Elsevier

Journal of Anxiety Disorders

Volume 35, October 2015, Pages 19-26
Journal of Anxiety Disorders

Mechanisms of change during group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder

https://doi.org/10.1016/j.janxdis.2015.07.003Get rights and content

Highlights

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    Investigated mechanisms of change in brief group metacognitive therapy (MCT).

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    Patients had primary and non-primary generalized anxiety disorder.

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    Tested indirect effects of metacognitive beliefs (MCBs) on symptoms via repetitive negative thinking (RNT).

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    An indirect effect of negative MCBs on symptoms via RNT was found.

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    An indirect effect was not found for positive MCBs.

Abstract

Repetitive negative thinking (RNT) is a transdiagnostic process that serves to maintain emotional disorders. Metacognitive theory suggests that positive and negative metacognitive beliefs guide the selection of RNT as a coping strategy which, in turn, increases psychological distress. The aim of this study was to test the indirect effect of metacognitive beliefs on psychological distress via RNT. Patients (NĀ =Ā 52) with primary and non-primary generalized anxiety disorder attended a brief, six-week group metacognitive therapy program and completed measures of metacognitive beliefs, RNT, and symptoms at the first and final treatment sessions, and at a one-month follow-up. Prospective indirect effects models found that negative metacognitive beliefs (but not positive metacognitive beliefs) had a significant indirect effect on psychological distress via RNT. As predicted by metacognitive theory, targeting negative metacognitions in treatment appears to reduce RNT and, in turn, emotional distress. Further research using alternative measures at multiple time points during therapy is required to determine whether the absence of a relationship with positive metacognitive beliefs in this study was a consequence of (a) psychometric issues, (b) these beliefs only being relevant to a subgroup of patients, or (c) a lack of awareness early in treatment.

Introduction

Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry and hyperarousal (e.g., restlessness, irritability, muscle tension; American Psychiatric Association [APA], 2013). GAD has a lifetime prevalence of around 6% (Kessler et al., 2005, McEvoy et al., 2011) and is highly comorbid with other anxiety disorders and depression (Brown, Campbell, Lehman, Grisham, & Mancill, 2001). In a large treatment-seeking sample (NĀ =Ā 1127), Brown et al. (2001) found that GAD was the most common comorbid diagnosis for individuals with major depression. GAD was also the second most common comorbid anxiety disorder for those with another primary anxiety disorder. Studies investigating treatment effects and mechanisms of change in primary and non-primary GAD therefore have the potential to have a large impact by increasing the generalizability of findings to many real world clients. A recent trial of metacognitive therapy in a sample with primary and non-primary GAD found large effect sizes that were comparable to studies using samples with primary GAD (McEvoy, Erceg-Hurn, Anderson, et al., 2015). The aim of the current study was to extend these findings by examining mechanisms of change during group metacognitive group therapy for primary and non-primary GAD.

Worry has been defined as ā€œa chain of thoughts and images, negatively affect-laden, and relatively uncontrollableā€ (Borkovec, Robinson, Pruzinsky, & DePree, 1983, p. 10). Worry is the cardinal feature of, but not exclusive to, GAD (American Psychiatric Association, 2013, Harvey et al., 2004). Worry is elevated in a range of emotional disorders, including depression, social anxiety disorder, and panic disorder (McEvoy, Watson, Watkins, & Nathan, 2013). Worry also shares many features with other forms of repetitive negative thinking (RNT), including rumination in depression and post-event processing in social anxiety (Ehring and Watkins, 2008, McEvoy et al., 2010, Watkins et al., 2005). These findings have lead clinical researchers to conclude that the processes driving RNT are likely to be common across emotional disorders even though the cognitive content and associated emotional responses may differ (Watkins, 2008). Prospective and experimental research suggests that RNT contributes to the onset and maintenance of a range of emotional disorders and negative emotional states, and thus it is an important target for intervention (McLaughlin and Nolen-Hoeksema, 2011, Nolen-Hoeksema, 2000, Nolen-Hoeksema, 1991, Park et al., 2004). The common underlying pathological processes of RNT across emotional disorders, along with high rates of comorbidity, provide a strong rationale for targeting elevated RNT regardless of an individual's primary emotional disorder.

