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A 30-month follow-up of generalized anxiety disorder: Status after metacognitive therapy and intolerance of uncertainty-therapy



Objectives: Although metacognitive therapy and intolerance-of-uncertainty therapy are considered efficacious treatments for generalized anxiety disorder, little is known about the long-term course in patients who engaged in treatment studies. Method: We conducted a continuation study of patients with GAD who had participated in a randomized, delayed treatment controlled trial in which the relative efficacy of MCT and IUT were compared.Results: Of the original 85 patients who completed the study, 34 were available for assessment of worry severity at 30-month follow-up. Both treatment groups showed maintenance of treatment gains from 6-month to 30-month follow-up assesment. However, MCT produced better results at long-term follow-up, which was reflected in statistically and clinically significant differences, and in terms of sustained efficacy (i.e., the degree in which patients who improved with treatment remained improved).Conclusion: Both MCT and IUT may be associated with long-term benefits for patients diagnosed with GAD, with MCT performing significantly better than IUT, and showing greater sustained efficacy.
European Journal for Person Centered Healthcare Vol 2 Issue 4 pp 434-438
A 30-month follow-up of generalized anxiety disorder: Status
after metacognitive therapy and intolerance of uncertainty-
Colin van der Heiden PhDa and Kim Melchior MScb
a Psychotherapist, Department of Anxiety Disorders and Head of Department of Research and Development of PsyQ,
Rotterdam, The Netherlands
b Cognitive-behavioural Therapist, Department of Anxiety Disorders and Researcher, Department of Research and
Development, PsyQ, Rotterdam, The Netherlands
Objectives: Although metacognitive therapy and intolerance-of-uncertainty therapy are considered efficacious treatments
for generalized anxiety disorder, little is known about the long-term course in patients who engaged in treatment studies.
Method: We conducted a continuation study of patients with GAD who had participated in a randomized, delayed treatment
controlled trial in which the relative efficacy of MCT and IUT were compared.
Results: Of the original 85 patients who completed the study, 34 were available for assessment of worry severity at 30-
month follow-up. Both treatment groups showed maintenance of treatment gains from 6-month to 30-month follow-up
assessment. However, MCT produced better results at long-term follow-up, which was reflected in statistically and
clinically significant differences and in terms of sustained efficacy (i.e., the degree in which patients who improved with
treatment remained improved).
Conclusion: Both MCT and IUT may be associated with long-term benefits for patients diagnosed with GAD, with MCT
performing significantly better than IUT and showing greater sustained efficacy. The study is advanced as an important
contribution to the person-centered healthcare literature.
Generalized anxiety disorder, intolerance-of-uncertainty therapy, long-term follow-up, metacognitive therapy, person-
centered healthcare, sustained efficacy
Correspondence address
Dr. Colin van der Heiden, PsyQ, Max Euwelaan 70, 3062 MA Rotterdam, The Netherlands.
Accepted for publication: 27 November 2013
Generalized anxiety disorder (GAD) is characterized by
excessive anxiety and uncontrollable worry about a
number of events or activities for at least 6 months [1]. If
left untreated, the prognosis of GAD is poor [2]. However,
even after cognitive-behavioral therapy (CBT), the
treatment which is currently considered the psychological
treatment of choice for GAD, only about 40% of treatment
completers meet the criteria for recovery [3]. In an attempt
to further improve person-centered therapy for GAD, our
group published a randomized, delayed-treatment
controlled study comparing metacognitive therapy (MCT)
[4] and intolerance of uncertainty-therapy (IUT) [5], two
forms of cognitive-behavioral therapy based on GAD-
specific theoretical models.
MCT focuses on modification of the metacognitive
factors that contribute to the development and persistence
of GAD, including negative beliefs about the
uncontrollability and dangerousness of worry, positive
beliefs related to the patient’s reliance on worry as a
coping strategy and ineffective attempts to avoid worry
and to control thoughts. IUT is based on the idea that
patients with GAD become distressed and upset when
confronted with uncertain or ambiguous situations and
experience persistent worry in response to such events.
Treatment therefore focuses on decreasing anxiety and the
tendency to worry by promoting an increased tolerance of
uncertainty. The study design and treatment programs are
described in detail elsewhere [6]. Both treatments were
highly effective in reducing GAD-specific and general
psychopathology, with large effect sizes (ranging between
0.94 and 2.39) and high proportions of clinically
significant change (ranging between 77% and 95%).
