Académique Documents
Professionnel Documents
Culture Documents
A R T I C L E I N F O A B S T R A C T
Keywords: Few studies have compared the effects of Metacognitive therapy (MCT) and Cognitive behavioral therapy (CBT)
Metacognitive therapy for comorbid anxiety disorders. In the current study we compared CBT and MCT for heterogeneous anxiety
CBT disorders in a residential setting. Ninety patients with a primary diagnosis of Post Traumatic Stress Disorder,
Transdiagnostic Social Phobia or Panic disorder, with and without Agoraphobia, were randomized to either CBT or MCT. Patients
Comorbidity
were assessed at pre-treatment, post-treatment and one-year follow-up. Primary outcome measures were Beck
Anxiety
Anxiety Inventory and ADIS IV and secondary outcome measures were SCID II, Beck Depression Inventory, Penn
State Worry Questionnaire, The Symptom Checklist-90 and the Inventory of Interpersonal Problems–64.
Treatment fidelity was satisfactory and therapist credibility was equal in both treatments. There was a significant
difference in the level of anxiety favouring MCT at post-treatment (d = 0.7), but there were no differences at
one-year follow-up, mainly due to a further improvement in the CBT group during the follow-up period. Both
treatments were efficacious. No differences in effect on comorbid diagnoses and symptoms were found, but MCT
produced larger change in personality problems. MCT seems to have a more rapid effect on anxiety symptoms,
but there were no significant differences in the long term for patients with comorbid anxiety disorders.
1. Introduction research have shifted towards processes that are common across psy-
chological disorders (Aldao & Nolen-Hoeksema, 2010; Harvey, Watkins,
Cognitive behavioral therapy (CBT) has grown into a collection of Mansell, & Shafran, 2004; Moses & Barlow, 2006; Wells & Matthews,
treatments for specific disorders and problems that have one key aspect 1994).
in common − changing maladaptive thoughts and behaviours (Beck, Several transdiagnostic processes have been discussed, each with a
1976). Meta-analyses have indicated that CBT has solid empirical evi- different treatment model, such as Metacognitive therapy (Wells, 2009)
dence and works well for a wide range of different disorders (Butler, and the Unified Protocol (Barlow et al., 2011). However, few studies
Chapman, Forman, & Beck, 2006; Tolin, 2010). CBT has developed by have evaluated the effect of transdiagnostic treatment models com-
designing specific variants of CBT for particular disorders (e.g., Clark, pared to a gold standard of disorder-specific treatments, such as CBT
1986). The use of a treatment for a single disorder may be problematic (Norton & Paulus, 2015 Reinholt & Krogh, 2014). A study by Norton
because comorbidity is common in psychiatric patients, especially for and Barrera (2012) compared a transdiagnostic cognitive-behavioral
anxiety disorders (Kessler et al., 2012). Further, comorbidity is associated group treatment to 12-week disorder-specific CBT protocols for panic
with higher level of disease burden (Gadermann, Alonso, Vilagut, disorder, social phobia, and generalized anxiety disorder, and failed to
Zaslavsky, & Kessler, 2012) and lowers the likelihood of recovery from find differences between transdiagnostic and the disorder-specific CBTs.
anxiety disorders (Bruce et al., 2008). To address comorbidity, trans- Moreover, no differences were found between disorder-specific and
diagnostic treatment models have been emerging and clinical theory and transdiagnostic CBT delivered in internet-format for GAD (Dear et al.,
☆
This study was supported by “The National Program for Integrated Clinical Specialist and PhD-training for Psychologists” in Norway. The results of this paper were presented at the
3rd international conference of Metacognitive Therapy in Milano, 2016.
⁎
Corresponding author at: Research Institute, Modum Bad, NO-3370, Vikersund, Norway.
E-mail addresses: Sverre.Johnson@modum-bad.no (S.U. Johnson), Asle.Hoffart@modum-bad.no (A. Hoffart), Hmor-n@online.no (H.M. Nordahl),
wampold@education.wisc.edu (B.E. Wampold).
http://dx.doi.org/10.1016/j.janxdis.2017.06.004
Received 18 November 2016; Received in revised form 5 June 2017; Accepted 12 June 2017
Available online 15 June 2017
0887-6185/ © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
2015), panic disorder with and without agoraphobia (Fogliati et al., Anxiety Disorder at Modum Bad Psychiatric Center in Norway in 2013.
2016) and depression (Titov et al., 2015). There is some evidence that Modum Bad is a specialist hospital conducting, which includes an in-
transdiagnostic CBT may reduce comorbid symptoms more than dis- patient program for treatment resistant patients with anxiety disorders.
order-specific CBT (Norton et al., 2013). However, this pattern was not Before admission all patients received treatment in their local com-
found in a trial comparing acceptance and commitment therapy (ACT) munity and had not responded to previous treatments. The patients
with disorder-specific CBT for mixed anxiety disorders (Arch et al., were admitted to the hospital in groups of eight, but were treated in-
2012). Thus, it seems preliminarily that transdiagnostic CBT produces dividually. Treatment took place from the autumn of 2013 to the au-
similar results as disorder-specific CBT, and there is inconclusive evi- tumn of 2014 and one-year follow up was finished in the autumn of
dence regarding the differential effect on comorbid diagnoses and 2015. Recruitment was designed to be liberal using the clinical criteria
symptoms. for treatment used at the department. We used the Anxiety Disorders
An innovative transdiagnostic treatment model is Metacognitive Interview Schedule (IV) (ADIS IV; Brown, Di Nardo, & Barlow, 1994) for
therapy (MCT). MCT is based on the transdiagnostic S-REF model diagnostic evaluation. To be eligible for participation in the study,
(Wells & Matthews, 1994, 1996). According to this theory, psycholo- participants had to meet criteria for a principal DSM-IV disorder, ex-
gical disorders are linked to the activation of self-regulatory strategies ceeding above four on the clinical severity rating (CSR) on the ADIS IV
called the cognitive attentional syndrome (CAS). CAS consists of ex- of PTSD, SAD or PD/A. Further, participants had to have failed to
tended thinking in the form of worry and rumination, threat monitoring benefit from at least one structured psychological treatment, be 18
and unhelpful coping behaviours, and is maintained by positive and years or older, able to speak Norwegian, and provide informed consent.
