínica y Salud [Clinical and Health], 16, 121-142.
Sanz, J., Perdigón, A. L., & Vázquez, C. (2003). The Spanish adaptation of Beck’s Depression Inventory-II (BDI-II): Psychometric properties in the general population [The Spanish adaptation of Beck's Depression Inventory-II (BDI-II): Psychometric properties in the general population]. Clínica y Salud [Clinical and Health], 14, 249–280.
Sarwer, D. B., & Heinberg, L. J. (2020). A Review of the psychosocial aspects of clinically severe obesity and bariatric surgery. American Psychological Association, 75(2), 252-264. http://dx.doi.org/10.1037/amp0000550
Sauer-Zavala, S., Cassiello-Robbins, C., Ametaj, A. A., Wilner, J. G., & Pagan, D. (2019). Transdiagnostic treatment personalization: The feasibility of ordering unified protocol modules according to patient strengths and weaknesses. Behavior Modification, 43(4), 518-543. https://doi.org/10.1177/0145445518774914
Sauer-Zavala, S., Fournier, J., Jarvi Steele, S., Woods, B., Wang, M., Farchione, T., & Barlow, D. (2020). Does the unified protocol really change neuroticism? Results from a randomized trial. Psychological Medicine, 1-10. doi:10.1017/S0033291720000975
Sauer-Zavala, S., Gutner, C. A., Farchione, T. J., Boettcher, H. T., Bullis, J. R., & Barlow, D. H. (2017). Current Definitions of “transdiagnostic” in treatment development: A search for consensus. Behavior Therapy, 48, 128-138. https://doi.org/10.1016/j.beth.2016.09.004
Sheehan, D. V. (2015). Mini International Neuropsychiatric Interview 7.0. (MINI 7.0). Jacksonville, FL: Medical Outcomes Systems.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59(20).
Simon, G. E., Von Korff, M., Saunders, K., Miglioretti, D. L., Crane, P. K., van Belle, G., & Kessler, R. C. (2006). Association between obesity and psychiatric disorders in the US adult population. Archives of General Psychiatry, 63, 824-830. http://dx.doi.org/10.1001/archpsyc.63.7.824
Sockalingam, S., Cassin, S. E., Wnuk, S., Du, C., Jackson, T., Hawa, R., & Parikh, S. V. (2017). A pilot study on telephone cognitive behavioral therapy for patients’ six-months post-bariatric surgery. Obesity Surgery, 27(3), 670–675. https://doi.org/10.1007/s11695-016-2322-x
Sockalingam, S., Leung, S. E., Hawa, R., Wnuk, S., Parikh, S. V., Jackson, T., & Cassin, S. E. (2019). Telephone-based cognitive behavioural therapy for female patients’ 1-year post-bariatric surgery: A pilot study. Obesity Research and Clinical Practice, 13(5), 499-504. https://doi.org/10.1016/j.orcp.2019.07.003
Spirou, D., Raman, J., & Smith, E. (2020). Psychological outcomes following surgical and endoscopic bariatric procedures: A systematic review. Obesity Reviews, 1–24. https://doi.org/10.1111/obr.12998
Tirpak, J. W., Cassiello-Robbins, C., Ametaj, A., Olesnycky, O. S., Sauer-Zavala, S., Farchione, T. J., & Barlow, D. H. (2019). Changes in positive affect in cognitive-behavioral treatment of anxiety disorders. General Hospital Psychiatry, 61, 111-115. https://doi.org/10.1016/j.genhosppsych.2019.06.008
Wilfley, D. E., Vannucci, A., & White, E. K. (2010). Early Intervention of Eating- and Weight-Related Problems. Journal of Clinical Psychology in Medical Settings, 17(4), 285–300. http://dx.doi.org/10.1007/s10880-010-9209-0
World Health Organization. (1992). The ICD-10 Classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines (10th revision). Geneva: Author.
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group therapy (5th ed.). New York: IUP
Copyright (c) 2022 Servicio de Publicaciones, University of Murcia (Spain)
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
The works published in this journal are subject to the following terms:
1. The Publications Service of the University of Murcia (the publisher) retains the property rights (copyright) of published works, and encourages and enables the reuse of the same under the license specified in paragraph 2.
© Servicio de Publicaciones, Universidad de Murcia, 2022
2. The works are published in the online edition of the journal under a Creative Commons Reconocimiento-CompartirIgual 4.0 (legal text). You can copy, use, distribute, transmit and publicly display, provided that: i) you cite the author and the original source of publication (journal, editorial and URL of the work), ii) are not used for commercial purposes, iii ) mentions the existence and specifications of this license.
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
3. Conditions of self-archiving. Is allowed and encouraged the authors to disseminate electronically pre-print versions (version before being evaluated and sent to the journal) and / or post-print (version reviewed and accepted for publication) of their works before publication, as it encourages its earliest circulation and diffusion and thus a possible increase in its citation and scope between the academic community. RoMEO Color: Green.