Treatment gains were maintained at 6-month follow-up.
However, analyses showed that MCT produced
significantly better effects on almost all outcome measures
than IUT at both the post-treatment and 6-month follow-up
European Journal for Person Centered Healthcare
assessments and in terms of the degree of clinical response
and recovery. The fact that MCT produced better effects
than IUT was also reflected in the between-group effect
sizes (most medium) on all outcome measures. These
findings extended results of other studies into the efficacy
of MCT and IUT for GAD, all of which achieved quite
favorable results [7-11]. However, little is known about the
longer-term durability of these treatments for GAD. This
continuation study of a published randomized controlled
trial [6] aimed to assess the 30-month follow-up results of
both treatments. In particular, we were interested in the
stability of treatment effects, that is, on how likely patients
who improved in the original study were to remain
improved (so called sustained efficacy) [12].
Thus, we focus not only on the percentage improved,
but also on the percentage of patients that remained
reliably improved and recovered in the 2-year period after
the 6-month follow-up assessment in the original study.
This distinction is crucial, as the latter does not capitalize
on chance factors and naturally occurring symptom
fluctuation, whereas the former does.
Procedure and patients
This long-term follow-up study was based at PsyQ, an
adult outpatient mental healthcare centre in The
Netherlands. All 85 patients with complete 6-month
follow-up data (MCT: 43; IUT: 42) were contacted
approximately 30 months after they were discharged from
treatment in the original trial. A standardized letter was
sent to their last known address, informing them about the
design and procedure of this continuation study, with the
request to send back the included informed consent
statement. In the case of participation, they were asked to
fill in and return the PSWQ, which was also included.
Thirty-four patients (40%) completed 30-month
follow-ups and 51 (60%) were lost through attrition. The
follow-up sample consisted of 6 men and 28 women with a
mean age of 36.5 years (SD: 13.0; range 19-65); 20
subjects had received MCT in the original trial and 14 had
received IUT.
Outcome measure
The Penn State Worry Questionnaire (PSWQ) [13] was
used as outcome measure. This widely used self-report
measure assesses the intensity, excessiveness and
uncontrollability of worry, the key figure of GAD. It
consists of 16 items that have to be rated on a 5-point
Likert scale, ranging from 1 (“not at all typical of me”) to 5
(“very typical of me”). Total scores on the PSWQ range
from 16 to 80, with higher scores representing a stronger
tendency to worry. Psychometric properties of both the
original English version and the Dutch translation are good
Statistical analysis
Data were analyzed using SPSS for Windows 20. All
analyses were run with completers only [15,16], as
intention-to-treat analyses with the last observation carried
forward assume that patients who did not attend the
follow-up assessments did not retoriate or relapse. In view
of the large number of patients who were unavailable at
follow-up, or who failed to respond to a postal invitation to
take part, differences between the 34 participants traced
and the remaining 51 untraced participants were assessed
by conducting between-group comparisons of baseline
clinical and demographic variables by means of chi-square
tests for dichotomous variables and one-way ANOVAs for
continuous variables. Full details of these comparisons are
available upon request. In summary, there were no
significant differences between follow-up participants and
non-participants with respect to the variables of age,
gender and presence of comorbid diagnosis at the time of
the original trial. The same was true for both original and
post-treatment worry severity (as measured with the Penn
State Worry Questionnaire [PSWQ]) and for gain scores
(i.e., post-treatment minus pre-treatment scores). As such,
we conclude that the traced sample was equivalent to the
untraced group on these demographic and clinical
variables. Follow-up participants in the IUT-condition,
however, had significantly higher pre-treatment
(participants: M = 69.0, SD = 10.59; non-participants: M =
65.89, SD = 7.42; d = 0.37) and post-treatment
(participants: M = 55.4, SD = 12.35; non-participants: M =
52.00, SD = 9.04; d = 0.34) scores on the PSWQ.
To determine if treatment gains were maintained or
improved upon in the follow-up period, matched pairs t-
tests compared 6-month and 30-month follow-up scores. In
order to assess the relative effects of treatments at 30-
month follow-up, a one-way ANCOVA with the pre-
treatment score as covariate was used. Further, Cohen’s d
statistic (M1 M2 / pooled SD) [17] was employed to
calculate within-group effect sizes for changes on outcome
measures and to evaluate between-group differences, using
the mean scores of 30-month follow-up minus pre-
treatment scores divided by the pooled standard deviation.