negative metacognitions. Positive metacognitions are positive beliefs Exclusion criteria followed the intake-procedures at the department of
about using the CAS (e.g., “If I worry I will be prepared.”) while ne- Anxiety Disorders at Modum Bad, which excluded patients who (a) in a
gative metacognitions are related to the subjective feeling of lack of clinical context would have required immediate treatment or simulta-
control or dangers of the CAS-processes (e.g., “My worrying is un- neous treatment that could interact with the treatment in unknown
controllable.”). In the MCT-treatment the therapist focuses on enhan- ways, (b) had current DSM-IV diagnoses of organic mental disorders, (c)
cing flexible thinking by explicitly challenging metacognitions (Wells, had clear and current suicidal risk or (d) had evidence of current sub-
2009). MCT models have shown promising results for specific disorders stance abuse. All participants had to terminate the use of psychotropic
like generalized anxiety disorder (GAD; McEvoy et al., 2015; Van der medications before treatment. The patients were contacted before
Heiden, Muris, & van der Molen, 2012), major depressive disorder treatment to ensure that medications were terminated or was being
(MDD; Hagen et al., 2017, Wells et al., 2012), post traumatic stress reduced. The study was approved by the Norwegian regional ethical
disorder (PTSD; Wells, Walton, Lovell, & Proctor, 2015) and comorbid committee (2013/209/REK South-East).
and complex anxiety disorders (Johnson & Hoffart, 2016). A recent Participants who were included in the trial (N = 90) were rando-
meta-analysis indicated that MCT was superior to both waitlist and CBT mized to treatment stratified on their principal disorder. There were six
(Normann, van Emmerik, & Morina, 2014). Further, a small study participants who did not arrive at the hospital or complete the first
(N = 30) comparing individual MCT with individual CBT found that assessment. The participants did not have any knowledge of their
MCT had a significantly better effect on anxiety and worry at post- treatment-group before arrival. After diagnostic screening six patients
treatment than CBT (Nordahl, 2009). However, to our knowledge no had a loss of eligibility and at start of treatment four patients were
other studies have investigated the effect of MCT across several dis- excluded due to a new therapist arriving at the hospital who was not
orders in a randomized controlled trial. A comparison of MCT with formally trained. The remaining 74 participants who started treatment
disorder-specific treatments in samples with high degree of comorbidity (n = 38 CBT, n = 36 MCT) were included in the final analysis. Of the
is needed. participants starting treatment, seven did not complete the treatment
The current study was designed to compare the best documented and program, leaving 67 who completed all the treatment sessions (n = 33
recommended treatments of CBT for post traumatic stress disorder in CBT, n = 34 in MCT). See Table 1 for final sample characteristics and
(PTSD), social phobia (SAD) and panic disorder with and without agor- Fig. 1 for flowchart.
aphobia (PD/A) with a generic version of individual MCT in routine
clinical practice. The disorders were grouped together because there is
high degree of comorbidity between PTSD and the other anxiety dis- 2.2. Baseline scores
orders (Brady, Killeen, Brewerton & Lucerini, 2000). Furthermore, social
phobia and PTSD symptoms are often comorbid (Collimore, Carleton, The participants had on average 3.7 diagnoses at the start of
Hofmann, Asmundson, 2010; McMillan, Sareen, & Asmundson, 2014), treatment with 90.5% having a comorbid disorder and 30 (41%) a
and panic attacks often occur together with PTSD and SAD (Cougle, personality disorder. Only four participants (5%) had been working full
Feldner, Keough, Hawkins, & Fitch, 2010; Kessler et al., 2005). The me- time when entering treatment (see Tables 1 and 3). That few partici-
tacognitive model is also based on a theory (S-REF model) in which pants were working regularly, which in combination with long duration
common processes (i.e., worry, rumination and threat monitoring) be- of the anxiety disorder (M = 16.1 years, SD = 11.8) indicates a sample
tween the different disorders is highlighted, and thus it is possible to of chronic and dysfunctional patients.
conceptualize a transdiagnostic case-formulation for PD/A, SAD and
PTSD.
Based on previous studies, it was hypothesized that MCT would 2.3. Study design
have larger effects on the anxiety and primary diagnoses than would the
disorder-specific CBT. Further, due to the more general focus of trans- Participants in the study were randomized to two different treatment
diagnostic processes it was hypothesized that MCT would have a larger modalities, generic MCT and disorder-specific CBT. Patients in both MCT
effect on comorbid diagnoses and other symptoms compared to dis- and CBT were assessed at evaluation, pre-treatment, at the end of
order-specific CBT. treatment, and after a one-year follow-up period. At evaluation the
participants were assessed by clinicians in the department who con-
2. Method firmed the presence of an anxiety disorder before randomization, and a
new formal assessment including two diagnostic interviews (ADIS IV and
2.1. Participants SCID II) and self report questionnaires were conducted at the start of
treatment. Assessors were blind to treatment conditions.
Participants were referred to treatment at the Department of
104
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
Table 1
Sample and group characteristics at pre-treatment and 1-year-follow-up (1YFW)f.
