A pilot randomized trial of metacognitive therapy vs applied relaxation in the treatment of adults with generalized anxiety disorder

Evaluating the effect of detached mindfulness techniques on gaming-related urges and intentions to play

Individuals who struggle to regulate their gaming involvement, particularly those with gaming disorder, often report strong subjective urges to play games. Desire thinking has been proposed to be an active driver of urge, and therefore disrupting desire thinking processes may reduce urges to play. Detached mindfulness, a meta-cognitive therapy technique, is a candidate option for reducing desire thinking, but the available research in relation to gaming is limited. To address this gap, this pre-registered study employed a 3 (Group: mindfulness, relaxation, control) x 3 (Time: baseline, pre-task, post-task) mixed experimental design to evaluate the effectiveness of different techniques to reduce gaming urges. Gamers (N = 337) were recruited via the crowd-sourcing platform Prolific. Participants were administered interactive video-based tasks that induced gaming-related desire thinking and were then randomly delivered one of three techniques. Results showed that the desire thinking exercise significantly increased gaming urge. However, the detached mindfulness technique had no significant effect on urge to play, whereas relaxation significantly reduced urge compared to control. The effect of relaxation on urge was stronger for those with moderate to high impulsivity. These results support the proposed link between desire thinking and gaming urge. Gaming urges may be reliably induced using a brief self-guided protocol, which has applications for interventions involving exposure exercises without the use of physical gaming stimuli. Relaxation techniques may have short-term utility in reducing gaming-related urges. Further research should examine other meta-cognitive therapy-based techniques to support a broader research program on CBT for gaming disorder.

The role of metacognitive beliefs in generalised anxiety disorder in men who have sex with men living with HIV in Nigeria

Men who have sex with men (MSM) living with HIV tend to experience a range of mental health issues, in particular generalised anxiety disorder (GAD), often caused and maintained by psychosocial variables including HIV stigma, discrimination, self-esteem issues, substance abuse and loneliness. This is particularly problematic in countries like Nigeria where same sex activity is illegal and can result in up to 14 years imprisonment. An important psychological variable that may contribute to the experience of GAD are metacognitive beliefs. Participants (N = 311) completed measures to examine the relationship between these variables. Results indicated that metacognition was associated with, and significantly predicted, GAD in this population. Moderation analysis showed that the effect of HIV stigma on GAD was explained by the proposed interaction with metacognition. Findings suggest that metacognition may be an important variable in explaining GAD symptoms in MSM living with HIV in Nigeria.

A retrospective chart review to assess the impact of alpha-guided transcranial magnetic stimulation on symptoms of PTSD and depression in active-duty special operations service members

Introduction

Special Operations Forces service members (SOF) are regularly exposed to traumatic and concussive events, increasing the prevalence of symptoms of post-traumatic stress disorder (PTSD) and depression, shortening potential years of service.

Methods

This retrospective chart review presents preliminary data on a Human Performance Optimization (HPO) program that provided an average of 30 sessions of individualized alpha frequency repetitive transcranial magnetic stimulation (α-rTMS) to active-duty SOF as to reduce symptoms of PTSD and depression following traumatic brain injury. Scores from the PTSD Checklist for DSM-5, PROMIS Depression short form and Perceived Deficits Questionnaire (PDQ) were reviewed.

Results

Significant reductions were noted after the HPO program in all clinical scales with an average 37% decrease in PCL-5 (p<.01), 11.3% reduction in PROMIS depression T-scores (p<.01), and 45.5% reduction in PDQ scales by session 30 (p<.01), with side effects matching those commonly reported in rTMS. Importantly, the average PCL-5 score decreased from 42.9 to 27 by end of the treatment program, which is below the clinical threshold of 33 for presence of PTSD. For those with depression symptoms scores greater than cut off clinical thresholds at baseline, 46% resolved following treatment.

Conclusion

This data provides preliminary support for safe application of α-rTMS for symptom reduction in active-duty special operations military personnel.

Psychotherapies for Generalized Anxiety Disorder in Adults: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

Importance

Generalized anxiety disorder (GAD) is one of the most common mental disorders in adults. Psychotherapies are among the most recommended treatments for GAD, but which should be considered as first-line treatment needs to be clarified.

Objective

To use a network meta-analysis to examine the short- and long-term associations of different psychotherapies with outcomes of effectiveness and acceptability in adults with GAD.

Data Sources

MEDLINE, Embase, PsycINFO, and the Cochrane Register of Controlled Trials were searched from database inception to January 1, 2023, to identify randomized clinical trials (RCTs) of psychotherapies for adults with GAD.

Study Selection

RCTs comparing any type of psychotherapy against another or with a control condition for the treatment of adults (≥18 years, both sexes) with a primary diagnosis of GAD were eligible for inclusion.

Data Extraction and Synthesis

This study followed Cochrane standards for extracting data and assessing data quality and used the PRISMA guideline for reporting. Risk of bias of individual studies was assessed using the second version of the Cochrane risk of bias tool, and the Confidence in Network Meta-Analysis was used to rate the certainty of evidence for meta-analytical results.

Main Outcomes and Measures

Eight psychotherapies were compared against one another and with 2 control conditions. Primary outcomes were severity of GAD symptoms and acceptability of the psychotherapies. Random-effects model pairwise and network meta-analyses were conducted. For effectiveness, standardized mean differences (SMDs) were pooled, and for acceptability, relative risks with 95% CIs were calculated.

Results

Data from 65 RCTs were included. Effect size estimates on data from 5048 participants (mean [SD], 70.9% [11.9%] women; mean [SD] age, 42.2 [12.5] years) suggested that third-wave cognitive behavior therapies (CBTs) (SMD, -0.76 [95% CI, -1.15 to -0.36]; certainty, moderate), CBT (SMD, -0.74 [95% CI, -1.09 to -0.38]; certainty, moderate), and relaxation therapy (SMD, -0.59 [95% CI, -1.07 to -0.11]; certainty, low) were associated with reduced GAD symptoms vs treatment as usual. Relative risks for all-cause discontinuation (indication of acceptability) signaled no differences compared with treatment as usual for all psychotherapies (eg, relative risk, 1.04 [95% CI, 0.64-1.67] for CBT vs treatment as usual). When excluding studies at high risk of bias, relaxation therapy lost its superiority over treatment as usual (SMD, -0.47; 95% CI, -1.18 to 0.23). When considering anxiety severity at 3 to 12 months after completion of the intervention, only CBT remained significantly associated with greater effectiveness than treatment as usual (SMD, -0.60; 95% CI, -0.99 to -0.21).