Moreover, the clinical significance of treatment effects
were examined using the criteria as defined by Jacobson
and Truax [18]. According to these criteria, patients are
recovered as they achieve a score on an outcome measure
below a cut-off point representative of normal functioning,
together with statistically reliable improvement on that
measure. Patients were classified as clinical responders if
they met the criterion of reliable change, but scored not
within the normative range. Here, we used the criteria for
the PSWQ as calculated in the original trial (cut-off point ≤
53; reliable change index ≥ 7).
van der Heiden and Melchior
Long-term follow-up treatment of GAD
Table 1 Mean scores (standard deviations) on the PSWQ for each treatment condition as obtained
during the pre-treatment, post-treatment and follow-up assessments
6-month follow-up
30-month follow-up
MCT (n = 20)
67.60 (8.02)
44.70 (12.72)
45.85 (12.72)
45.35 (10.65)
IUT (n = 14)
69.00 (10.59)
55.43 (12.35)
49.38 (14.51)
55.79 (11.46)
Notes: MCT = metacognitive therapy; IUT = intolerance-of-uncertainty therapy; PSWQ = Penn State Worry Questionnaire.
Table 2 Percentages of patients meeting criteria for clinical response and recovery on the PSWQ at
6- and 30-month follow-up assessments
6-month follow-up
30-month follow-up
Status maintained
Status achieved
Overall rate
Reliable change
Reliable change
Table 1 displays PSWQ scores for the follow-up sample at
pre- and post-treatment and both follow-up assessments for
each treatment group. A comparison of 6-month follow-up
scores and 30-month follow-up scores did not reveal
significant changes on the PSWQ for both treatments
[MCT: t(19) = 0.24, ns; IUT: t(13) = -1.42, ns], indicating
that treatment gains were maintained over the follow-up
period. However, a one-way ANCOVA with pre-treatment
scores as covariate revealed that MCT yielded a
significantly better effect than IUT on the PSWQ at 30-
month follow-up assessment [F(1,33) = 7.75, p < 0.05].
Also, at 30-month follow-up, within-group effect sizes
were large for both treatments (MCT: d = 2.36; IUT: d =
1.20), whereas the between-group ES on the PSWQ (d =
1.16) was also large.
Table 2 shows the actual number and proportion of 30-
month follow-up participants who achieved or maintained
clinical response and recovery on the PSWQ. As can be
seen, all patients in the MCT-condition who had achieved
recovery on the PSWQ at 6-month follow-up (70%), had
maintained their recovery at 30-month follow-up. In
addition, of those not recovered at 6-month follow-up, one
patiënt had achieved recovery at 30-month follow-up,
making the overall recovery rate as high as 75%. In the
IUT-condition, half of the patients had achieved recovery
at both follow-up assessments. Interestingly, only 5 of the
7 patients maintained recovery from 6-month to 30-month
follow-up, but 2 other patients achieved recovery status in
the interim period (1 patient who already met criteria for
clinical response and 1 patient who had not made a reliable
change at 6-month follow-up). In addition, of the
participants who did not meet criteria for recovery at 6-
month follow-up, 1 patient in the MCT-condition had
achieved recovery at 30-month follow-up in the interim
period and 3 had maintained their status of clinical
responder. However, 1 patient did no longer meet criteria
for reliable change, giving an overall response rate at 30-
month follow-up of 90%. In the IUT-condition, 1 clinical
responder had achieved recovery and 1 patient had
maintained clinical responder status. Further, 2 non-
responders at 6-month follow-up had achieved clinical
response in the interim period, but 2 clinical responders did
no longer meet criteria for reliable change. As such, the
overall response rate in the IUT-condition at 30-month
follow-up was 86%.
At both assessment points, clinical responder and
recovery rates were higher for MCT than IUT (6-month
follow-up: clinical responder: 95% vs. 79; recovered: 70%
vs. 50%; 30-month follow-up: clinical responder: 90% vs.
86%; recovered: 75% vs. 50%), although none of these
differences proved to be significant (all χ2 2.25, ps >
0.05). With respect to sustained efficacy, proportions were
also higher for MCT. In the MCT-condition, 89% (17 out
of 19) of the patients maintained their improved status
from 6-month to long-term follow-up, whereas in the IUT-
condition only 55% (6 out of 11) maintained their
improved status.
This is the first naturalistic study to examine the long-term
maintenance of treatment gains of MCT and IUT for GAD.