Characteristic Total (74) CBT (38) MCT (36) Total (59) CBT (30) MCT (29)
a,b
Occupational status (last 6 months)
Disabled 18 (24.7) 8 (21.6) 10 (27.8) 15 (25.4) 8 (26.7) 7 (24.1)
Unemployed 30 (41.1) 17 (45.9) 13 (36.1) 14 (23.7) 8 (26.7) 6 (20.7)
Sick leave 11 (15.1) 7 (18.9) 4 (11.1) 3 (5.1) 1 (3.3) 2 (6.9)
Partly employed 7 (9.6) 2 (5.4) 5 (13.9) 10 (16.9) 5 (16.7) 5 (17.2)
Employed 4 (5.5) 2 (5.4) 2 (5.6) 6 (10.2) 4 (13.3) 2 (6.9)
Other reasons 3 (4.1) 1 (2.7) 2 (5.6) 11 (18.6) 4 (13.3) 7 (24.1)
Treatment c,d
Former treatment 74 (100) 38 (100) 36 (100) 40 (67.8) 22 (73.3) 18 (62.1)
Outpatient psychiatric treatment 63 (85.1) 32 (84.2) 31 (86.1) 36 (61.0) 19 (63.3) 17 (58.6)
Inpatient psychiatric treatment 30 (40.5) 18 (47.3) 12 (33.3) 3 (5.1) 2 (6.6) 1 (3.4)
e
Use of medication before treatment
Yes/no 62/10 32/4 30/6 23/36 12/18 11/18
Minor tranquilizers 20 8 12 8 2 6
Antidepressants 38 20 18 15 10 5
Major tranquilizers 2 2 0 0 0 0
Other 2 2 0 0 0 0
Note.
a
Other reasons = founded by spouse/living on old fundings.
b
Percentages given in parenthesis. 1 person missing in CBT.
c
Patients had both inpatient and outpatient treatment.
d
Timeframe of pre-treatment is since the patient got sick.
e
Before treatment indicates all former uses of medication. 2 persons did not report use of medication before treatment.
f
The sample analysed consisted of primary diagnosis: PD/A N = 28, SAD N = 22, PTSD N = 24.
105
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
2.7. Treatment fidelity clinical psychology students trained by the MCT and CBT experts and
the first author. The two MCT trained students rated 313 MCT videos
Therapist competency for CBT was assessed using the Cognitive (across 33 patients) and the two CBT trained students rated 281 CBT
Therapy Scale (CTS; Young & Beck, 1980) and for MCT the Meta Cog- (across 34 patients). Patients’ average competence and adherence rat-
nitive Therapy Competency Scale (MCT-CS; Nordahl & Wells, 2009). ings across sessions were calculated. Every 15th to 18th video, chosen
CTS has shown good psychometric properties (Vallis, Shaw & Dobson, at random, was coded independently by the first author for inter-rater
1986), while MCT-CS has not undergone psychometric investigation reliability, and for giving necessary supervision to avoid rater drift.
(see supplementary A), but was developed to directly mirror the items Inter-rater reliability using a one-way random intraclass correlation
in the CTS. Competence was evaluated on a scale from 0 to 6 in both (ICC [1,1]) was 0.88 for MCT competence (N = 17) and 0.76 for ad-
MCT and CBT, and trial target for competence ratings was four or herence. The ICC (1, 1) for the CBT competence ratings (N = 18) was
above. Adherence to the treatment protocols was calculated based on 0.93 and 0.83 for adherence.
six items: setting agenda, checking homework, following the structure
of the treatment protocol, using CBT/MCT interventions, giving
2.8. Measures
homework and asking for feedback at the end of session. All available
videos from the trial (N = 594) were rated by one of four advanced
Measures that were not specific to a particular anxiety disorder, but
106
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
assessed anxiety as a generalized condition, were selected. The Beck 2.8.5. The inventory of interpersonal problems-64-circumplex (IIP-64-C;
Anxiety Inventory (BAI) and Anxiety Disorder Interview Schedule for Horowitz, Alden, Wiggins, & Pincus, 2000; Horowitz, Rosenberg, Baer,
DSM-IV (ADIS-IV) were used as primary outcomes of the trial. Ureño, & Villaseñor, 1988)
Secondary outcomes1 included the Structured Clinical Interview for IIP-64-C is a self-report measure of maladaptive relationship beha-
Diagnosis of DSM-IV Axis II (SCID II), Symptom Check List-90 (SCL-90), vior. The scale consisted of 64 items of which 8 subscales are con-
IIP-64, BDI, Penn State Worry Questionnaire (PSWQ) and use of the ceptually organized in a circumplex manner and the patients are asked
ADIS IV CSR-scores. To cover those diagnoses not measured by ADIS IV, to rate interpersonal behavior on a 5-point Likert scale. The IIP 64C has
the patients were screened for eating disorder and body dysmorphic shown good psychometric properties (Horowitz et al., 1988). The
disorder using the Mini-International Neuropsychiatric Interview Cronbach’s alpha coefficient for the IIP-64-C for this study at start of
(M.I.N.I.; Sheehan et al., 1998), both at pre-treatment and one-year treatment, at the end of treatment and at one-year follow-up was 0.96,
follow up. 0.98 and 0.96, respectively.
2.8.6. Beck depression inventory II (BDI II; Beck, Steer & Brown, 1996)
2.8.1. Beck anxiety inventory (BAI; Beck, Epstein, Brown & Steer, 1988)
BDI-II is a 21-item self-report scale assessing current level of de-
BAI is an instrument with 21 items, measuring anxiety symptoms
pression. The range of scores is from 0 to 63, and the items are scored
during the prior week. The items are rated on a Likert scale from 0 to 3,
on a Likert scale from 0 to 4. The psychometric properties of BDI are
and the total score ranges from 0 to 63. BAI has been found reliable and
adequate (Beck, Steer, & Garbin, 1988). The Cronbach’s alpha coeffi-
valid for measuring anxiety symptoms (Steer, Ranieri, Beck, & Clark,
cient for the BDI II for this study at start of treatment, at the end of
1993). We used the BAI as the primary self-report outcome because it
treatment and at one-year follow-up was 87, 0.93 and 0.93, respec-
was necessary to have a measure of anxiety that was appropriate across
tively.
the three anxiety disorders. The Cronbach’s alpha coefficients for BAI in
this study at start of treatment, at the end of treatment and at one-year
2.8.7. Penn state worry questionnaire (PSWQ; Meyer, Miller,
follow-up were 0.89, 0.92 and 0.91, respectively.
