Abstract
Background: Multiple sclerosis (MS) is a degenerative disease affecting the central nervous system, significantly impacting quality of life. Relapsing-remitting MS (RRMS) is the most common subtype and is often worsened by comorbidities such as obesity, which heighten symptoms and disability. Emotional regulation and eating behaviors are critical areas influencing the progression and management of RRMS.
Objective: evaluate the effectiveness of the Unified Protocol (UP), a transdiagnostic treatment, in improving psychological symptoms, emotional regulation, and eating behaviors in RRMS patients, particularly those with obesity or overweight issues.
Method: The sample included 7 RRMS patients who underwent 14 sessions of the UP. The UP aims to manage and prevent emotional symptoms by enhancing emotional regulation skills, crucial for reducing future psychological distress such as anxiety and depression. The intervention focused on disrupting the cycle of emotional eating and enhancing overall quality of life.
Results: Results showed improvements in emotional regulation and reductions in depression and anxiety. However, these effects diminished over time, with an increase in emotional eating, underscoring the need for continuous support and targeted strategies.
Conclusions: These findings highlight the potential of the UP in treating RRMS, emphasizing the importance of comprehensive, multidisciplinary approaches and further research into sustained and tailored treatments. This study is an extension of a wider RCT which has already been pre-registered [osf.io/sr4bx].
keywords: Multiple sclerosis, Emotional regulation, anxiety, depression.
References
Andrés, A., Oda-Montecinos, C., & Saldaña, C. (2017). Eating behaviors in a male and female community sample: psychometric properties of the DEBQ. Terapia , 35(2), 153-164. https://doi.org/10.4067/s0718-48082017000200141
Aoun, A., Ghoussoub, C., Farsoun, C., Al Mallah, A., Ayoub, F., Trezia, N., & Abi Karam, S. (2025). Examining the Efficacy of Mindfulness-Based Interventions in Treating Obesity, Obesity-Related Eating Disorders, and Diabetes Mellitus. Journal of the American Nutrition Association, 44(4), 292-305. https://doi.org/10.1080/27697061.2024.2428290
Barlow, D. H., Sauer-Zavala, S., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344–365. https://doi.org/10.1177/2167702613505532
Barlow, D.H., Farchione, T.J., Sauer-Zavala, S., Murray-Latin, H., Ellard, K.K., Bullis, J.R., Bentley, K.H., Boettcher, H.T., & Cassiello-Robbins, C. (2019). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide (2a ed.). Alianza Editorial.
Benbaibeche, H., Saidi, H., Bounihi, A., & Koceir, E. A. (2023). Emotional and external eating styles associated with obesity. Journal of eating disorders, 11(1), 67. https://doi.org/10.1186/s40337-023-00797-w
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
Blanca, M. J., Arnau, J., García-Castro, F. J., Alarcón, R., & Bono, R. (2023). Repeated measures ANOVA and adjusted F-tests when sphericity is violated: Which procedure is best? Frontiers in Psychology, 14. https://doi.org/10.3389/fpsyg.2023.1192453
Boeschoten, R. E., Braamse, A. M. J., Beekman, A. T. F., Cuijpers, P., van Oppen, P., Dekker, J., & Uitdehaag, B. M. J. (2017). Prevalence of depression and anxiety in Multiple Sclerosis: A systematic review and meta-analysis. Journal of the neurological sciences, 372, 331-341. https://doi.org/10.1016/j.jns.2016.11.067
Brooks, J., McCluskey, S., Turley, E., & King, N. (2015). The Utility of Template Analysis in Qualitative Psychology Research. Qualitative research in psychology, 12(2), 202–222. https://doi.org/10.1080/14780887.2014.955224
Brooks, R. (1996). EuroQol: the current state of play. Health Policy, 37(1), 53–72. https://doi.org/:10.1016/0168-8510(96)00822-6
Bullis, J. R., Boettcher, H., Sauer-Zavala, S., Farchione, T. J., & Barlow, D. H. (2019). What is an emotional disorder? A transdiagnostic mechanistic definition with implications for assessment, treatment, and prevention. Clinical Psychology: Science and Practice, 26(2), 1-19. https://doi.org/10.1111/cpsp.12278