Results indicated that in both conditions treatment gains on
a worry measure were maintained in the interim period
from 6-month to 30-months follow-up, with MCT
producing a significantly better outcome than IUT at long-
term follow-up assessment. The superiority of MCT over
IUT was substantiated by the large between-group effect
size (d = 1.16) and the higher recovery rate (75% vs. 50%).
European Journal for Person Centered Healthcare
Most importantly, the percentages of patients that
remained improved suggest that MCT has the ability to
produce lasting changes in worrying, whereas the
treatment effects of IUT seem less stable. Although the
clinical responder rate in the IUT-condition at 30-month
follow-up was 86% (which was even higher than at 6-
month follow-up), only 55% of the patients had remained
their improved status. This indicates that the high
percentage of clinical response might in part be the result
of naturally occurring symptom fluctuation (i.e., treatment
failures can appear to become treatment successes over
time due to natural remission or fluctuations in worrying
over the 30-month period) [12].
This study has several limitations. First, it must be
acknowledged that our relatively low contact rate (40% of
patients who completed the original study) opens up the
possibility that the follow-up sample may not be
representative of the original one. An analysis of relevant
demographic and clinical variables revealed no bias
between participants and non-participants in this
continuation study, although we did find that participants
in the IUT-condition had significantly higher pre-treatment
and post-treatment scores on the PSWQ than untraced
participants in this condition. The results may, therefore,
present a more negative picture of outcome in the IUT-
condition than is actually the case. Second, although
participants did not receive treatment in the 6-month
follow-up period in the original study, we did not obtain
data on the number of individuals who engaged in
treatment during the interim period from 6- to 30-months
follow-up. Therefore, we do not know whether other
treatments contributed to the maintenance of gains. As
such, it is possible that the long-term benefits attained by
both treatments are not a result of the unique and long-
lasting curative effect of MCT and IUT, but should be
attributed to other treatments participants may have
obtained since the study. Although the high response rates
at 6-month follow-up might suggest that there was no need
for further treatment in the interim period, future studies
would benefit from assessing the initiation, termination, or
change of any form of treatment utilized by participants
since post-treatment. Third, we used only one outcome
measure. Although worrying is considered the key feature
of GAD, it would be preferable to also include a measure
of anxiety, a second central symptom of GAD.
Despite these limitations, we believe that this study
represents the first demonstration that both MCT and IUT
may be associated with long-term benefits for patients
diagnosed with GAD, with MCT performing significantly
better than IUT and showing greater sustained efficacy. As
such, we advance our study as an important contribution to
the person-centered healthcare literature.
Acknowledgements and Conflicts of
We would like to thank Noor van Wijk and Lucas
Roelandt for their help in collecting the data for this study.
We declare no conflicts of interest.
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... However, we do not know much about the stability of therapeutic gains. Two recent studies have indicated stability effects of MCT in GAD and PTSD, but not in depression [21,22]. One study reported maintenance of treatment effects from 6 months to 30 months follow up on worry assessment in patients with generalized anxiety disorder (GAD) [21]. ...
... Two recent studies have indicated stability effects of MCT in GAD and PTSD, but not in depression [21,22]. One study reported maintenance of treatment effects from 6 months to 30 months follow up on worry assessment in patients with generalized anxiety disorder (GAD) [21]. Given the chronic and recurrent nature of MDD there is a need to investigate the longer term effectiveness of treatment. ...
... This study is the first one that aims to examine the long term stability of group MCT effects in the treatment of MDD. In view of the mechanisms of action of MCT and based on the results of recent follow up studies on MCT in GAD (and PTSD) [21,22] we expected that the therapeutic gains would be stable over a period of one to two years. ...
Objective: Preliminary data support the implementation of individual metacognitive therapy (MCT) for depression and recently published data indicate that group MCT in the treatment of depression is effective and well-accepted. This study examined 12 and 24 months follow up of patients treated with group MCT. We conducted a one and two year follow-up of an open trial of group MCT. Method: Ten patients who were consecutively referred by general practitioners to a specialist psychiatric practice in Norway participated in an open trial of the effects and feasibility associated with group MCT for depression. All of the patients met the DSM-IV criteria for major depressive disorder (MDD) and were followed up for 6 months, one and two year. The primary symptom outcome measure was severity of depression whilst secondary outcome measures included levels of anxiety, rumination, and metacognitive beliefs. We also assessed recovery rates and changes in comorbid Axis I and Axis II diagnoses at one and two year follow up. Result: Large clinically significant improvements across all measures that were detected at post-treatment were maintained at one year and two year follow up. Based on objectively defined recovery criteria, 70% of the patients were classified as recovered at 1 year and 80% at 2 year follow up. Conclusion: These preliminary data indicate that group MCT in the treatment of depression had sustained efficacy after one and two years, beyond what has been typically reported for cognitive behavioral therapy (CBT).