Metzger, & Borkovec, 1990)
PSWQ is a widely used 16- item self-report inventory assessing the
2.8.2. ADIS −IV (Brown, DiNardo & Barlow, 1994) pervasiveness, excessiveness, and uncontrollability of worry. Total
ADIS-IV is a semi structured diagnostic interview designed to assess scores on the PSWQ range from 16 to 80 and the items are scored on a
the presence, nature and severity of DSM-IV anxiety and mood dis- Likert scale from 1 to 5. The PSWQ is a reliable and valid instrument for
orders. Clinical Severity Ratings (CSR) are conducted for each disorder measuring worry (Meyer et al., 1990). The Cronbach’s alpha coefficient
on a scale from 0 to 8. ADIS-IV interviewers were advanced clinical for the PSWQ for this study at start of treatment, at the end of treatment
psychology students, trained to reliability standards, who had demon- and at one-year follow-up was 0.92, 0.94 and 0.92, respectively.
strated adequate diagnostic reliability on three consecutive interviews.
All interviewers were blind to treatment condition. Reliability assessors 2.8.8. Generalization of treatment effects
who were blind to the original diagnosis coded videos of 15 percent of Co-occurring mood and anxiety disorders (with CSR of 4 or more) at
randomly chosen diagnostic interviews (N = 20). Inter-rater reliability post-treatment and one-year follow-up were analysed as an index of
on the principal diagnosis, PD/A, SAD and PTSD, was 100%. Inter-rater generalization of treatment effects. We used number of diagnoses and
agreement on dimensional CSR ratings for the primary diagnosis, using the total score of CSR for each patient as the measure of generalization
a one-way random intraclass correlation (ICC [1,1]) was 0.96 with a of treatment effects. The procedure was similar to the one used in a
single-measure,. The ICC (1, 1) across all the anxiety and mood dis- recently published RCT (Arch et al., 2012). Further, we used total
orders (met DSM IV criteria vs subclinical vs. none) was 0.85 and the number of 3 criteria (SCID II) as a marker for the effect on personality
ICC (1, 1) for the sum score of dimensional CSR rating was 0.89. problems.
107
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
Table 2
Mean, Standard deviation and effect sizes from pre- to post-treatment and 1-year-follow-up (IYFW).
Measure and condition Pre M (SD) Post M (SD) IYFW M (SD) d pre-posta d pre-IYFW
BAI
CBT (N = 38) 24.8 (10.0) 20.8 (12.1) 15.8 (10.9) 0.36 CI [-0.10, 0.81] 0.86 CI [0.38, 1.32]
MCT (N = 36) 26.7 (11.7) 15.7 (10.2) 17.4 (10.4) 1.00 CI [0.5, 1.48] 0.84 CI [0.35, 1.31]
BDI
CBT (N = 38) 20.8 (9.3) 16.9 (10.9) 16.6 (10.9) 0.38 CI [-0.07, 0.83] 0.41 CI [-0.04, 0.86]
MCT (N = 36) 22.0 (9.2) 12.1 (9.6) 15.8 (10.9) 1.05 CI [0.55, 1.53] 0.61 CI [0.14, 1.08]
IIP 64c
CBT (N = 38) 1.43 (0.60) 1.24 (0.67) 1.20 (0.62) 0.30 CI [-0.16, 0.75] 0.38 CI [-0.07, 0.83]
MCT (N = 36) 1.32 (0.58) 1.06 (0.71) 1.15 (0.63) 0.40 CI [-0.07, 0.86] 0.28 CI [-0.19, 0.74]
SCL 90
CBT (N = 38) 1.52 (0.51) 1.15 (0.67) 1.10 (0.70) 0.62 CI [0.15, 1.08] 0.68 CI [0.22, 1.14]
MCT (N = 36) 1.53 (0.58) 0.88 (0.60) 1.05 (0.66) 1.10 CI [0.59, 1.58] 0.77 CI [0.29, 1.24]
PSWQ
CBT (N = 37) 58.03 (14.8) 54.73 (15.8) 52.39 (13.2) 0.22 CI [-0.24, 0.66] 0.40 CI [-0.06, 0.86]
MCT (N = 36) 61.22 (12.1) 50.24 (14.3) 52.12 (13.4) 0.83 CI [0.34, 1.30] 0.71 CI [0.23, 1.18]
Note. BAI = Beck Anxiety Inventory, BDI = Beck Depression Inventory, IIP 64 = Inventory of Interpersonal Problems 64, SCL–90 = Symptom Checklist 90, PSWQ = Penn State Worry
Questionnaire.
a
Cohen's d = M1 − M2/SDpooled.
significance criteria on the BAI (Jacobson & Truax, 1991). The cut off 2.12. Power estimation
score of 15 was used to demark the clinical range, which based on the
norms from Gillis, Haaga and Ford (1995). The norms from Beck et al. Power analysis, conducted with Optimal Design (Raudenbush & Liu,
(1988) were used to calculate the standard error of the difference be- 2000), indicated that to reach 80% power with an effect size of d = 0.6,
tween the two scores and the reliable change index (RCI). Using the cut required 78 participants. Therefore our total sample size (N = 90) was
off point and the RCI, each patient could be classified as recovered expected to be sufficient to detect between group differences of mod-
(passed both criteria), improved (passed only the RCI criterion in the erate size at each assessment point as found in previous research by
positive direction), unchanged (did not pass the RCI criterion), or de- Nordahl (2009) and Normann et al. (2014).
teriorated (passed the RCI criterion in the negative direction).