Burckhardt, C. S., Woods, S. L., Schultz, A. A., & Ziebarth, D. M. (1989). Quality of life of adults with chronic illness: a psychometric study. Research in nursing & health, 12(6), 347–354. https://doi.org/10.1002/nur.4770120604
Cash, T. F. (1990). Multidimensional Body-Self Relations Questionnaire (MBSRQ, BSRQ) [Database record]. APA PsycTests. https://doi.org/10.1037/t08755-000
Ciampi, E., Soler, B., Uribe-San-Martin, R., Jürgensen, L., Guzman, I., Keller, K., Reyes, A., Bravo-Grau, S., Cruz, J., & Cárcamo, C. (2023). Socioeconomic, health-care access and clinical determinants of disease severity in Multiple Sclerosis in Chile. Multiple Sclerosis and Related Disorders, 78, 104918. https://doi.org/10.1016/j.msard.2023.104918
Cruzat-Mandich, C., Díaz-Castrillón, F., Pérez-Villalobos, C. E., Lizana, P., Moore, C., Simpson, S., & Oda-Montecinos, C. (2019). Factor structure and reliability of the Multidimensional Body-Self Relations Questionnaire in Chilean youth. Eating and weight disorders, 24(2), 339–350. https://doi.org/10.1007/s40519-017-0411-z
Dakanalis, A., Mentzelou, M., Papadopoulou, S. K., Papandreou, D., Spanoudaki, M., Vasios, G. K., Pavlidou, E., Mantzorou, M., & Giaginis, C. (2023). The Association of Emotional Eating with Overweight/Obesity, Depression, Anxiety/Stress, and Dietary Patterns: A Review of the Current Clinical Evidence. Nutrients, 15(5), 1173. https://doi.org/10.3390/nu15051173
Derogatis, L. R. (1994). SCL-90-R. Administration, Scoring and Procedures Manual (3a ed.). National Computer Systems.
Estrada, E., Ferrer, E., & Pardo, A. (2019). Statistics for Evaluating Pre-post Change: Relation Between Change in the Distribution Center and Change in the Individual Scores. Frontiers in Psychology, 9, 1-12. https://doi.org/10.3389/fpsyg.2018.02696
Ferrer, R., & Pardo, A. (2014). Clinically meaningful change: False positives in the estimation of individual change. Psychological Assessment, 26(2), 370–383. https://doi.org/10.1037/a0035419
Ferreres-Galán, V., Quilez-Orden, A. B., & Osma, J. (2022). Application of the unified protocol for transdiagnostic treatment of emotional disorders in post-bariatric surgery patients: an effectiveness and feasibility study in group format. Anales de Psicología/Annals of Psychology, 38(2), 219-231. https://doi.org/10.6018/analesps.482301
Field, A. (2013). Discovering statistics using IBM SPSS statistics. Sage.
Fiest, K., Walker, J., Bernstein, C., Graff, L., Zarychanski, R., Abou-Setta, A., Patten, S., Sareen, J., Bolton, J., Marriott, J., Fisk, J., Singer, A., & Marrie, R. (2016). Systematic review and meta-analysis of interventions for depression and anxiety in persons with multiple sclerosis. Multiple Sclerosis and Related Disorders, 5, 12-26. https://doi.org/10.1016/j.msard.2015.10.004
GBD 2016 Multiple Sclerosis Collaborators. (2019). Global, regional, and national burden of multiple sclerosis 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. Neurology, 18(3), 269–285. https://doi.org/10.1016/S1474-4422(18)30443-5
Gempp, R., & Avendaño, C. (2008). Datos Normativos y Propiedades Psicométricas del SCL-90-R en Estudiantes Universitarios Chilenos. Terapia psicológica, 26(1), 39-58. https://doi.org/10.4067/S0718-48082008000100004
Gil-González, I., Martín-Rodríguez, A., Conrad, R., & Pérez-San-Gregorio, M. Á. (2020). Quality of life in adults with multiple sclerosis: a systematic review. BMJ open, 10(11), e041249. https://doi.org/10.1136/bmjopen-2020-041249
Graphpad Software (2018). GraphPad Prism version 8.0.1 [Software de computador]. www.graphpad.com
Gratz, K., & 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. https://doi.org/10.1023/B:JOBA.0000007455.08539.94
Guevara, C., Villa, E., Rosas, C. S., Diaz, V., & Naves, R. (2020). Treating patients with multiple sclerosis during the COVID-19 pandemic: Assessing the expert recommendations. Multiple sclerosis and related disorders, 43, 102224. https://doi.org/10.1016/j.msard.2020.102224