Conclusions and Relevance

Given the evidence in this systematic review and network meta-analysis for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

Prospective Relations Between Dysfunctional Metacognitive Beliefs, Metacognitive Strategies, and Anxiety: Results From a Four-Wave Longitudinal Mediation Model

The metacognitive model of psychological disorders suggests that emotional disorders are related to maladaptive metacognitive strategies corresponding to underlying dysfunctional metacognitive beliefs. There is substantial empirical evidence supporting a role of metacognition in psychopathology, but fewer studies have evaluated the metacognitive model using longitudinal data and taken into consideration its differentiation between components and how they are hypothesized to be related to each other. Thus, more specific model evaluation is important as it relates to identifying mechanisms of disorder with a potential to provide clinical advances. In the present study, 868 participants took part in a 4-wave survey and reported on metacognitive beliefs and strategies and anxiety symptoms. Two longitudinal mediation models (forward and reversed causation) were run to test temporal precedence and bidirectional relations. The results indicated that metacognitive beliefs significantly predicted metacognitive strategies, which further predicted anxiety symptoms and mediated the indirect effect in the relationship between metacognitive beliefs and anxiety over time. The relationship between metacognitive beliefs and anxiety symptoms over time were bidirectional, but this relationship was not accounted for by metacognitive strategies. These findings largely support central predictions set forward by the metacognitive model and indicate that metacognitions play a preceding and maintaining role in anxiety.

Change in interpersonal problems and metacognitive beliefs as predictors of improvement in patients with generalized anxiety disorder

INTRODUCTION

Generalized anxiety disorder (GAD) is characterized by persistent worry and anxiety, often with a chronic course. We tested the role of two suggested underlying factors in GAD, interpersonal problems and negative metacognitive beliefs, as predictors of trait-worry and trait-anxiety.

METHODS

The sample consisted of 56 patients with a primary diagnosis of GAD from a randomized controlled trial. We first estimated the proportion of variance lying between the higher level of the data structure to account for potential therapists' effects. Two hierarchical regression analyses were conducted testing change in interpersonal problems and negative metacognitive beliefs as predictors of change in trait-worry and trait-anxiety following treatment. Change in depression and anxiety symptoms was controlled.

RESULTS

Change in negative metacognitive beliefs was the strongest predictor of improvement of both trait-worry and trait-anxiety. Change in interpersonal problems was not a unique predictor of change in trait-worry but did make a significant and unique contribution to trait-anxiety.

CONCLUSIONS

Negative metacognitive beliefs may be important targets to improve trait-worry and trait-anxiety in GAD. Interpersonal problems may be relevant for trait-anxiety but could also be a surface marker of higher order vulnerability factors. Implications for treatment are discussed.

Age-related decreases in global metacognition are independent of local metacognition and task performance

Metacognition refers to a capacity to reflect on and control other cognitive processes, commonly quantified as the extent to which confidence tracks objective performance. There is conflicting evidence about how "local" metacognition (monitoring of individual judgments) and "global" metacognition (estimates of self-performance) change across the lifespan. Additionally, the degree to which metacognition generalises across cognitive domains may itself change with age due to increased experience with one's own abilities. Using a gamified suite of performance-controlled memory and visual perception tasks, we measured local and global metacognition in an age-stratified sample of 304 healthy volunteers (18-83 years; N = 50 in each of 6 age groups). We calculated both local and global metrics of metacognition and quantified how and whether domain-generality changes with age. First-order task performance was stable across the age range. People's global self-performance estimates and local metacognitive bias decreased with age, indicating overall lower confidence in performance. In contrast, local metacognitive efficiency was spared in older age and remained correlated across the two cognitive domains. A stability of local metacognition indicates distinct mechanisms contributing to local and global metacognition. Our study reveals how local and global metacognition change across the lifespan and provide a benchmark against which disease-related changes in metacognition can be compared.

Generalized Anxiety Disorder: Does the Emotion Dysregulation Model Predict Symptoms Beyond the Metacognitive Model?

While the Metacognitive Model (MCM) of generalized anxiety disorder (GAD) is well-established, the Emotion Dysregulation Model (EDM) of GAD has received less attention. This study examined whether the EDM helps explain GAD above and beyond the MCM. The influence of gender was also explored. A non-clinical university sample (N = 626) completed measures of GAD symptoms, worry severity, the MCM, and the EDM. In support of the EDM, it was found that fear of depression predicted GAD symptoms for men, while fear of anxiety predicted GAD symptoms for women. However, across genders, the strongest predictor of GAD symptoms and worry severity was negative beliefs about worry. While these findings support the MCM view that holding the beliefs that worry is harmful and dangerous is the strongest predictor of GAD overall, incorporating aspects of the EDM into our understanding and treatment of GAD may be beneficial.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10942-022-00479-7.

Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts

INTRODUCTION

Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT.

AREAS COVERED

The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups.

EXPERT OPINION

We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.

Comparative efficacy of face-to-face and internet-based cognitive behavior therapy for generalized anxiety disorder: A meta-analysis of randomized controlled trial

Objective

The study aimed to ascertain the comparative efficacy of these two forms on reducing anxiety scores of scales in patients with a generalized anxiety disorder (GAD) by examining the available evidence for face-to-face cognitive behavior therapy (CBT) and internet-based cognitive behavior therapy (ICBT). Moreover, this study attempted to determine whether ICBT can obtain similar benefits as CBT for GAD patients during coronavirus disease 2019 (COVID-19) due to the quarantine policy and the requirement of social distance.

Methods

This meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO) according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (registration number CRD42021241938). Therefore, a meta-analysis of randomized controlled trials (RCTs) examining CBT or ICBT was conducted in this study to treat GAD patients diagnosed with DMS-IV. The researchers searched PubMed, MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews for relevant studies published from 2000 to July 5, 2022. Evidence from RCTs was synthesized by Review Manager 5.4 as mean difference (MD) for change in scores of scales through a random-effects meta-analysis.

