Metacognitive therapy for generalized anxiety disorder: An open trial

Abstract

Generalized anxiety disorder (GAD) responds only modestly to existing cognitive-behavioural treatments. This study investigated a new treatment based on an empirically supported metacognitive model [Wells, (1995). Metacognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320; Wells, (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, UK: Wiley]. Ten consecutive patients fulfilling DSM-IV criteria for GAD were assessed before and after metacognitive therapy, and at 6, and 12-month follow-up. Patients were significantly improved at post-treatment, with large improvements in worry, anxiety, and depression (ESs ranging from 1.04–2.78). In all but one case these were lasting changes. Recovery rates were 87.5% at post treatment and 75% at 6 and 12 months. The treatment appears promising and controlled evaluation is clearly indicated.

Introduction

Generalized anxiety disorder (GAD) appears moderately responsive to cognitive-behavioural treatments (e.g. Durham & Allan, 1993). In a reanalysis of data from six CBT outcome studies, Fisher and Durham (1999) reported a recovery rate across all treatments of 40% overall based on trait-anxiety scores (Speilberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Two treatments, applied relaxation (AR) and individual cognitive behaviour therapy (CBT), did best with recovery rates at post treatment of 17–59% for AR and 26–71% for CBT. At 6-month follow-up one particular study (Borkovec & Costello, 1993) obtained a recovery rate for AR of 81%.

In two more recent studies, AR appeared less effective (Arntz, 2003; Ost & Breitholtz, 2000). Ost and Brietholtz obtained small improvements in trait anxiety following AR. Arntz (2003) compared cognitive therapy with applied relaxation. At post treatment he reported that 35% of cognitive therapy patients and 44.4% of applied relaxation patients were recovered. At 6-month follow-up this had increased to 55% of cognitive therapy patients and 53.3% of applied relaxation patients on the basis of the trait-anxiety scale.

These data show that the outcomes for AR and CBT show considerable variability, and there is a need for more effective treatments. Recent attempts to improve treatment have combined these treatment elements, and increased the amount of therapy delivered (e.g. Borkovec, Newman, Pincus, & Lytle, 2002; Durham et al., 2004). However, so far treatment outcomes have not improved.

Progress might be made by basing treatment on a model of the mechanisms and factors underlying pathological worry, the hallmark of this disorder. The present study reports an initial evaluation of a new form of cognitive therapy (metacognitive therapy (MCT): Wells (1995), Wells (1997)) that is based on a specific model of GAD. Furthermore, it aims to assess the impact of the treatment on multiple dimensions of worry.

The metacognitive model (Wells (1995), Wells (1997)) asserts that individuals with GAD, like most people, hold positive beliefs about worrying as an effective means of dealing with threat. However, worry is used as an inflexible means of coping, and this becomes a problem when negative beliefs concerning the uncontrollability and the dangers of worrying develop, leading to unhelpful control strategies.

In this model two broad subtypes of worry are distinguished called type 1 and type 2 worry. Type 1 refers to worry about external events and physical symptoms, and can be distinguished from type 2, which concerns negative appraisals of worrying. Essentially type 2 worry is worry about worrying. In the model worrying is used as a means of coping with threat. It persists until the individual achieves an internal/external signal that signifies that it is safe to stop worrying or until the person is distracted from the activity. During the development GAD negative appraisals of worrying and associated negative beliefs about worry develop. Two domains of negative belief/appraisals are important and concern (1) the uncontrollability of worrying, and (2) its dangerous consequences for physical, psychological, and social functioning. When negative metacognitions of this kind develop, the person experiences an elevation in distress and worry. The co-existence of positive and negative beliefs about worrying lead to unhelpful vacillation in attempts to avoid and engage in worry, and the use of unhelpful mental regulation strategies such as reassurance seeking and thought suppression. Such strategies when they are successful prevent the person from discovering that worrying does not lead to catastrophe. Some strategies do not work and reinforce beliefs in loss of control. For example, attempting to suppress thoughts that trigger worry can backfire and increase preoccupation with these thoughts. Strategies such as seeking reassurance do not allow the person to unambiguously discover that worrying can be controlled by the self. It follows from this model that successful treatment of GAD should focus on modifying several metacognitive factors, including counterproductive thought control strategies, erroneous beliefs about the uncontrollability of worry, negative beliefs about the danger of worrying, and positive beliefs that support the over-reliance on worrying as a coping strategy.