3. Results
The data from all patients who started treatment were analysed. Chi Table 1 gives an overview of the characteristics of the patients at
square tests and t-tests (two-tailed) were conducted to check for dif- pre-treatment and one-year follow-up. The patients’ did not differ on
ferences at pre-treatment. Treatment differences were analysed using key variables at pre-treatment, including number of diagnoses, former
Hierarchical Linear Modelling (HLM; Raudenbush & Bryk, 2002). In treatment, use of medications, age and gender (p > 0.05 for all vari-
HLM all available data is used. Thus, a research participant with only ables). Further, no significant pre-treatment differences between con-
baseline data can be included in an analysis and contribute to the es- ditions emerged on the outcome variables (p > 0.05 for all variables;
timation of model parameters (Kwok et al., 2008). The models were see supplementary material B). The sample analysed included 74 pa-
built by starting with a model with only fixed intercept and no random tients, of whom 72 were Norwegians (Caucasian), 1 was African and 1
effects. Random intercepts and random slope were then added if they was Asian. The mean age was 42.0 (SD = 12.8), mean duration of ill-
significantly increased model fit. The data was modelled for hetero- ness was 16.1 years (SD = 11.8), 45 (60.8%) were female and 29
scedastic residual variance over time. A diagonal covariance structure (39.2%) were male, 39 (52.7%) lived alone. Only 9 (12.2%) had a
of the residuals gave the best model fit. Maximum likelihood (ML) was university degree, while the majority had only upper secondary school
used as the estimation method (Fitzmaurice, Laird, & Ware, 2004). All 28 (37.8%). Of the 74 patients entering treatment, seven patients
models were tested for model fit using log likelihood tests, and the most (9.5%) terminated treatment prematurely. Two patients dropped out of
parsimonious model was selected. Since a non-linear relationship was MCT late in therapy (i.e.,after 4 weeks), and five patients dropped out
expected, with a larger decrease from pre-treatment to post-treatment, of CBT early (i.e., before 4 weeks). Drop out rate in the two conditions
we used a piecewise HLM with two different time variables. did not significantly differ (p = 0.159; Fisher’s exact test). The reasons
The MCAR (Missing Completely at Random) test (Little, 1988) was for drop out in MCT were loss of motivation (n = 1) and use of alcohol
not significant on the BAI (χ2 = 3,2, p = 0.669) or the other measures, (n = 1). In CBT the reasons were lack of motivation (n = 4) and use of
indicating that the data could be considered to be missing at random. alcohol (n = 1). In total, sixty-seven patients (MCT, N = 34; CBT,
Multiple imputations with twenty-five datasets were used on all the N = 33) completed the post-treatment assessment. See Fig. 1 for par-
self-report measures (Graham, Olchowski, & Gilreath, 2007; Graham, ticipant flow.
2009; Rubin, 1996). Pre-treatment scores were used as predictors, and
the pooled estimates used in the calculation of clinical significant
3.2. Treatment effects
change, mean and standard deviation. Due to the number of analyses
and in an effort to minimise Type I error, the false discovery rate pro-
3.2.1. Primary and secondary outcomes
cedure (Benjamini & Hochberg, 1995) was applied to determine sig-
The means and standard deviations for patients in the two treat-
nificance. Effect sizes (Cohen’s d) for HLM-analysis are calculated based
ments across outcome assessment are reported in Table 2 (self-report
on Feingold (2009). Interpretations were based on the classifications of
measures) and Table 3 (interview-based ADIS). To test for treatment
Cohen (1988). SPSS version 21.0 was used.
differences we conducted HLM with linear splines on all outcome
108
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
Table 4
BAI, SCL-90, BDI, IIP-64, PSWQ and ADIS in HLM.
Fixed parameters
Intercept 24.6*** (1.8), 21.2*** (1.5), 1.5*** (0.9), 58.0*** (2.4), 1.4*** (0.1), 7.0*** (0.3),
[20.9, 28.3] [18.2, 24.2] [1.3, 1.7] [53.3, 62.8] [1.2, 1.6] [6.3, 7.6]
Slope −3.5 (2.1), −4.3** (1.6), −0.4*** (0.09), −2.7 (2.0), −0.2* (0.1), −2.2** (0.8),
[−7.7, 0.7] [−7.4, −1.2] [−0.5, −0.2] [−6.6, 1.2] [−0.4,−0.1] [−3.8, −0.6]
Slope2 −2.3 (3.7), 3.6 (3.0), 0.3 (0.2), −0.01 (3.2), 0.1 (0.2), 0.6 (1.8),
[−9.6, 5.1] [−2.4, 9.5] [−0.06, 0.6] [−6.4, 6.3] [−0.2, 0.4] [−3.0, 4.1]
Group 1.9 (2.7), 0.8* (2.2), 0.01(01) 3.2 (3.4), −0,1 (0.1), 0.1 (0.2),
[−3.4, 7.2] [−3.5, 5.2] [−0.2, 0.3] [−3.6, 10.0] [−0.4, 0.2] [−0.4, 0.4]
Group*slope −7.6* (3.0), −6.0** (2.2), −0.3* (0.13), −8.7** (2.7), −0.1 (0.1), −0.3 (0.5),
[−13.5, −1.6] [−10.4, −1.6] [−0.5, −0.04] [−14.1, −3.2] [−0.3, 0.2] [−1.3, 0.7]
Group*slop- 15.0** (5.2) 10.5* (4.2) 0.5* (0.24), 13.6** (4.4), 0.2 (0.2), 1.1 (1.1),
e2 [4.7, 25.3] [2.1, 18.8] [0.04, 1.04] [4.8, 22.4] [−0.2, 0.7] [−1.1, 3.4]
Random parameters
Intercept 42.3*** (12.1) 53.0*** (11.7) 0.20*** (0.04) 139.7*** (26.5) 0.26*** (0.05) 0.5** (0.2)
-2 LL 1462.5 1403.2 306.8 1463.2 291.6 732.2
Note. 2 LL = −2 Log Likelihood Standard error is given in parenthesis, 95% Confidence interval given in brackets.