Results

A total of 26 trials representing 1,687 participants were pooled. The results demonstrated that ICBT and CBT were very close in the effect size of treating GAD (MD = -2.35 vs. MD = -2.79). Moreover, they still exhibited a similar response (MD = -3.45 vs. MD = -2.91) after studies with active control were removed.

Conclusion

Regarding the treatment of GAD, ICBT can achieve a similar therapeutic effect as CBT and could be CBT's candidate substitute, especially in the COVID-19 pandemic era, since the internet plays a crucial role in handling social space constraints.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=241938, identifier CRD42021241938.

Association between Metacognitive Beliefs and COVID-19 phobia in a community population: a cross-sectional study

This study aims to investigate the relationship between metacognitive beliefs and COVID-19 phobia. The sample included 514 Turkish adults, 295 of whom are women (57,4%), and 219 are men (42,6%). Their ages ranged between 18 and 70 years (M = 32.96, SD = 10.79). COVID-19 Phobia Scale (C19P-S) and Metacognitions Questionnaire-30 (MCQ-30) were administered. Our analysis showed that women reported significantly higher COVID-19 phobia. The participants with chronic illnesses showed significantly higher COVID-19 phobia and MCQ-30 scores. It was found that C19P-S total score positively correlated with negative beliefs about worry concerning uncontrollability of thoughts, the need to control thoughts, cognitive self-consciousness, positive beliefs, cognitive confidence, and MCQ-30 total score respectively (r = .47, p < .001; r = .33, p < .001; r = .30, p < .001; r = .29, p < .001; r = .12, p < .001; r = .44, p < .001). Then, hierarchical multiple regression was conducted, and the relationships were tested via structural equation modeling. To sum up, it can be concluded that negative beliefs about worry concerning the uncontrollability of thoughts contribute to COVID-19 phobia. However, explained variance was small suggesting that there are additional factors involved. These results provided preliminary findings relating to the association between metacognitive beliefs and coronavirus phobia symptoms. Further longitudinal research is necessary to determine the causal direction of these findings.

The Scope of Metacognitive Therapy in the Treatment of Psychiatric Disorders

Metacognitive therapy (MCT) is a novel and promising transdiagnostic psychotherapy intervention based on the Self-Regulatory Executive Function model of conceptualizing emotional disorders. It was developed by Adrian Wells in 2009. Its therapeutic response occurs by reducing dysfunctional metacognitive beliefs regarding worry and rumination, often seen in patients with psychiatric disorders. Since its inception, it has been increasingly applied to a wide spectrum of psychiatric illnesses, but mainly focusing on mood and anxiety disorders. To our knowledge, no study has detailed its existing therapeutic scope in psychiatry. In this comprehensive narrative review, we describe the various psychiatric illnesses in which MCT has been used, the advantages of MCT, and the limitations of the MCT research. In addition, we propose some solutions to systematically examine its place in psychiatry. We encountered its potential role in treating trauma and stress-related disorders, obsessive-compulsive spectrum disorders, personality disorders, psychotic disorders, substance use disorders, and sexual disorders.

Validity and Reliability of the Turkish Version of Generalized Anxiety Disorder Scale-Revised

OBJECTIVE

This study aims to assess the psychometric values of the Generalized Anxiety Disorder Scale-Revised (GADS-R) which measures the intensity and duration of worry, various coping and avoidance strategies to cope with worrying, and positive and negative metacognitive beliefs about worrying.

METHODS

114 patients with generalized anxiety disorder and 198 healthy controls were included in the study. These patients were diagnosed according to DSM-IV TR, and the primary diagnosis of the patients was generalized anxiety disorder which was confirmed via SCID I and II, subsequently. Sociodemographic form, GADS-R total and subscale scores, and Meta-Cognitions Questionnaire-30 (MCQ-30), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder-7 Scale (GAD-7), and Penn State Worry Questionnaire (PSWQ) were used to assess validity, reliability and cut-off point.

RESULTS

GADS-R total and subscale scores and MCQ-30, BDI, BAI, GAD-7, and PSWQ were found to be statistically higher in the patients with GAD compared to a healthy control group. GADS-R has five factors and showed relatively acceptable sensitivity and specificity for detecting anxiety disorders at a cut-off point of 1188.

CONCLUSION

The GADS-R is a valid and reliable scale that can be used in the Turkish population as an assessment tool.

Metacognitive therapy versus cognitive-behavioral therapy in adults with generalized anxiety disorder: A 9-year follow-up study

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.

Cognitive Behavior Therapy Targeting Intolerance of Uncertainty Versus Selective Serotonin Reuptake Inhibitor for Generalized Anxiety Disorder: A Randomized Clinical Trial

Given the high prevalence and adverse outcomes associated with generalized anxiety disorder (GAD), development and expansion of effective treatment modalities are important. The present study compared the effectiveness of cognitive behavior therapy targeting intolerance of uncertainty (CBT-IU) and selective serotonin reuptake inhibitors (SSRIs) for treating GAD. A total of 30 Iranian patients with GAD (Mage = 25.16 ± 6.73) were randomised to receive either CBT-IU (n = 15) or SSRI (n = 15). Measures included the Structured Clinical Interview for DSM-5 (SCID-5), Penn State Worry Questionnaire (PSWQ), Why Worry-II (WW-II), Intolerance of Uncertainty Scale (IUS), and Negative Problem Orientation Questionnaire (NPOQ). Repeated measures analysis of variance tested differential treatment outcomes. The results of intention-to-treat (ITT) analysis indicated that although both CBT-IU and SSRI were effective treatments for GAD, CBT-IU produced significantly better results than SSRI at post-treatment. This clinical trial provides preliminary cross-cultural support for the treatment of GAD using CBT-IU, with findings suggesting that this non-medication intervention reduces GAD symptoms.

Therapist-guided online metacognitive intervention for excessive worry: a randomized controlled trial with mediation analysis

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156.

