Generalized Anxiety Disorder and Comorbid Symptoms of Sleep: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders

  • Mohsen Mohammadpour Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
  • Amir Bavafa Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
  • Aliakbar Foroughi Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
  • Sahar Pouyanfard Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
  • Adele Elahi Department of Psychiatry, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
  • Nasrin Jaberghaderi Department of Clinical Psychology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
Comorbidity, Generalized anxiety disorder, Sleep disorders, Clinical protocols


Background and Objective: Generalized anxiety disorder (GAD) has high comorbidity with other psychological disorders and causes functional impairments. A unified protocol (UP) for transdiagnostic treatment is an emotion-based treatment and can be effective in improving comorbid symptoms. This study aimed at evaluating the effectiveness of UP for transdiagnostic treatment and pharmacotherapy treatment-as-usual (UP + TAU) compared with pharmacotherapy treatment-as-usual (TAU) in reducing the symptoms of GAD and comorbid sleep problems.

Materials and Methods: The present study was a clinical trial and the statistical population of this study consisted of all the people with GAD referred to mental health clinics in Kermanshah, Iran. The participants were 24 individuals with GADs and their comorbid symptoms (sleep problems) and were randomly assigned to control (TAU) and experimental groups (UP + TAU). The participants completed the Penn State Worry Questionnaire (PSWQ), Pittsburgh Sleep Quality Index ‎ (PSQI), and Work and Social Adjustment Scale (WSAS) in the three stages of assessment. One-way analysis of covariance (ANCOVA) was used to analyze the data.

Results: Among the participants in the TAU + UP group, the symptoms of GAD and sleep problems (only in follow-up) significantly decreased and overall performance improved in comparison to the TAU group (P > 0.001). However, this significant effect was shown only in some of the components of sleep quality.

Conclusion: Based on the findings of this study, UP was effective in reducing the symptoms of GAD and its comorbid symptoms (sleep problems), and improving overall performance. However, the reduction in sleep problems (only in a few components) was statistically significant only at the follow-up stage.