... Metacognitive therapy (MCT) modifies the processes and beliefs that maintain distress using a range of well-specified strategies and techniques (see [28] for treatment manual). In mental health settings, MCT for depression and anxiety disorders has been evaluated in case series, as well as in uncontrolled and controlled trials [29][30][31][32][33][34][35]. A recent meta-analysis found MCT to be highly effective in treating depression and anxiety disorders. ...
... Given the limitations of existing CR services and treatment options, there is an urgent need for new, effective psychological interventions for depression and anxiety to be integrated into the CR pathway in order to improve clinical outcomes. MCT [28] has been empirically tested in mental health settings through case series and uncontrolled and controlled trials [29][30][31][32][33][34][35][36], where it has consistently demonstrated large post-treatment reductions in depression and anxiety and high recovery rates. The PATHWAY Group-MCT trial will establish the effectiveness of Group-MCT in alleviating anxiety and depression in CR patients. ...
Full-text available
Background: Anxiety and depression are prevalent among cardiac rehabilitation patients but pharmacological and psychological treatments have limited effectiveness in this group. Furthermore, psychological interventions have not been systematically integrated into cardiac rehabilitation services despite being a strategic priority for the UK National Health Service. A promising new treatment, metacognitive therapy, may be well-suited to the needs of cardiac rehabilitation patients and has the potential to improve outcomes. It is based on the metacognitive model, which proposes that a thinking style dominated by rumination, worry and threat monitoring maintains emotional distress. Metacognitive therapy is highly effective at reducing this thinking style and alleviating anxiety and depression in mental health settings. This trial aims to evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy for cardiac rehabilitation patients with elevated anxiety and/or depressive symptoms. Methods/design: The PATHWAY Group-MCT trial is a multicentre, two-arm, single-blind, randomised controlled trial comparing the clinical- and cost-effectiveness of group-based metacognitive therapy plus usual cardiac rehabilitation to usual cardiac rehabilitation alone. Cardiac rehabilitation patients (target sample n = 332) with elevated anxiety and/or depressive symptoms will be recruited across five UK National Health Service Trusts. Participants randomised to the intervention arm will receive six weekly sessions of group-based metacognitive therapy delivered by either cardiac rehabilitation professionals or research nurses. The intervention and control groups will both be offered the usual cardiac rehabilitation programme within their Trust. The primary outcome is severity of anxiety and depressive symptoms at 4-month follow-up measured by the Hospital Anxiety and Depression Scale total score. Secondary outcomes are severity of anxiety/depression at 12-month follow-up, health-related quality of life, severity of post-traumatic stress symptoms and strength of metacognitive beliefs at 4- and 12-month follow-up. Qualitative interviews will help to develop an account of barriers and enablers to the effectiveness of the intervention. Discussion: This trial will evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy in alleviating anxiety and depression in cardiac rehabilitation patients. The therapy, if effective, offers the potential to improve psychological wellbeing and quality of life in this large group of patients. Trial registration: UK Clinical Trials Gateway, ISRCTN74643496 , Registered on 8 April 2015.
... Frafallsprosenten for MCT-gruppene ved siste oppfølgingsmåletid i studiene varierte fra 0 % til 40 %. van derHeiden & Melchior (2014)sin 30-måneders oppfølgingsstudie hadde for øvrig en frafallsprosent på 67.2 % i MCT-gruppen da kun 20 av totalt 61 pasienter ble målt i 30-måneders oppfølgingsstudien. Ved eksklusjon av denne oppfølgingsstudien på grunn av høy frafallsprosent, blir et utregnet gjennomsnitt av frafallsprosenten for MCT-gruppen fra pre-måling til siste oppfølgingsmåletid 21.1 % og 16.1 % ved post-behandling. ...