Guzmán-González, M., Mendoza-Llanos, R., Garrido-Rojas, L., Barrientos, J., & Urzúa, A. (2020). Propuesta de valores de referencia para la Escala de Dificultades de Regulación Emocional (DERS-E) en población adulta chilena. Revista médica de Chile, 148(5), 644-652. https://doi.org/10.4067/S0034-98872020000500644
Habbestad, A., Willumsen, J. S., Aarseth, J. H., Grytten, N., Midgard, R., Wergeland, S., Myhr, K. M., & Torkildsen, O. (2024). Increasing age of multiple sclerosis onset from 1920 to 2022: a population-based study. Journal of neurology, 271(4), 1610–1617. https://doi.org/10.1007/s00415-023-12047-9
Kassambara, A. (2023, February 1). Pipe-Friendly Framework for Basic Statistical Tests [R package rstatix version 0.7.2]. https://bit.ly/4jAQuzr
Kavaliunas, A., Karrenbauer, V.D., Binzer, S., & Hillert, J. (2022). Systematic Review of the Socioeconomic Consequences in Patients With Multiple Sclerosis With Different Levels of Disability and Cognitive Function. Frontiers in Neurology, 12, 737211. https://doi.org/10.3389/fneur.2021.737211
Kurtzke J. F. (1983). Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology, 33(11), 1444–1452. https://doi.org/10.1212/wnl.33.11.1444
Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: development of a general scale. Evaluation and program planning, 2(3), 197–207. https://doi.org/10.1016/0149-7189(79)90094-6
Latorre-Román, P. A., Martínez-Amat, A., Martínez-López, E., Moral, A., Santos, M. A., & Hita-Contreras, F. (2014). Validation and psychometric properties of the Spanish version of the Quality of Life Scale (QOLS) in patients with fibromyalgia. Rheumatology international, 34(4), 543–549. https://doi.org/10.1007/s00296-013-2874-1
Lee, K. S., Feltner, F. J., Bailey, A. L., Lennie, T. A., Chung, M. L., Smalls, B. L., Schuman, D. L., & Moser, D. K. (2019). The relationship between psychological states and health perception in individuals at risk for cardiovascular disease. Psychology research and behavior management, 12, 317–324. https://doi.org/10.2147/PRBM.S198280
Longley, S. L., & Gleiser, T. S. (2023). Efficacy of the Unified Protocol: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology: Science and Practice, 30(2), 208–221. https://doi.org/10.1037/cps000014
Magyari, M., & Sorensen, P. S. (2020). Comorbidity in Multiple Sclerosis. Frontiers in neurology, 11, 851. https://doi.org/10.3389/fneur.2020.00851
Marrie, R., Horwitz, R., Cutter, G., Tyry, T., Campagnolo, D., & Vollmer, T. (2009). High frequency of adverse health behaviors in multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England), 15(1), 105–113. https://doi.org/10.1177/1352458508096680
Mikula, P., Timkova, V., Fedicova, M., Szilasiova, J., & Nagyova, I. (2021). Self-management, self-esteem and their associations with psychological well-being in people with multiple sclerosis. Multiple sclerosis and related disorders, 53, 103069. https://doi.org/10.1016/j.msard.2021.103069
Momenabadi, V., Kaveh, M. H., Nakhaee, N., Karimzadeh Shirazi, K., Sedighi, B., & Tabatabaei, S. H. R. (2020). Health Promoting Self-care Behaviors in Patients With Multiple Sclerosis in the Southeast of Iran: Developing a Model for Practice. Basic and clinical neuroscience, 11(5), 687–699. https://doi.org/10.32598/bcn.11.5.1670.1
Nazari, N., Aligholipour, A. & Sadeghi, M. (2020). Transdiagnostic treatment of emotional disorders for women with multiple sclerosis: a randomized controlled trial. BMC Women's Health, 20. https://doi.org/10.1186/s12905-020-01109-z
Norman, S. B., Cissell, S. H., Means-Christensen, A. J. & Stein, M. B. (2006). Development and validation of an overall severity and impairment scale (OASIS). Depression and Anxiety, 23, 245-249. https://doi.org/10.1002/da.20182
Osma, J. & Farchione, J. T. (2023). Applications of the unified protocol in health conditions. Oxford University Press. https://doi.org/10.1093/oso/9780197564295.001.0001