Self-critical Rumination and Associated Metacognitions as Mediators of the Relationship Between Perfectionism and Self-esteem

Past research has shown that perfectionism, can negatively impact self-esteem. However, the mediating factors that explain this relationship remain unclear. The current study aimed to investigate whether specific cognitive processes, namely, self-critical rumination and associated metacognitions, mediate this relationship. An opportunity sample of 347 participants completed a battery of online questionnaires measuring clinical perfectionism, self-critical rumination, metacognitions about self-critical rumination, self-esteem, and levels of psychological distress. Several hypotheses were tested to examine the associations between the study variables. Following this, a path analysis was used to determine whether the influence of perfectionistic concerns and perfectionistic striving on self-esteem is mediated by positive metacognitions about self-critical rumination, self-critical rumination, and negative metacognitions about self-critical rumination, serially. Positive metacognitions about self-critical rumination, self-critical rumination, and negative metacognitions about self-critical rumination partially mediated the relationship between perfectionistic concerns and self-esteem and fully mediated the relationship between perfectionistic striving and self-esteem. These results point towards possible interventions for those who struggle with low self-esteem due to their perfectionistic tendencies. Further investigations should explore additional factors that help to explain why perfectionism impacts self-esteem levels, whilst also addressing the limitations of this current research.

Group meta-cognitive therapy and depression in women with breast cancer: a randomized controlled trial

BACKGROUND

Breast cancer is one of the most common cancers in Iranian women. They will experience a mental health problem like depression before, during or after treatment. This study aimed to determine the effectiveness of group metacognitive therapy on depression, cognitive-emotional regulation, and meta-cognitive beliefs in women with breast cancer.

METHODS

In this randomized controlled clinical trial, a total of 24 depressed patients with breast cancer were randomly allocated to experimental and control groups. The experimental group received meta-cognitive therapy in 8 weekly sessions, but the control group received treatment as usual. Beck Depressive Inventory, cognitive emotion regulation questionnaire, and meta-cognitions questionnaire were completed before, after and one month after the intervention. Data were analyzed using Wilcoxon and Chi-square tests.

RESULTS

The mean score of depression in the experimental group was reduced from 21.6 ± 4.83 in the pre-test to 13.83 ± 8.12 in one-month follow-up (p = 0.16); however, there was no significant difference in the control group. The mean score of cognitive emotion regulation did not show a significant change in the two groups during the study and follow-up period. The mean score of meta-cognitive beliefs reached 68.75 ± 15.74 from 79.51 ± 10.72 in the experimental group during the follow-up period (p = 0.006); however, there was no significant difference in the control group in the score of metacognitive beliefs.

CONCLUSION

These findings support the efficacy of meta-cognitive therapy as a viable psychosocial intervention in depressed patients with breast cancer. Trial registration IRCT201606288473N5. Registered on: 05/09/2016 https://www.irct.ir/trial/8946 .

A randomised controlled trial of metacognitive training for psychosis, depression, and belief flexibility

BACKGROUND

Metacognitive training (MCT) has been shown to be effective in reducing psychotic symptoms, including delusions. However, less is known on whether MCT, or its specific modules, are effective in ameliorating reasoning biases e.g. belief flexibility. As inflexibility in appraisal has been associated with psychosis and major depressive disorder (MDD), this study examined the efficacy of a 4-session MCT on delusions, depression, and belief flexibility, in two clinical groups (Psychosis and Depression).

METHODS

This study adopted a single-blind randomised controlled design, with patients with schizophrenia spectrum disorders (and delusions) and patients with MDD being randomised, respectively, into the MCT condition or a treatment-as-usual (TAU) condition. The MCT intervention consisted of specific modules targeting belief flexibility. Participants were assessed before and after treatment, and at 1- and 6-month follow-ups.

RESULTS

Among the 113 participants, 27 patients with psychosis and 29 patients with MDD attended MCT. There were significant improvements in psychotic symptoms, especially delusions, for the Psychosis group, and in depressive symptoms for the MDD group. Symptom improvements following MCT were of large effect sizes, were significantly greater than TAU, and persisted at 6-month. Belief flexibility also improved in both groups, although changes were smaller in size and were not significantly greater than TAU.

LIMITATIONS

An active control condition was not included.

CONCLUSIONS

This study demonstrated large and stable symptom reductions in delusions and depression, and smaller (yet stable) improvement in belief flexibility across groups, following a 4-session MCT, carrying implications for transdiagnostic process-based interventions and their mechanisms of change.

Specificity of trait anxiety in anxiety and depression: Meta-analysis of the State-Trait Anxiety Inventory

The State-Trait Anxiety Inventory - Trait version (STAI-T) was developed to measure an individual's tendency to experience anxiety, but it may lack discriminant evidence of validity based on strong observed relationships with measures of depression. The present series of meta-analyses compares STAI-T scores among individuals with depressive disorders, anxiety disorders, and nonclinical comparison groups, as well as correlations with measures of anxiety and depressive symptom severity, in order to further examine discriminant and convergent validity. A total of 388 published studies (N = 31,021) were included in the analyses. Individuals with an anxiety disorder and those with a depressive disorder displayed significantly elevated scores on the STAI-T compared to nonclinical comparison groups. Furthermore, anxiety and depressive symptom severity were similarly strongly correlated with the STAI-T (mean r = .59 - .61). However, individuals with a depressive disorder had significantly higher STAI-T scores than individuals with an anxiety disorder (Hedges's g = 0.27). Given these findings, along with previous factor analyses that have observed a depression factor on the STAI-T, describing the scale as a measure of 'trait anxiety' may be a misnomer. It is proposed that the STAI-T be considered a non-specific measure of negative affectivity rather than trait anxiety per se.

The relations among worry, meta-worry, intolerance of uncertainty and attentional bias for threat in men at high risk for generalized anxiety disorder: a network analysis

BACKGROUND

Improving the psychotherapies for generalized anxiety disorder (GAD) is dependent on a deeper understanding of the relations between GAD and its associated cognitive factors. In the present study, we investigate how the core feature of GAD (i.e., worry) and its associated cognitive factors, such as meta-worry, intolerance of uncertainty, and attention bias towards threat, relate to each other in men at high risk for GAD.

METHODS

We used network analysis to explore the relations among these variables in a cross-sectional sample of 122 men at high risk for generalized anxiety disorder. Specifically, we computed the expected influence and predictability of each variable.

RESULTS

In the final network, we found that worry and meta-worry had the highest expected influence and predictability. In contrast, attention bias towards threat showed the lowest expected influence and predictability. The estimates of the expected influence of the nodes were stable (correlation stability coefficient = 0.52).

CONCLUSIONS

The present study is the first to investigate the relations among worry, meta-worry, intolerance of uncertainty, and attention bias towards threat in men at high risk for generalized anxiety disorder. These findings indicate that worry and meta-worry may play important roles in the present network. The implications for clinical interventions and future studies are discussed.