1. Tyrer P, Baldwin D. Generalised anxiety disorder. Lancet 2006; 368: 2156-66.
2. Wittchen HU, Hoyer J. Generalized anxiety disorder: Nature and course. J Clin Psychiatry 2001; 62: 15-9.
3. American Psychiatric Association. Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Association; 2013.
4. Hajebi A, Motevalian SA, Rahimi-Movaghar A, et al. Major anxiety disorders in Iran: prevalence, sociodemographic correlates and service utilization. BMC Psychiatry 2018; 18: 261.
5. Wittchen HU. Generalized anxiety disorder: prevalence, burden, and cost to society. Depress Anxiety 2002; 16: 162-71. 6. Dugas MJ, Dugas MJ, Robichaud M. Cognitivebehavioral treatment for generalized anxiety disorder: From science to practice. London, UK: Routledge; 2007.
7. Castillo RJ, Carlat DJ, Millon T, et al. Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association Press; 2007.
8. Marcks BA, Weisberg RB, Edelen MO, et al. The relationship between sleep disturbance and the course of anxiety disorders in primary care patients. Psychiatry Res 2010; 178: 487-92.
9. Belanger L, Morin CM, Langlois F, et al. Insomnia and generalized anxiety disorder: Effects of cognitive behavior therapy for gad on insomnia symptoms. J Anxiety Disord 2004; 18: 561-71.
10. Harvey AG. A cognitive model of insomnia. Behav Res Ther 2002; 40: 869-93.
11. Jansson M, Linton SJ. The development of insomnia within the first year: a focus on worry. Br J Health Psychol 2006; 11: 501-11.
12. Waters AM, Craske MG. Generalized anxiety disorder. In: Antony MM, Ledley DR, Heimberg RG, editors. Improving outcomes and preventing relapse in cognitive-behavioral therapy. New York, NY: Guilford Press; 2005. p. 77-127.
13. Butler AC, Chapman JE, Forman EM, et al. The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clin Psychol Rev 2006; 26: 17-31.
14. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res 2012; 36(5): 427-40.
15. McIntosh A, Cohen A, Turnbull N, et al. Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder. Sheffield, UK: University of Sheffield/London - National Collaborating Centre for Primary Care; 2004. p. 1-142.
16. Gelenberg AJ, Freeman MP, Markowitz JC, Rosenbaum JF, Thase ME, Trivedi MH, et al. Practice guideline for the treatment of patients with major depressive disorder third edition. Am J Psychiatry 2000; 157(4 Suppl): 1-45.
17. Covin R, Ouimet AJ, Seeds PM, et al. A metaanalysis of CBT for pathological worry among clients with GAD. J Anxiety Disord 2008; 22: 108-16.
18. McHugh RK, Murray HW, Barlow DH. Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behav Res Ther 2009; 47: 946-53.
19. Boisseau CL, Farchione TJ, Fairholme CP, et al. The development of the unified protocol for the transdiagnostic treatment of emotional disorders: A case study. Cogn Behav Pract 2010; 17: 102-13.
20. Abasi I, Fata L, Sadeghi M, et al. A comparison of transdiagnostic components in generalized anxiety disorder, unipolar mood disorder and nonclinical population. International Journal of Medical, Health, Biomedical, Bioengineering and Pharmaceutical Engineering 2013; 7: 803-11.
21. Newby JM, McKinnon A, Kuyken W, et al. Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clin Psychol Rev 2015; 40: 91-110.
22. Reinholt N, Krogh J. Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: a systematic review and meta-analysis of published outcome studies. Cogn Behav Ther 2014; 43: 171-84.
23. Pearl SB, Norton PJ. Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis. J Anxiety Disord 2017; 46: 11-24.
24. Wilamowska ZA, Thompson-Hollands J, Fairholme CP, et al. Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders. Depress Anxiety 2010; 27: 882-90. 25. de Ornelas Maia AC, 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.
26. Ellard KK, Bernstein EE, Hearing C, et al. Transdiagnostic treatment of bipolar disorder and comorbid anxiety using the Unified Protocol for Emotional Disorders: A pilot feasibility and acceptability trial. J Affect Disord 2017; 219: 209-21.
27. Sauer-Zavala S, Bentley KH, Wilner JG. Transdiagnostic treatment of borderline personality disorder and comorbid disorders: A clinical replication series. J Pers Disord 2016; 30: 35-51.
28. Ehrenreich JT, Goldstein CM, Wright LR, et al. Development of a unified protocol for the treatment of emotional disorders in youth. Child Fam Behav Ther 2009; 31: 20-37.
29. Maia AC, Braga AA, Nunes CA, et al. Transdiagnostic treatment using a unified protocol: Application for patients with a range of comorbid mood and anxiety disorders. Trends Psychiatry Psychother 2013; 35: 134-40.
30. Brown TA, Dinardo P, Barlow DH. Anxiety Disorders Interview Schedule Adult Version (ADISIV): Client interview schedules. Boulder, CO Graywind Publications; 1994.
31. Mohammadi A, Birashk B, Gharraee B. Comparison of the effect of group transdiagnostic treatment and group cognitive therapy on emotion regulation. Iran J Psychiatry Behav Sci 2014; 19: 187-94. [In Persian].
32. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006; 166: 1092-7.
33. Zargar F. Comparing the effectiveness of acceptance-based behavior therapy to applied relaxation on worry and generalized anxiety disorder symptoms. J Fundam Ment Health 2014; 17:26-30. [In Persian].
34. Brown TA, Antony MM, Barlow DH. Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behav Res Ther 1992; 30: 33-7.