Osma, J., Martínez-Loredo, V., Quilez-Orden, A., Peris-Baquero, Ó., & Suso-Ribera, C. (2021). Validity Evidence of the Multidimensional Emotional Disorders Inventory among Non-Clinical Spanish University Students. International journal of environmental research and public health, 18(16), 8251. https://doi.org/10.3390/ijerph18168251
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, 9–18. https://doi.org/10.1016/j.jad.2019.03.063
Payne, R. W., & Jones, H. G. (1957). Statistics for the investigation of individual cases. Journal of Clinical Psychology, 13(2), 115–121. https://doi.org/bznw9v
R Core Team. (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/
Retamal-Matus, H., Fernández-Calderón, R., Fernández-Elgueta, A., Martínez-Alarcón, C., & Montaña-Yañez, G. (2020). Calidad de vida relacionada a la salud de las personas con esclerosis múltiple en la Región de Magallanes, Chile. Revista Chilena De Salud Pública, 23(2), p. 97–104. https://doi.org/10.5354/0719-5281.2019.56345
Revelle, W. (2022). Psych: Procedures for Psychological, Psychometric, and Personality Research. Northwestern University, Evanston, Illinois. R package version 2.2.9. https://CRAN.R-project.org/package=psych
Rojas-Barahona, C. A., Zegers, B., & Förster, C. E. (2009). La escala de autoestima de Rosenberg: Validación para Chile en una muestra de jóvenes adultos, adultos y adultos mayores. Revista médica de Chile, 137(6), 791-800. https://doi.org/10.4067/S0034-98872009000600009
Rosellini, A. J., & Brown, T. A. (2019). The multidimensional emotional disorder inventory (MEDI): Assessing transdiagnostic dimensions to validate a profile approach to emotional disorder classification. Psychological Assessment, 31(1), 59-72. https://doi.org/10.1037/pas0000649
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton University Press. https://doi.org/10.1515/9781400876136
Russell, R. D., Langer-Gould, A., Gonzales, E. G., Smith, J. B., Brennan, V., Pereira, G., Lucas, R. M., Begley, A., & Black, L. J. (2020). Obesity, dieting, and multiple sclerosis. Multiple sclerosis and related disorders, 39, 101889. https://doi.org/10.1016/j.msard.2019.101889
Superintendence of Health. (2005). Calidad de Vida Relacionada a la Salud en Población General de Chile [Biblioteca digital]. Superintendencia de Salud. Gobierno de Chile. Recuperado el 15 de noviembre de 2017, de http://www.supersalud.gob.cl/documentacion/666/w3-article-3818.html.
Tettey, P., Simpson, S., Jr, Taylor, B., Blizzard, L., Ponsonby, A. L., Dwyer, T., Kostner, K., & van der Mei, I. (2014). An adverse lipid profile is associated with disability and progression in disability, in people with MS. Multiple sclerosis (Houndmills, Basingstoke, England), 20(13), 1737–1744. https://doi.org/10.1177/1352458514533162
Thompson, AJ., Baranzini, S.E., Geurts, J., Hemmer, B., & Ciccarelli, O. (2018). Multiple sclerosis. The Lancet, 39, 1622-1636. https://doi.org/10.1016/S0140-6736(18)30481-1
Uanhoro, J. O. (2017). Effect size calculators. https://effect-size-calculator.herokuapp.com/
Van Strien, T., Frijters, J. E. R., Bergers, G. P. A., & Defares, P. B. (1986). The Dutch Eating Behavior Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior. International Journal of Eating Disorders, 5(2), 295–315. https://doi.org/b23rfz
Warren, J., Smith, N., & Ashwell, M. (2017). A structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviours: Effectiveness and associated potential mechanisms. Nutrition Research Reviews, 30(2), 272-283. https://doi.org/10.1017/S0954422417000154
Walton, C., King, R., Rechtman, L., Kaye, W., Leray, E., Marrie, R. A., Robertson, N., La Rocca, N., Uitdehaag, B., van der Mei, I., Wallin, M., Helme, A., Napier, C.A., Rijke, N., & Baneke, P. (2020). Rising prevalence of multiple sclerosis worldwide: Insights from the Atlas of MS, third edition. Multiple Sclerosis Journal, 26(14), 1816–1821. https://doi.org/10.1177/1352458520970841