A randomized clinical trial of metacognitive therapy and nortriptyline for anxiety, depression, and difficulties in emotion regulation of patients with functional dyspepsia

Functional Dyspepsia (FD) as a psychosomatic disorder is an upper gastrointestinal tract disease without organic pathogenesis causes. The psychopathological nature of this disease and its high correlation with anxiety and depression implies the need for psychological interventions. The purpose of the present study is to compare the efficacy of Metacognitive Therapy (MCT) and medication for the symptoms of anxiety, depression, and difficulties in emotion regulation in patients with FD. In a randomized clinical trial, 65 patients with FD were recruited during their visit to gastroenterology clinics. These patients were randomly assigned to three groups to receive MCT, nortriptyline treatment, and controls. They were treated for 10 weeks and followed up three months later. The instruments used in this study were Hamilton anxiety and Depression Rating Scale (HAM-A and HDRS) and difficulties in emotion regulation scale. The results were analyzed using repeated measure analysis by SPSS (19- IBM). Data analysis showed statistically significant differences in the variables of depression, anxiety among MCT, nortriptyline treatment, and controls at pre-test, post-test and follow-up phases. Moreover, MCT had a better and more persistent effect on anxiety compared to nortriptyline treatment, as well as a better efficacy in treating anxiety and depression symptoms compared to the controls. MCT demonstrated better efficacy in treating anxiety symptoms compared to nortriptyline treatment and controls.

Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health

The self-regulatory executive function (S-REF) model explains the role of strategic processes and metacognition in psychological disorder and was a major influence on the development of metacognitive therapy. The model identifies a universal style of perseverative negative processing termed the cognitive attentional syndrome (CAS), comprised of worry, rumination, and threat monitoring in the development of disorder. The CAS is linked to dysfunctional metacognitions that include beliefs and plans for regulating cognition. In this paper, I extend the theoretical foundations necessary to support further research on mechanisms linking metacognition to cognitive regulation and effective treatment. I propose a metacognitive control system (MCS) of the S-REF that can be usefully distinguished from cognition and is comprised of multiple structures, information, and processes. The MCS monitors and controls activity of the cognitive system and regulates the behavior of neural networks whose activities bias the way cognition is experienced. Metacognitive information involved in the regulation of on-line processing includes metacognitive beliefs, metacognitive procedural commands, and more transient cybernetic code. Separation of the cognitive and metacognitive systems and modeling their relationship presents major implications concerning what should be done in therapy and how it should be done. The paper concludes with an in-depth consideration of methods that strengthen the psychological basis of psychotherapy and aid in understanding and applying metacognitive therapy in particular. Finally, limitations of the model and implications for future research on self-awareness, self-regulation, and metacognition are discussed.

Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.

Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis

Generalized anxiety disorder (GAD) is a significant and common mental illness with a lifetime prevalence of 3.7%. Regardless of the complexity of treatment decisions for GAD, few studies have conducted systematic comparisons of the efficacies of varying interventions. Thus, this study performed a valid network meta-analysis (NMA) of randomized controlled trials (RCTs) to synthesize direct and indirect evidence for alternative interventions for GAD. We searched four major bibliographic databases, the Cochrane Central Register of Controlled Trials, Embase, PsycINFO, and PubMed, for published RCTs of adult patients with a diagnosis of GAD and allowed for all comorbidities. A total of 91 articles (14,812 participants) were identified in the final NMA. The results showed that all pharmacological treatments except for serotonin modulators and second-generation antipsychotics had greater effects than placebo: norepinephrine-dopamine reuptake inhibitors (standardized mean difference (SMD) -1.84, 95% credible interval -3.05 to -0.62), noradrenergic and specific serotonergic antidepressants (-0.91, -1.62 to -0.20), melatonergic receptor agonists (-0.68, -1.15 to -0.21), selective serotonin reuptake inhibitors (SSRIs; -0.67, -0.90 to -0.43), azapirones (-0.58, -1.00 to -0.17), anticonvulsants (-0.56, -0.85 to -0.28), serotonin-norepinephrine reuptake inhibitors (SNRIs; -0.54, -0.79 to -0.30), and benzodiazepines (BZDs; -0.40, -0.65 to -0.15). Most psychological and self-help interventions exerted greater effects than the waitlist group. However, no psychological interventions had greater effects compared with the psychological placebo. Overall, most pharmacological interventions had larger effect sizes than psychological interventions, and most psychological interventions showed larger effect sizes than self-help interventions.

The Metacognitions Questionnaire and Its Derivatives in Children and Adolescents: A Systematic Review of Psychometric Properties

Background: The Metacognitions Questionnaire (MCQ) and its derivatives have been instrumental in research examining the Self-Regulatory Executive Function Model in adults. Studies testing whether findings are applicable to children and adolescents have been increasing and several different measures adapting the MCQ for younger populations have been developed. The current study aimed to systematically review the psychometric properties of MCQ measures or derivatives used in young people (aged 18 or less), to help assess current findings in this population and to guide future research in this growing area of investigation. Method: Systematic searches were carried out on PubMed and PsycINFO of studies published up to June 2018. Additional studies were identified through Google Scholar and article references. Validity, reliability, range and responsiveness of measures were examined as well as analyses of age and gender differences on scores. Results: Forty-five articles were identified. The total sample consisted of 7,803 children and adolescents (6,922 non-clinical, 881 clinical) aged 7-18. Studies used one of seven versions of the questionnaire, five adapted from the MCQ for younger populations: (1) The Metacognitions Questionnaire-Adolescent version; (2) The Metacognitions Questionnaire-Child version; (3) The Metacognitions Questionnaire-Child Version-Revised; (4) The Metacognitions Questionnaire-Child-30; and (5) The Metacognitions Questionnaire-65 Positive Beliefs Scale Revised; and two adult versions used without adaptation: (1) The Metacognitions Questionnaire-30 and (2) The Cognitive Self Consciousness Scale-Expanded. The validity and reliability of the Metacognitions Questionnaire-Adolescent version had the most extensive support. Other questionnaires had either mixed psychometrics or promising initial findings but more limited data. Conclusions: It is recommended that studies using adolescents (age 12-18) consider using the Metacognitions Questionnaire-Adolescent version. Based on initial data, it is suggested studies using younger populations should consider the Metacognitions Questionnaire-Child-30 but further psychometric research into this and other measures is needed.