*p < 0.05. **p < 0.01. ***p < 0.001. BAI = Beck Anxiety Inventory, BDI = Beck Depression Inventory, IIP 64 = Inventory of Interpersonal Problems 64, SCL–90 = Symptom
Checklist 90, PSWQ = Penn State Worry Questionnaire, ADIS = Anxiety Disorder Interview Scale (primary diagnosis clinical severity rating).
109
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
110
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
thank the individuals who participated in the study, the department of Washington, DC: American Psychiatric Press.
Fitzmaurice, G., Laird, N., & Ware, J. (2004). Applied longitudinal analysis. New York: John
anxiety disorder at Modum Bad for data collection and the research Wiley and Sons.
assistants who assisted in data collection. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD:
Emotional processing of traumatic experiences therapist guide (Treatments that work).
USA: Oxford University Press.
Appendix A. Supplementary data Fogliati, V. J., Dear, B. F., Staples, L. G., Terides, M. D., Sheehan, J., Johnston, L., ... Titov,
N. (2016). Disorder-specific versus transdiagnostic and clinician-guided versus self-
Supplementary data associated with this article can be found, in the guided internet-delivered treatment for panic disorder and comorbid disorders: A
randomized controlled trial. Journal of Anxiety Disorders, 39, 88–102. http://dx.doi.
online version, at http://dx.doi.org/10.1016/j.janxdis.2017.06.004. org/10.1016/j.janxdis.2016.03.005.
Gadermann, A., Alonso, J., Vilagut, G., Zaslavsky, A., & Kessler, R. (2012). Comorbidity
References and disease burden in the national comorbidity survey replication (NCS-R).
Depression and Anxiety, 29, 797–806. http://dx.doi.org/10.1002/da.21924.
Gillis, M. M., Haaga, D. A. F., & Ford, G. T. (1995). Normative values for the beck anxiety
Aldao, A., & Nolen-Hoeksema, S. (2010). Specificity of cognitive emotion regulation inventory, fear questionnaire, penn state worry questionnaire, and social phobia and
strategies: A transdiagnostic examination. Behaviour Research and Therapy, 48, anxiety inventory. Psychological Assessment, 7, 450–455. http://dx.doi.org/10.1037/
974–983. http://dx.doi.org/10.1016/j.brat.2010.06.002. 1040-3590.7.4.450.
Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Graham, J. W., Olchowski, A. E., & Gilreath, T. D. (2007). How many imputations are
Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance really needed? Some practical clarifications of multiple imputation theory. Prevention
and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Science, 8, 206–213. http://dx.doi.org/10.1007/s11121-007-0070-9.
Clinical Psychology, 80, 750–765. http://dx.doi.org/10.1037/a0028310. Graham, J. W. (2009). Missing data analysis: Making it work in the real world. Annual
Beck, A. T., Steer, R., & Brown, G. (1996). Beck depression inventory-II manual. San Review of Psychology, 60, 549–576. http://dx.doi.org/10.1146/annurev.psych.58.
Antonio, TX: The Psychological Corporation. 110405.085530.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Hagen, R., Hjemdal, O., Solem, S., Kennair, L. E. O., Nordahl, H. M., Fisher, P., & Wells, A.
Universities Press. (2017). Metacognitive therapy for depression in adults: A waiting list randomized
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring controlled trial with six months follow-Up. Frontiers in Psychology, 8(31), http://dx.
clinical anxiety: Psychometric properties. Journal of Consulting and Clinical doi.org/10.3389/fpsyg.2017.00031.
Psychology, 56, 893–897. http://dx.doi.org/10.1037/0022-006X.56.6.893. Harvey, A. G., Watkins, E. R., Mansell, W., & Shafran, R. (2004). Cognitive-behavioral
Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck processes across psychological disorders: A transdiagnostic approach to research and
Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, treatment. Oxford: Oxford University Press.
77–100. http://dx.doi.org/10.1037/0022-006X.56.6.893. Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short
Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and version of the Working Alliance Inventory. Psychotherapy Research, 16, 12–25. http://
powerful approach to multiple testing. Journal of the Royal Statistical Society. Series B dx.doi.org/10.1080/10503300500352500.
(Methodological), 57, 289–300. Hoffart, A., Øktedalen, T., Svanøe, K., Hedley, L. M., & Sexton, H. (2015). Predictors of
Borkovec, T. D., & Nau, S. D. (1972). Credibility of analogue therapy rationales. Journal of short- and long-term avoidance in completers of inpatient group interventions for
Behavior Therapy and Experimental Psychiatry, 3, 257–260. http://dx.doi.org/10. agoraphobia. Journal of Affective Disorders, 181, 33–40. http://dx.doi.org/10.1016/j.
1016/0005-7916(72)90045-6. jad.2015.04.015.
Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S. (2000). Comorbidity of psy- Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult anxiety
chiatric disorders and posttraumatic stress disorder. Journal of Clinical Psychiatry, disorders: A meta-analysis of randomized placebo-controlled trials. The Journal of
61(Suppl. 7), 22–32. Clinical Psychiatry, 69, 621–632.
Brown, T. A., Di Nardo, P. A., & Barlow, D. H. (1994). Anxiety disorders interview schedule Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G., & Villaseñor, V. S. (1988).
for DSM-IV (adult version). Albany, NY: Graywind. Inventory of interpersonal problems: Psychometric properties and clinical applica-
Bruce, S. E., Yonkers, K. A., Otto, M. W., Eisen, J. L., Weisberg, R. B., Pagano, M., ... tions. Journal of Consulting and Clinical Psychology, 56, 885–892. http://dx.doi.org/
Keller, M. B. (2008). Influence of psychiatric comorbidity on recovery and recurrence 10.1037/0022-006X.56.6.885.
in generalized anxiety disorder, social phobia, and panic disorder: A 12-year pro- Horowitz, L. M., Alden, L. E., Wiggins, J. S., & Pincus, A. L. (2000). Inventory of inter-
spective study. Focus, 6, 539–548. http://dx.doi.org/10.1176/foc.6.4.foc539. personal problems: San Antoni. TX: Psychological Corporation.
Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the working
cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, alliance inventory. Journal of Counseling Psychology, 36, 223–233. http://dx.doi.org/
26, 17–31. http://dx.doi.org/10.1016/j.cpr.2005.07.003. 10.1037/0022-0167.36.2.223.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Social Phobia: Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to de-
Diagnosis, Assessment, and Treatment, 41, 68. fining meaningful change in psychotherapy research. Journal of Consulting and
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, Clinical Psychology, 59, 12–19. http://dx.doi.org/10.1037/0022-006X.59.1.12.
461–470. http://dx.doi.org/10.1016/0005-7967(86)90011-2. Johnson, S. U., & Hoffart, A. (2016). Metacognitive therapy for comorbid anxiety dis-
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Lawrence Erlbaum orders: A case study. Frontiers in Psychology, 7(1515), http://dx.doi.org/10.3389/
Associates. fpsyg.2016.01515.
Collimore, K. C., Carleton, R. N., Hofmann, S. G., & Asmundson, G. J. G. (2010). Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and
Posttraumatic stress and social anxiety: The interaction of traumatic events and in- comorbidity of 12-month DSM-IV disorders in the national comorbidity survey re-
terpersonal fears. Depression and Anxiety, 27, 1017–1026. http://dx.doi.org/10.1002/ plication. Archives of General Psychiatry, 62, 617–627. http://dx.doi.org/10.1001/
da.20728. archpsyc.62.6.617.
Cougle, J. R., Feldner, M. T., Keough, M. E., Hawkins, K. A., & Fitch, K. E. (2010). Kessler, R. C., Avenevoli, S., McLaughlin, K. A., Green, J. G., Lakoma, M. D., Petukhova,
Comorbid panic attacks among individuals with posttraumatic stress disorder: M., ... Merikangas, K. R. (2012). Lifetime co-morbidity of DSM-IV disorders in the US
Associations with traumatic event exposure history, symptoms, and impairment. national comorbidity survey replication adolescent supplement (NCS-A).
Journal of Anxiety Disorders, 24, 183–188. http://dx.doi.org/10.1016/j.janxdis.2009. Psychological Medicine, 42, 1997–2010. http://dx.doi.org/10.1002/mpr.1359.
10.006. Kwok, O.-M., Underhill, A. T., Berry, J. W., Luo, W., Elliott, T. R., & Yoon, M. (2008).
Dear, B. F., Staples, L. G., Terides, M. D., Karin, E., Zou, J., Johnston, L., ... Titov, N. Analyzing longitudinal data with multilevel models: An example with individuals
(2015). Transdiagnostic versus disorder-specific and clinician-guided versus self- living with lower extremity intra-articular fractures. Rehabilitation Psychology, 53,
guided internet-delivered treatment for generalized anxiety disorder and comorbid 370–386. http://dx.doi.org/10.1037/a0012765.
disorders: A randomized controlled trial. Journal of Anxiety Disorders, 36, 63–77. Little, R. J. A. (1988). A test of missing completely at random for multivariate data with
http://dx.doi.org/10.1016/j.janxdis.2015.09.003. missing values. Journal of the American Statistical Association, 83, 1198–1202. http://
Derogatis, L. R. (1983). The symptom checklist −90 revised: Administration. scoring and dx.doi.org/10.2307/2290157.
procedures manual II (1983). Baltimore: Clinical Psychometric Research. McEvoy, P. M., Erceg-Hurn, D. M., Anderson, R. A., Campbell, B. N. C., Swan, A.,
Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/ex- Saulsman, L. M., ... Nathan, P. R. (2015). Group metacognitive therapy for repetitive
pectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, negative thinking in primary and non-primary generalized anxiety disorder: An ef-
73–86. http://dx.doi.org/10.1016/S0005-7916(00)00012-4. fectiveness trial. Journal of Affective Disorders, 175, 124–132. http://dx.doi.org/10.
Devilly, G. J., & McFarlane, A. C. (2009). When wait lists are not feasible, nothing is a 1016/j.jad.2014.12.046.
thing that does not need to be done. Journal of Consulting and Clinical Psychology, 77, McMillan, K. A., Sareen, J., & Asmundson, G. J. (2014). Social anxiety disorder is asso-
1159–1168. http://dx.doi.org/10.1037/a0016878. ciated with PTSD symptom presentation: An exploratory study within a nationally
Durham, R. C., Chambers, J. A., Power, K. G., Sharp, D. M., Macdonald, R. R., Major, K. representative sample. Journal of Traumatic Stress, 27, 602–609. http://dx.doi.org/
A., ... Gumley, A. L. (2005). Long-term outcome of cognitive behaviour therapy 10.1002/jts.21952.
clinical trials in central Scotland. Healt Technology Assessment, 9, 1–4. Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and
Feingold, A. (2009). Effect sizes for growth-modeling analysis for controlled clinical trials validation of the penn state worry questionnaire. Behaviour Research and Therapy, 28,
in the same metric as for classical analysis. Psychological Methods, 14, 43–53. http:// 487–495. http://dx.doi.org/10.1016/0005-7967(90)90135-6.
dx.doi.org/10.1037/a0014699. Moses, E. B., & Barlow, D. H. (2006). A new unified treatment approach for emotional
First, B. M., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). User’s disorders based on emotion science. Current Directions In Psychological Science, 15,
guide for the structured clinical interview for DSM-IV Axis II personality disorders: SCID-II. 146–150. http://dx.doi.org/10.1111/j.0963-7214.2006.00425.x.
111
S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112
Murphy, G. C., & Athanasou, J. A. (1999). The effect of unemployment on mental health. Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.):
Journal of Occupational and Organizational Psychology, 72, 83–99. http://dx.doi.org/ The development and validation of a structured diagnostic psychiatric interview for
10.1348/096317999166518. DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33.