Full-text available
Tilbakefall blant angstlidelser og depressiv lidelse har gjennom flere meta-analyser vist seg å være vanlig. Samtidig har langtidseffekten av psykoterapi i for liten grad blitt undersøkt. Denne systematiske litteraturgjennomgangen sammenlignet langtidseffekten av metakognitiv terapi (MCT) med andre behandlingsmetoder for angstlidelser og depressiv lidelse. Langtidseffekten ble definert som minimum seks måneder. Aktuelle studier ble søkt etter i databasene PsycInfo, PubMed, Web of Science og Cochrane Library, noe som genererte seks studier. Resultatene viste at MCT hadde bedre langtidseffekt for generalisert angstlidelse (GAD) sammenlignet med andre behandlingsmetoder. For depressiv lidelse ble det ikke funnet forskjeller, mens MCT i komorbide utvalg viste større effekt sammenlignet med andre behandlingsmetoder ved post-behandling, men ikke ved oppfølging. Samlet sett viser MCT rask og relativt stabil effekt for angstlidelser og depressiv lidelse og bedre langtidseffekt for GAD, mens andre behandlingsmetoder viser økt effekt fra post-behandling til oppfølging i komorbide utvalg. Imidlertid er det begrenset med kunnskap om hvordan effekten i MCT og kontrollgruppene oppstår og forløper over tid, hvor det er behov for flere studier som inkluderer mediator- og moderatoranalyser. Implikasjonene av funnene fra litteraturgjennomgangen blir diskutert.
... The mean length of the included follow-up periods was 8.2 months from post-treatment (standard deviation 5.9, range 3-24 months). As displayed in Figure 1, we excluded one publication (van der Heiden and Melchior, 2014), which was a 30-month follow-up of an included trial (van der Heiden et al., 2012), as the publication reported on 34 out of the original 126 participants. We further chose not to include the follow-up data in another study (van der Heiden et al., 2013), as the authors had not included the data in their primary analysis due to a large dropout rate. ...
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Background Metacognitive therapy (MCT) continues to gain increased ground as a treatment for psychological complaints. During the last years, several clinical trials on the efficacy of MCT have been published. The aim of the current study was to provide an updated meta-analytic review of the effect of MCT for psychological complaints. Methods We conducted a systematic search of trials on MCT for young and adult patients with psychological complaints published until January 2018, using PsycINFO, PubMed, the Cochrane Library, and Google Scholar. Trials with a minimum of 10 participants in the MCT condition were included. Results A total of 25 studies that examined a variety of psychological complaints met our inclusion criteria, of which 15 were randomized controlled trials. We identified only one trial that was conducted with children and adolescents. In trials with adult patients, large uncontrolled effect size estimates from pre- to posttreatment and follow-up suggest that MCT is effective at reducing symptoms of the targeted primary complaint, anxiety, depression, and dysfunctional metacognitions. The comparison with waitlist control conditions also resulted in a large effect (Hedges’ g = 2.06). The comparison of MCT to cognitive and behavioral interventions at posttreatment and at follow-up showed pooled effect sizes (Hedges’ g) of 0.69 and 0.37 at posttreatment (k = 8) and follow-up (k = 7), respectively. Conclusions Our findings indicate that MCT is an effective treatment for a range of psychological complaints. To date, strongest evidence exists for anxiety and depression. Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions. However, more trials with larger number of participants are needed in order to draw firm conclusions.
... MCT has been shown to be superior to cognitive and behaviour therapies in the treatment of generalised anxiety disorder, with superior gains maintained over follow-up periods of 12-30 months (20). Furthermore, MCT can be effectively used in group treatment formats (21). ...
Conference Paper
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A. Wells, 2015 " …….Metacognition is that part of cognition that is responsible for monitoring, controlling and appraising thinking, learning and memory. It is cognition applied to cognition. So we can usefully divide thinking into two levels; a level of cognition and a level of metacognition that monitors and controls it. I believe this distinction, which is well known in cognitive and educational psychology, is important in understanding and developing more effective treatments of psychological disorder. Why should this be so? If we assume that thinking can be usefully divided into two meaningful levels, as exemplified in the model of Nelson and Narens, in which the meta-level regulates the cognitive level, then the biases and disturbances in thinking that are core features of psychological disorder probably result from metacognition. More specifically, in earlier work I have proposed that most psychological disorders are the result of repetitive negative self-focused thinking (worry and rumination) and this must be regulated by metacognition. One of the common factors in distress is the occurrence of difficult to control repetitive and negative thoughts or memories. Cognitive-behaviour therapy places the content of these thoughts in centre stage and aims to challenge the validity of them or use exposure methods to extinguish anxiety responses. In contrast, the metacognitive approach does not consider the content of thoughts or memories to cause disorder. It is not a given that the person who thinks or believes that they are " a failure " develops social anxiety or depression. Instead it is the person's reaction to these inner events (controlled by metacognition) that counts. Back in the early 1990's a colleague (Gerald Matthews) and I published the Self-Regulatory Executive Function (S-REF) model of psychological disorder (1, 2). Our research up to that point had led us to discover that psychological disorder was associated with a common set of cognitive and attentional responses. We proposed that all disorders are linked to the activation of an unhelpful pattern of thinking that we named the Cognitive Attentional Syndrome (CAS). This consists of repetitive thinking in the form of worry and rumination, focusing attention on potential sources of threat, coping behaviours such as trying to suppress thoughts/memories and avoidance. Crucially, the CAS is a form of self-regulation or coping but it backfires and has negative effects. Central to our model was the idea that those people that activate this thinking pattern in response to negative thoughts and experiences create escalating and prolonged distress (anxiety/depression).