A Preliminary Investigation of Cognitive Features Associated With Worry Among African American Youth

Although knowledge of the cognitive factors that place children at risk for worry has grown, little is known about these processes within African American youth. The present study investigated cognitive factors associated with worry in a sample of 47 African American children, ages 8 to 13. Participants completed self-report measures of worry, intolerance of uncertainty, positive and negative beliefs about worry, and negative problem orientation. Results supported the hypothesis that cognitive factors demonstrated significant positive associations with worry. Based on a model predicting worry from all cognitive factors, negative beliefs about worry emerged as the only individual predictor. This is the first study to examine cognitive factors associated with worry in an African American sample of children and provides initial support for the applicability of these cognitive factors in future examinations of worry within this population. Future research should continue to explore cognitive as well as other factors that predispose African America children to worry.

The relationships between worry, happiness and pain catastrophizing in the experience of acute pain

BACKGROUND

The current study aimed to (a) evaluate the effects of an experimental manipulation of worry and happiness on pain perception and measures of worry about pain and pain catastrophizing and (b) determine if changes in situation-specific worry about pain and pain catastrophizing would be related to changes in acute pain.

METHODS

The study included 120 healthy, pain-free volunteers. Participants were exposed to four levels of noxious stimulation and asked to report on the pain intensity, worry about pain and pain catastrophizing they experienced during the stimulation procedures. They were then randomly assigned to either a Happy or a Worry condition, where they were exposed to emotion induction procedures. The noxious exposure procedures and measures of pain, pain-related worry and pain catastrophizing were then repeated.

RESULTS

Participants in the Worry condition reported significant increases in pain intensity, and those in the Happy condition reported significant decreases in pain intensity. Further, the Worry condition participants reported significant increases in both pain-related worry and pain catastrophizing, while the Happy condition showed the opposite effects. Finally, changes in worry about pain and pain catastrophizing were found to mediate the impact of the affect induction procedure on pain intensity.

CONCLUSIONS

The findings demonstrate that pain intensity, worry about pain and pain catastrophizing are all sensitive to changes in mood. The results have potential clinical implications.

SIGNIFICANCE

The current study shows that manipulation-induced changes in pain-related worry, pain catastrophizing, and affect have direct effects on the experience of acute pain. More broadly, the overlap of these three variables provides with anxiety and mood disorders offers the promise of new vistas for research and treatment of pain conditions by assessing and targeting the cognitions and behaviors that are common to worry and catastrophizing.

Group Metacognitive Therapy for Generalized Anxiety Disorder: A Pilot Feasibility Trial

Background: Individual metacognitive therapy (MCT) for generalized anxiety disorder (GAD) is well established, but only one study has investigated the effectiveness of Group MCT (g-MCT) for GAD. The aim of the current study was therefore to evaluate the feasibility and effectiveness of g-MCT for GAD within a community mental health setting whilst addressing limitations evident in the previous study.

Methods: The study used an open trial design, and 23 consecutively referred adults with GAD completed 10 sessions (90 min) of g-MCT, delivered by two therapists trained in MCT. Diagnoses were assessed by trained raters using the Anxiety Disorder Interview Schedule-IV. All patients but one had previous psychosocial treatment, and 17 (73.9%) had at least one comorbid axis-I disorder. Self-reported symptoms were assessed using the Penn State Worry Questionnaire, the Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9 at pre- and post-treatment as well as 3-month follow-up. Feasibility was assessed using rates of patients who declined group treatment in favor of individual treatment, patients not able to attend due to pre-scheduled dates for sessions, and drop-out rate.

Results: Of 32 eligible participants, six patients (19%) declined g-MCT in favor of individual MCT, and three (9%) were unable to attend due to scheduling conflicts. No patients dropped out during treatment, but two patients did not complete the self-report questionnaires at 3-month follow-up. g-MCT was associated with significant reductions in worry, anxiety, depression, metacognitive beliefs, and maladaptive coping. According to the standardized Jacobson criteria for recovery, 65.3% were recovered at post-treatment, whereas 30.4% were improved and 4.3% showed no change. At 3-month follow-up, the recovery rate increased to 78.3%. Moreover, recovery rates were comparable for patients with- and without comorbidity. Number of therapist hours per patient was 6.5 and the treatment has now been implemented as a standard treatment option at the clinic.

Conclusion: g-MCT for GAD is an acceptable treatment which may offer a cost-effective alternative approach to individual MCT. Recovery rates and effect sizes suggested that g-MCT could be just as efficient as individual MCT and cognitive behavioral therapy.

What Lies Beneath Trait-Anxiety? Testing the Self-Regulatory Executive Function Model of Vulnerability

Vulnerability to psychological disorder can be assessed with constructs such as trait anxiety and neuroticism which among others are transdiagnostic risk factors. However, trait-anxiety and related concepts have been criticised because they don't illuminate the etiological mechanisms of psychopathology. In contrast, the metacognitive (S-REF) model offers a framework in which metacognitive knowledge conceptualised in trait terms is part of a core mechanism underlying trait-anxiety and related constructs. The present study therefore set out to explore metacognitions as potential underlying factors in trait-anxiety (the propensity to depression and anxiety). Nine hundred and eighty two participants completed self-report measures of metacognitions and trait-anxiety at time 1, and 425 individuals completed the same measures 8 weeks later. At the cross-sectional level, metacognitions accounted for 83% of the variance in anxiety- and 64% of depression propensity. Furthermore, despite both domains of trait-anxiety showing high stability over time, negative- and positive metacognitive beliefs were significant prospective predictors of both domains of vulnerability. These findings suggests that metacognitive beliefs may be an underlying mechanism of vulnerability attributed to trait-anxiety with the implication that the metacognitive (S-REF) model informs conceptualization of psychological vulnerability, and that metacognitive therapy applications might be employed to enhance psychological resilience.