35. Meyer TJ, Miller ML, Metzger RL, et al. Development and validation of the Penn State Worry Questionnaire. Behav Res Ther 1990; 28: 487-95.
36. Dehshiri GR, Golzari M, Borjali A, et al. Psychometrics particularity of Farsi Version of Pennsylvania State Worry Questionnaire for college students. Journal of Clinical Psychology 2010; 1: 67-75. [In Persian].
37. Mundt JC, Marks IM, Shear MK, et al. The Work and Social Adjustment Scale: A simple measure of impairment in functioning. Br J Psychiatry 2002; 180: 461-4.
38. Backhaus J, Junghanns K, Broocks A, et al. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosom Res 2002; 53: 737-40.
39. Buysse DJ, Reynolds CF 3rd, Monk TH, et al. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res 1989; 28: 193-213.
40. Ohayon M. Sleep disorders questionnaire and decision trees of the eval system. Quebec, Canada: Bibliotheque Nationale du Quebec; 1994.
41. Farrahi MJ, Nakhaee N, Sheibani V, et al. Reliability and validity of the Persian version of the Pittsburgh Sleep Quality Index (PSQI-P). Sleep Breath 2012; 16: 79-82.
42. Barlow DH, Farchione TJ, Sauer-Zavala S, et al. Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide (Treatments that work). 2nd ed. Oxford, UK: Oxford University Press; 2017.
43. Ito M, Okumura Y, Horikoshi 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: 71.
44. Norton PJ, Barrera TL. Transdiagnostic versus diagnosis-specific cbt for anxiety disorders: A preliminary randomized controlled noninferiority trial. Depress Anxiety 2012; 29: 874-82.
45. Barlow DH, Farchione TJ, Bullis JR, 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: 875-84.
46. Cuijpers P, Sijbrandij M, Koole S, et al. Psychological treatment of generalized anxiety disorder: A meta-analysis. Clin Psychol Rev 2014; 34: 130-40.
47. Beer JS, Lombardo MV. Insights into emotion regulation from neuropsychology. In: Gross JJ, editor. Handbook of emotion regulation. New York, NY: The Guilford Press; 2007. p. 69-86.
48. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clin Psychol Rev 2010; 30: 217-37.
49. Forsyth P, Barrios V, Acheson T. Exposure therapy and cognitive interventions for the anxiety disorders: Overview and newer third-generation perspectives. In: Richard DCS, Lauterbach D, editors. Handbook of exposure therapies. Burlington, MA: Academic Press; 2007. p. 61-108.
50. Gratz KL, Weiss NH, Tull MT. Examining emotion regulation as an outcome, mechanism, or target of psychological treatments. Curr Opin Psychol 2015; 3: 85-90.
51. Barlow DH. Clinical handbook of psychological disorders: A step-by-step treatment manual. 5th ed. New York, NY: Guilford Publications; 2014.
52. Gallagher MW, Sauer-Zavala SE, Boswell JF, et al. The impact of the unified protocol for emotional disorders on quality of life. Int J Cogn Ther 2013; 6: 1-16.
53. Sauer-Zavala S, Cassiello-Robbins C, Conklin LR, et al. Isolating the unique effects of the unified protocol treatment modules using single case experimental design. Behav Modif 2017; 41: 286-307.
54. Brake CA, Sauer-Zavala S, Boswell JF, et al. Mindfulness-based exposure strategies as a transdiagnostic mechanism of change: an exploratory alternating treatment design. Behav Ther 2016; 47: 225-38.
55. Craske MG, Barlow DH. Mastery of your anxiety and panic: Therapist guide. Oxford, UK: Oxford University Press; 2007.
56. Harvey AG, Murray G, Chandler RA, et al. Sleep disturbance as transdiagnostic: Consideration of neurobiological mechanisms. Clin Psychol Rev 2011; 31: 225-35.
57. Benca RM, Obermeyer WH, Thisted RA, et al. Sleep and psychiatric disorders. A meta-analysis. Arch
Gen Psychiatry 1992; 49: 651-68.
58. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep 2005; 28: 1049-57.
59. Belleville G, Cousineau H, Levrier K, et al. The impact of cognitive-behavior therapy for anxiety disorders on concomitant sleep disturbances: A metaanalysis. J Anxiety Disord 2010; 24: 379-86.
60. Dolsen MR, Asarnow LD, Harvey AG. Insomnia as a transdiagnostic process in psychiatric disorders. Curr Psychiatry Rep 2014; 16: 471.
61. Heidenreich T, Tuin I, Pflug B, et al. Mindfulness-based cognitive therapy for persistent insomnia: A pilot study. Psychother Psychosom 2006; 75: 188-9.
62. Ong JC, Shapiro SL, Manber R. Combining mindfulness meditation with cognitive-behavior therapy for insomnia: A treatment-development study. Behav Ther 2008; 39: 171-82.
63. Harvey AG. A transdiagnostic approach to treating sleep disturbance in psychiatric disorders. Cogn Behav Ther 2009; 38: 35-42.
64. Lund HG, Reider BD, Whiting AB, et al. Sleep patterns and predictors of disturbed sleep in a large population of college students. J Adolesc Health 2010; 46: 124-32.
65. Bartel KA, Gradisar M, Williamson P. Protective and risk factors for adolescent sleep: A metaanalytic review. Sleep Med Rev 2015; 21: 72-85.
66. Jansson-Frojmark M. The work and social adjustment scale as a measure of dysfunction in chronic insomnia: reliability and validity. Behav Cogn Psychother 2014; 42: 186-98.
How to Cite
Mohammadpour M, Bavafa A, Foroughi A, Pouyanfard S, Elahi A, Jaberghaderi N. Generalized Anxiety Disorder and Comorbid Symptoms of Sleep: The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. J Sleep Sci. 3(3-4):80-89.
Original Article(s)