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Objective Metacognitive therapy (MCT) and cognitive–behavior therapy (CBT) are effective treatments for generalized anxiety disorder. In this study, we followed-up patients who had previously participated in a randomized controlled trial of MCT compared against CBT. Method We collected 9-year follow-up data on 39 out of 60 original patients (i.e., 65% response rate). Results At 9 years, the recovery rates were 57% for MCT and 38% for CBT (completer analysis). Following MCT, 43% maintained their recovery status and a further 14% achieved recovery. Following CBT, the sustained recovery rate was 13%, while a further 25% achieved recovery. Patients in the MCT condition showed significantly more improvement with respect to symptoms of worry and anxiety. In the CBT group, 23.1% were re-diagnosed with generalized anxiety disorder (GAD) compared with 9.5% in the MCT group. Conclusions This follow-up study showed a continuation of gains in both treatments at long-term follow-up, but with outcomes continuing to favor MCT and strengthening its comparative superiority.
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Repetitive negative thinking (RNT) is a transdiagnostic process that serves to maintain emotional disorders. Metacognitive theory suggests that positive and negative metacognitive beliefs guide the selection of RNT as a coping strategy which, in turn, increases psychological distress. The aim of this study was to test the indirect effect of metacognitive beliefs on psychological distress via RNT. Patients (N=52) with primary and non-primary generalized anxiety disorder attended a brief, six-week group metacognitive therapy program and completed measures of metacognitive beliefs, RNT, and symptoms at the first and final treatment sessions, and at a one-month follow-up. Prospective indirect effects models found that negative metacognitive beliefs (but not positive metacognitive beliefs) had a significant indirect effect on psychological distress via RNT. As predicted by metacognitive theory, targeting negative metacognitions in treatment appears to reduce RNT and, in turn, emotional distress. Further research using alternative measures at multiple time points during therapy is required to determine whether the absence of a relationship with positive metacognitive beliefs in this study was a consequence of (a) psychometric issues, (b) these beliefs only being relevant to a subgroup of patients, or (c) a lack of awareness early in treatment. Copyright © 2015 Elsevier Ltd. All rights reserved.
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This commentary evaluates the accomplishments of research on metacognitive therapy (MCT) featured in the Special Issue on this topic. It begins with an overview of key features of MCT and highlights its basis in information-processing theory. A summary of the contributions to the Special Issue demonstrates that contemporary research supports both the theoretical principles and clinical effectiveness of MCT. Several challenges will remain as MCT becomes further established as a therapy of first recourse for a range of emotional disorders. At a theoretical level, more fine-grained understanding of the temporal dynamics of specific attentional processes is needed, as well as investigation of implicit processing. For clinical application, larger scale trials of the effectiveness of MCT in comparison with other therapies are needed. Progress in meeting these challenges is expected as the benefits of MCT become more widely-known.
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Generalised anxiety disorder (GAD) responds well to individually delivered metacognitive therapy (MCT). The current study investigated the effectiveness of MCT administered to groups of patients with GAD in a general outpatient treatment centre. Thirty-three consecutively referred adult patients with GAD were assessed before treatment (pretreatment), after the last treatment session (posttreatment), and six months after treatment had ended (follow-up). Analyses of treatment effects were conducted for all patients entering the study (i.e., intent-to-treat analysis, using the last-observation-carried-forward procedure), and repeated for the patients who completed treatment (completers analysis), using paired samples t-tests. Further, effect sizes (ESs) and indices of clinical significance were calculated, and compared with those reported in studies into the efficacy and effectiveness of individually delivered MCT for GAD. Among both the intent-to-treat and the completers sample, large pre- to posttreatment reductions in symptoms of worry, trait-anxiety, and general psychopathology. The magnitude of change and the degree of clinical significance were smaller than those reported in studies into the effectiveness of individually delivered MCT for GAD, whereas the attrition rate (27 %) was higher. It is tentatively concluded that MCT for GAD can be effectively delivered in a group format in a heterogenous clinical practice setting. Further evaluation is clearly indicated.