National Institute for Health and Care Excellence (2013). Social anxiety disorder: Steer, R. A., Ranieri, W. F., Beck, A. T., & Clark, D. A. (1993). Further evidence for the
Recognition, assessment and treatment. NICE clinical guideline 159. validity of the beck anxiety inventory with psychiatric outpatients. Journal of Anxiety
Nordahl, H. M., & Wells (2009). Metacognitive therapy competence scale. Metacognitive Disorders, 7, 195–205. http://dx.doi.org/10.1016/0887-6185(93)90002-3.
Therapy Institute Unpublished manuscript. Titov, N., Dear, B. F., Staples, L. G., Terides, M. D., Karin, E., Sheehan, J., ... McEvoy, P. M.
Nordahl, H. M. (2009). Effectiveness of brief metacognitive therapy versus cognitive- (2015). Disorder-specific versus transdiagnostic and clinician-guided versus self-
behavioral therapy in a general outpatient setting. International Journal of Cognitive guided treatment for major depressive disorder and comorbid anxiety disorders: A
Therapy, 2, 152–159. http://dx.doi.org/10.1521/ijct.2009.2.2.152. randomized controlled trial. Journal of Anxiety Disorders, 35, 88–102. http://dx.doi.
Normann, N., van Emmerik, A. A. P., & Morina, N. (2014). The efficacy of metacognitive org/10.1016/j.janxdis.2015.08.002.
therapy for anxiety and depression: A meta-analytic review. Depression and Anxiety, Tolin, D. F. (2010). Is Cognitive-behavioural therapy more effective than other therapies?
31, 402–411. http://dx.doi.org/10.1002/da.22273. A meta-analytic review. Clinical Psychology Review, 30, 710–720. http://dx.doi.org/
Norton, P. J., & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for 10.1016/j.cpr.2010.05.003.
anxiety disorders: A preliminary randomized controlled noninferiority trial. Tsao, J. C. I., Lewin, M. R., & Craske, M. G. (1998). The effects of cognitive-behavior
Depression and Anxiety, 29, 874–882. http://dx.doi.org/10.1002/da.21974. therapy for panic disorder on comorbid conditions. Journal of Anxiety Disorders, 12,
Norton, P. J., & Paulus, D. J. (2015). Toward a unified treatment for emotional disorders: 357–371. http://dx.doi.org/10.1016/S0887-6185(98)00020-6.
Update on the science and practice. Behavior Therapy, 47, 854–868. http://dx.doi. Vallis, T. M., Shaw, B. F., & Dobson, K. S. (1986). The cognitive therapy scale:
org/10.1016/j.beth.2015.07.002. Psychometric properties. Journal of Consulting and Clinical Psychology, 54, 381–385.
Norton, P. J., Barrera, T. L., Mathew, A. R., Chamberlain, L. D., Szafranski, D. D., Reddy, http://dx.doi.org/10.1037/0022-006X.54.3.381.
R., & Smith, A. H. (2013). Effect of transdiagnostic CBT for anxiety disorders on Van der Heiden, C., Muris, P., & van der Molen, H. T. (2012). Randomized controlled trial
comorbid diagnoses. Depression and Anxiety, 30, 168–173. http://dx.doi.org/10. on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy
1002/da.22018. for generalized anxiety disorder. Behaviour Research and Therapy, 50, 100–109.
Raudenbush, S. W., & Bryk, A. S. (2002). Hierarchical linear models: Applications and data http://dx.doi.org/10.1016/j.brat.2011.12.005.
analysis methods (2nd ed.). Newbury Park, CA: Sage. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what
Raudenbush, S. W., & Liu, X. (2000). Statistical power and optimal design for multisite makes psychotherapy work (2nd ed.). Routledge.
randomized trials. Psychological Methods, 5, 199–213. Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Erlbaum
Reinholt, N., & Krogh, J. (2014). Efficacy of transdiagnostic cognitive behaviour therapy Associates.
for anxiety disorders: A systematic review and meta-analysis of published outcome Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF
studies. Cognitive Behaviour Therapy, 43, 171–184. http://dx.doi.org/10.1080/ model. Behaviour Research and Therapy, 34, 881–888. http://dx.doi.org/10.1016/
16506073.2014.897367. S0005-7967(96)00050-2.
Rubin, D. B. (1996). Multiple imputation after 18+ years (with discussion). Journal of the Wells, A., Fisher, P., Myers, S., Wheatley, J., Patel, T., & Brewin, C. R. (2012).
American Statistical Association, 91, 473–489. http://dx.doi.org/10.2307/2291635. Metacognitive therapy in treatment-resistant depression: A platform trial. Behaviour
Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Research and Therapy, 50, 367–373. http://dx.doi.org/10.1016/j.brat.2012.02.004.
Psychological treatment of panic disorder with or without agoraphobia: A meta- Wells, A., Walton, D., Lovell, K., & Proctor, D. (2015). Metacognitive therapy versus
analysis. Clinical Psychology Review, 30, 37–50. http://dx.doi.org/10.1016/j.cpr. prolonged exposure in adults with chronic post-traumatic stress disorder: A parallel
2009.08.011. randomized controlled trial. Cognitive Therapy and Research, 39, 70–80.
Schmitz, N., Hartkamp, N., Kiuse, J., Franke, G. H., Reister, G., & Tress, W. (2000). The Wells, A. (1997). Cognitive therapy of anxiety disorders. Wiley.
symptom check-list-90-R (SCL-90-R): A german validation study. Quality of Life Wells, A. (2009). Metacognitive therapy for anxiety and depression. The Guilford Press.
Research, 9, 185–193. Young, J., & Beck, A. (1980). Cognitive therapy scale: Rating manual. Philadelphia, PA:
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., ... Center for Cognitive Therapy Unpublished manuscript.
112