Effectiveness of metacognitive interventions for mental disorders in adults-A systematic review and meta-analysis (METACOG)

We evaluated the effectiveness and acceptability of metacognitive interventions for mental disorders. We searched electronic databases and included randomized and nonrandomized controlled trials comparing metacognitive interventions with other treatments in adults with mental disorders. Primary effectiveness and acceptability outcomes were symptom severity and dropout, respectively. We performed random-effects meta-analyses. We identified Metacognitive Training (MCTrain), Metacognitive Therapy (MCTherap), and Metacognition Reflection and Insight Therapy (MERIT). We included 49 trials with 2,609 patients. In patients with schizophrenia, MCTrain was more effective than a psychological treatment (cognitive remediation, SMD = -0.39). It bordered significance when compared with standard or other psychological treatments. In a post hoc analysis, across all studies, the pooled effect was significant (SMD = -0.31). MCTrain was more effective than standard treatment in patients with obsessive-compulsive disorder (SMD = -0.40). MCTherap was more effective than a waitlist in patients with depression (SMD = -2.80), posttraumatic stress disorder (SMD = -2.36), and psychological treatments (cognitive-behavioural) in patients with anxiety (SMD = -0.46). In patients with depression, MCTherap was not superior to psychological treatment (cognitive-behavioural). For MERIT, the database was too small to allow solid conclusions. Acceptability of metacognitive interventions among patients was high on average. Methodological quality was mostly unclear or moderate. Metacognitive interventions are likely to be effective in alleviating symptom severity in mental disorders. Although their add-on value against existing psychological interventions awaits to be established, potential advantages are their low threshold and economy.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis

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 post-treatment and follow-up suggest that MCT is effective at reducing symptoms of the targeted primary complaints, 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 post-treatment and at follow-up showed pooled effect sizes (Hedges' g) of 0.69 and 0.37 at post-treatment (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.

Metacognition - What did James H. Flavell really say and the implications for the conceptualization and design of metacognitive interventions

In the last two decades years, several interventions have been designed for people with major psychological disorders that all have "metacognitive" in their name: Metacognitive Therapy (MCT), Metacognitive Training (e.g., for people with psychosis) and Metacognitive Reflection and Insight Therapy (MERIT). Two of these interventions are primarily targeted at patients with schizophrenia. Prompted by a recent discussion about what constitutes "true" metacognitive treatment, we will first explore the original concept of metacognition as defined by James H. Flavell. Then, we will describe each approach in detail before highlighting how each intervention picks up on slightly different aspects of Flavell's original metacognitive construct. We will also discuss inherent problems with the label "metacognition."

The Effects of Metacognition-Oriented Social Skills Training on Psychosocial Outcome in Schizophrenia-Spectrum Disorders: A Randomized Controlled Trial

A pilot study of the effects of metacognition-oriented social skills training (MOSST) on social functioning in patients with schizophrenia spectrum disorders (SSDs) reported promising results. The main purpose of the current trial was to compare the effectiveness and potential benefits of MOSST vs conventional social skills training (SST). Single-blind randomized controlled trial with 2 groups of patients aged 18-65 with SSDs on partial hospitalization. Participants were randomly assigned (1:1) to receive 16 group sessions with MOSST or conventional SST, both in addition to standard care, over 4 months, with a 6-month follow-up. Psychosocial functioning, metacognition, and symptom outcomes were measured by blind assessors. Statistical analyses used mixed models to estimate treatment effects in each postrandomization time point. Thirty-six patients were randomly assigned to the MOSST group and 33 patients to the conventional SST group. Between-group differences were significant in favor of MOSST on Social and Occupational Functioning Assessment Scale (SOFAS) and Personal and Social Performance Scale (PSP) total scores at post-treatment and follow-up. Concerning PSP subscales, there were significant between-group differences in favor of MOSST at follow-up on socially useful activities, personal and social relationships, and disturbing and aggressive behaviors. Metacognition only improved following MOSST group. For people with SDDs, MOSST appears to have short- and long-term beneficial effects on social functioning and symptoms. Further studies are required to replicate the current results in other samples.

Metacognitive therapy versus cognitive-behavioural therapy in adults with generalised anxiety disorder

BACKGROUND

Cognitive-behavioural therapy (CBT) is the treatment of choice for generalised anxiety disorder (GAD), yielding significant improvements in approximately 50% of patients. There is significant room for improvement in the outcomes of treatment, especially in recovery.

AIMS

We aimed to compare metacognitive therapy (MCT) with the gold standard treatment, CBT, in patients with GAD (clinicaltrials.gov identifier: NCT00426426).

METHOD

A total of 246 patients with long-term GAD were assessed and 81 were randomised into three conditions: CBT (n = 28), MCT (n = 32) and a wait-list control (n = 21). Assessments were made at pre-treatment, post-treatment and at 2 year follow-up.

RESULTS

Both CBT and MCT were effective treatments, but MCT was more effective (mean difference 9.762, 95% CI 2.679-16.845, P = 0.004) and led to significantly higher recovery rates (65% v. 38%). These differences were maintained at 2 year follow-up.

CONCLUSIONS

MCT seems to produce recovery rates that exceed those of CBT. These results demonstrate that the effects of treatment cannot be attributed to non-specific therapy factors.

DECLARATION OF INTEREST

A.W. wrote the treatment protocol in MCT and several books on CBT and MCT, and receives royalties from these. T.D.B. wrote the protocol in CBT and has published several articles and chapters on CBT and receives royalties from these. All other authors declare no competing interests.

A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults

Emotion regulation therapy (ERT) for generalized anxiety disorder (GAD) and accompanying major depressive disorder (MDD) is a theoretically derived, evidence-based treatment that integrates principles from traditional and contemporary cognitive-behavioral and experiential approaches with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding self-referential regulatory characteristics. Preliminary evidence supports the efficacy of a 20-session version of ERT. However, previous trials of ERT and other traditional and contemporary cognitive-behavioral therapies have often utilized relatively homogeneous samples. Various contextual and demographic factors may be associated with challenges that increase risk for negative mental and social outcomes for young adults ages 18-29, particularly for individuals from diverse backgrounds. The aim of this pilot study was to examine the effectiveness of a briefer 16-session version of ERT in a racially and ethnically diverse sample of young adults. Participants (N = 31) were enrolled at an urban-based, commuter college who consented to treatment for anxiety, worry, or depression at an on-campus counseling center. Open-trial results demonstrate strong ameliorative changes in worry, rumination, self-reported and clinician-rated GAD and MDD severity, social disability, quality of life, attentional flexibility, decentering/distancing, reappraisal, trait mindfulness, and negative emotionality from pre- to posttreatment. These gains were maintained throughout a 3- and 9-month follow-up. These findings provide preliminary evidence for the efficacy of ERT in treating a racially and ethnically heterogeneous population. Further, this study highlights comparable effectiveness of a briefer 16-session version of ERT.