A meta-cognitive classification and analysis of factors contributing to the development of problematic worry is presented. Dimensions of meta-beliefs, meta-worry, cognitive consciousness, and strategies can be distinguished. A cognitive model of Generalized Anxiety Disorder is advanced based on this framework in which GAD results from an interaction between the motivated use of worry as a coping strategy, negative appraisal of worry, and worry control attempts. These factors result from combinations of dysfunctional meta-beliefs and contribute to subjectively diminished cognitive control. The model presents new implications for a cognitive therapy of GAD, and these are illustrated with a single case treatment study.
Resource-oriented cognitive-behavioral therapy (ROCBT) and cognitive therapy (CT) have been shown to be effective treatments for social anxiety disorder. However, so far few studies have examined the long-term effectiveness of these treatments. Thus, there is little information available about the durability of change in treated patients with social anxiety disorder. This study examined the effectiveness of both treatments at 2-year and 10-year follow-up assessments. Patients who received ROCBT or CT were re-contacted after 2 (n = 51), and 10 years (n = 27), respectively, and completed a battery of self-report questionnaires. Treatment gains were maintained over the 2-year follow-up on all measures. Furthermore, there was a significant improvement on 2 social anxiety measures between posttreatment and the 10-year follow-up. ROCBT and CT did not differ in overall effectiveness. The results suggest that both treatments are effective and durable approaches in the treatment of social anxiety disorder.
This randomized controlled trial compared the effectiveness of metacognitive therapy (MCT) and intolerance-of-uncertainty therapy (IUT) for generalized anxiety disorder (GAD) in an outpatient context. Patients with GAD (N = 126) consecutively referred to an outpatient treatment center for anxiety disorder were randomly allocated to MCT, IUT, or a delayed treatment (DT) condition. Patients were treated individually for up to 14 sessions. Assessments were conducted before treatment (pretreatment), after the last treatment session (posttreatment), and six months after treatment had ended (follow-up). At posttreatment and follow-up assessments, substantial improvements were observed in both treatment conditions across all outcome variables. Both MCT and IUT, but not DT, produced significant reductions in GAD-specific symptoms with large effect sizes (ranging between 0.94 and 2.39) and high proportions of clinically significant change (ranging between 77% and 95%) on various outcome measures, and the vast majority of the patients (i.e., 91% in the MCT group, and 80% in the IUT group) no longer fulfilled the diagnostic criteria for GAD. Results further indicate that MCT produced better results than IUT. This was evident on most outcome measures, and also reflected in effect sizes and degree of clinical response and recovery.
Metacognitive Therapy (MCT) and Applied Relaxation (AR) were compared in a pilot treatment trial of generalized anxiety disorder (GAD). Twenty outpatients meeting criteria for DSM-IV-TR GAD were assessed before treatment, after treatment and at 6 m and 12 m follow-up. The patients were randomized and treated individually for 8-12 weekly sessions. There was no drop-out from MCT and 10% at 6 m follow-up from AR. At post-treatment and at both follow-up points MCT was superior to AR. Standardized recovery rates for MCT at post-treatment were 80% on measures of worry and trait-anxiety compared with 10% following AR. At 6 m follow-up recovery rates for MCT were 70% on both measures compared with 10% and 20% for AR. At 12 m follow-up recovery rates for MCT were 80% (worry) and 60% (trait-anxiety) compared with 10% and 20% following AR. The recovery rates for MCT are similar to those obtained in an earlier uncontrolled trial (Wells & King, 2006). The effect sizes and standardized recovery rates for MCT suggest that it is a highly effective treatment.
In 1984, Jacobson, Follette, and Revenstorf defined clinically significant change as the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population. In the present article, ways of operationalizing this definition are described, and examples are used to show how clients can be categorized on the basis of this definition. A reliable change index (RC) is also proposed to determine whether the magnitude of change for a given client is statistically reliable. The inclusion of the RC leads to a twofold criterion for clinically significant change.
The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.