A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression

OBJECTIVE

Generalized anxiety disorder (GAD) and major depression (MDD), especially when they co-occur, are associated with suboptimal treatment response. One common feature of these disorders is negative self-referential processing (NSRP; i.e., worry, rumination), which worsens treatment outcome. Emotion Regulation Therapy (ERT) integrates principles from affect science with traditional and contemporary cognitive-behavioral treatments to identify and modify the functional nature of NSRP by targeting motivational and regulatory mechanisms, as well as behavioral consequences.

METHOD

Building on encouraging open trial findings, 53 patients with a primary diagnosis of GAD (43% with comorbid MDD) were randomly assigned to immediate treatment with ERT (n = 28) or a modified attention control condition (MAC, n = 25).

RESULTS

ERT patients, as compared with MAC patients, evidenced statistically and clinically meaningful improvement on clinical indicators of GAD and MDD, worry, rumination, comorbid disorder severity, functional impairment, quality of life, as well as hypothesized mechanisms reflecting mindful attentional, metacognitive, and overall emotion regulation, which all demonstrated mediation of primary outcomes. This superiority of ERT exceeded medium effect sizes with most outcomes surpassing conventions for a large effect. Treatment effects were maintained for nine months following the end of acute treatment. Overall, ERT resulted in high rates of high endstate functioning for both GAD and MDD that were maintained into the follow-up period.

CONCLUSIONS

Findings provide encouraging support for the efficacy and hypothesized mechanisms underlying ERT and point to fruitful directions for improving our understanding and treatment of complex clinical conditions such as GAD with co-occurring MDD. (PsycINFO Database Record

Systematic review and meta-analysis of dropout rates in individual psychotherapy for generalized anxiety disorder

BACKGROUND

Despite being a relatively prevalent and debilitating disorder, Generalized Anxiety Disorder (GAD) is the second least studied anxiety disorder and among the most difficult to treat. Dropout from psychotherapy is concerning as it is associated with poorer outcomes, leads to service inefficiencies and can disproportionately affect disadvantaged populations. No study to date has calculated a weighted mean dropout rate for GAD and explored associated correlates.

METHODS

A systematic review was conducted using PsycINFO, Medline and Embase databases, identifying studies investigating individual psychotherapies for adults with GAD. Forty-five studies, involving 2224 participants, were identified for meta-analysis.

RESULTS

The weighted mean dropout rate was 16.99% (95% confidence interval 14.42%-19.91%). The Q-statistic indicated significant heterogeneity among studies. Moderator analysis and meta-regressions indicated no statistically significant effect of client age, sex, symptom severity, comorbidity, treatment type, study type (randomized trial or not), study quality, number of sessions or therapist experience.

CONCLUSIONS

In research investigating psychotherapy for GAD, approximately one in six clients can be expected to drop out of treatment. Dropout rate was not significantly moderated by the client, therapist or treatment variables investigated. Future research should specify the definition of dropout, reasons for dropout and associated correlates to assist the field's progression.

Treating functional non-epileptic attacks - Should we consider acceptance and commitment therapy?

Patients who experience functional non-epileptic attacks (FNEA) are frequently seen in Neurology clinics. Diagnosis alone can result in cessation of attacks for some patients, but many patients require further treatment. There is evidence that certain psychological therapies, like cognitive-behavioral therapy (CBT) and psychodynamic interpersonal therapy (PIT) can be beneficial. Acceptance and commitment therapy (ACT) is a type of CBT that has been found to be effective at treating other somatic disorders, like epilepsy and chronic pain. In this paper, we explain what ACT is, the current evidence-base for its use, and the rationale for why it may be a beneficial treatment for patients who experience FNEA. We conclude that ACT is a potential treatment option for FNEA, and further research is required.

Efficacy of metacognitive therapy for hypoactive sexual desire disorder among Iranian couples

OBJECTIVE

The aim of present study was to compare the efficacy of metacognitive therapy (MCT) against Masters-Johnson sex therapy (MJST) for hypoactive sexual desire disorder (HSDD) in Iranian couples.

METHODS

A randomized treatment trial was conducted. Participants were recruited from the family counseling clinics in Tehran and Isfahan. All were suffering from HSDD as defined by DSM-IV-R criteria. They were assigned randomly to two groups that received 10 sessions of either MCT or MJST. A sexual desire questionnaire was completed by participants before and after therapy and at 6-month follow-up.

RESULTS

Sexual desire increased significantly in the MCT group with respect to the MJST group which failed to show any significant improvement from baseline. Both groups showed a reduction in scores at 6-month follow-up. The difference recorded between the two groups after therapy was no longer significant at 6-month follow-up.

CONCLUSION

MCT affected sexual desire more than MJST as evaluated after therapy but the gain was not maintained at follow-up. Future research needs to investigate whether a greater focus on metacognitive beliefs about sexual behavior can improve the stability of treatment effects.

Combining Metacognitive Strategies with Traditional Cognitive Behavior Therapy in Generalized Anxiety Disorder: A Case Illustration

CONTEXT

Generalized anxiety disorder (GAD) is a challenging clinical condition to manage. Recent psychological models of GAD emphasis on the need to focus on metacognitive processes in addition to symptom reduction.

AIMS

We examined the application of metacognitive strategies in addition to conventional cognitive behaviour therapy (CBT) techniques in an adult patient with GAD.

SETTINGS AND DESIGNS

Asingle case design with pre- and post-assessments on clinician-rated scales was adopted.

MATERIALS AND METHODS

Twelve weekly sessions of therapy were conducted on an outpatient basis. Assessments were carried out on clinical global impressions scales, Hamilton's anxiety rating scale at pre- and post-therapy points.

STATISTICAL ANALYSIS

Pre- and post-therapy changes were examined using the method of clinical significance.

RESULTS

A combination of traditional CBT with MCT was effective in addressing anxiety and worry in this patient with GAD. The case illustrates the feasibility of matching therapeutic strategies to patient's symptom list and demonstrates a blend of metacognitive strategies and conventional CBT strategies.

CONCLUSIONS

In clinical practice, matching strategies to patient's problem list is important to be an effective approach.