Wells and Matthewsā€™ (1996) Self-Regulatory Executive Function (S-REF) model provides a metacognitive account of processes that drive RNT across various emotional disorders. Wells (2004) defined metacognition as ā€œā€¦cognitive processes, strategies, and knowledge that are involved in the regulation and appraisal of thinking itself (p. 167)ā€. Within the metacognitive model, positive and negative metacognitive beliefs are thought to drive the initiation and maintenance of RNT, respectively. Positive metacognitions are beliefs that RNT is helpful in some way, such as increasing the likelihood that one can prevent, prepare for, or cope with adverse events. The more strongly an individual adheres to these beliefs the more motivated they will be to further engage in RNT as a coping strategy. Once individuals engage in RNT, Wells (2013) argues that negative metacognitive beliefs are then activated in individuals who are vulnerable to emotional disorder. Common negative metacognitions include beliefs that RNT is uncontrollable and dangerous, which lead to maladaptive and counterproductive attempts to reduce RNT, such as thought suppression, further threat monitoring, and avoidance (known as the cognitive affective syndrome). The escalation of RNT and negative affect resulting from these counterproductive coping strategies serves to confirm the negative metacognitive beliefs (i.e., RNT appears even less controllable and potentially more dangerous), thereby continuing the cycle.

Metacognitive therapy (MCT) is based on the S-REF model (Wells & Matthews, 1996) and aims to modify positive and negative metacognitive beliefs in order to reduce reliance on RNT as a coping strategy, and to reduce maladaptive responses to any occurrence of RNT. Trials of MCT across a range of emotional disorders have demonstrated large effects on RNT and symptoms (Bailey and Wells, 2014, Dammen et al., 2014, McEvoy et al., 2015a, Papageorgiou and Wells, 2015, Rees and van Koesveld, 2008, Wells et al., 2012, van der Heiden and Melchior, 2014, van der Heiden et al., 2013, van der Heiden et al., 2012; see Matthews, 2015). However, most MCT studies have used small samples and few have directly tested the theoretical mechanisms of change. Most of the evidence supporting the role of metacognitive beliefs in driving RNT to date is cross-sectional and correlational.

In a clinical sample with GAD van der Heiden et al. (2010) evaluated a cross-sectional hierarchical model and found that negative metacognitive beliefs mediated the relationship between the vulnerability factor of neuroticism and worry. McEvoy and Mahoney (2013) replicated and extended this model in a mixed-diagnosis sample and found that negative metacognitive beliefs mediated the relationship between neuroticism and a transdiagnostic measure of RNT. Other cross-sectional studies have found that the relationship between rumination and depression is partially mediated by negative beliefs about rumination (Papageorgiou & Wells, 2003). Roelofs, Huibers, Peeters, Arntz, and van Os (2010) used structural equation modeling in a depressed sample and found that both positive and negative metacognitions lead to rumination and worry and, in turn, symptoms of emotional disorder.

Longitudinal and treatment studies have also found support for an association between metacognitive beliefs, RNT, and emotional disorder symptoms. In a healthy sample of university students Weber and Exner (2013) found that positive metacognitive beliefs predicted rumination two months later, even after controlling for baseline rumination. Weber and Exner (2013) also found a significant indirect effect of positive beliefs about rumination on depressive symptoms via rumination. A recent trial of internet-based cognitive behavioral therapy in a mixed sample with anxiety and depression investigated the relationship between positive metacognitive beliefs, RNT, and symptom change (Newby, Williams, & Andrews, 2014). These researchers found that early reductions in positive metacognitive beliefs and RNT mediated improvements in depression, and early reductions in positive metacognitive beliefs mediated improvements in anxiety, thereby demonstrating that changes in metacognitive beliefs temporally preceded changes in emotional disorder symptoms. This study did not assess negative metacognitive beliefs. Findings from these cross-sectional, longitudinal, and treatment studies suggest that metacognitive beliefs are associated with RNT and may play a causal role in translating a temperamental vulnerability for emotional disorders into increased engagement in RNT, which, in turn, increases emotional symptoms. However, further prospective treatment studies investigating both positive and negative metacognitive beliefs are required to build the case for these causal relationships, particularly from a transdiagnostic perspective in mixed-diagnosis samples.

The main aim of this study was to examine whether changes in metacognitive beliefs during group MCT are associated with changes in emotional distress via changes in RNT in a mixed-diagnosis sample. Consistent with the S-REF model (Wells & Matthews, 1996), the first hypothesis was that positive and negative metacognitive beliefs would be positively associated with RNT and symptoms of emotional distress at pre-treatment, post-treatment, and follow-up. The second hypothesis was that negative and positive metacognitive beliefs would demonstrate significant indirect effects on emotional distress via RNT.

Section snippets

Participants and recruitment

Patients (NĀ =Ā 52) participated in a recent benchmarking study reporting outcomes from group MCT for individuals with primary and non-primary GAD (McEvoy, Erceg-Hurn, Anderson, et al., 2015). Mean age was 38 years (SDĀ =Ā 14.3) and 60% (nĀ =Ā 31) were women. Most were employed (63%, nĀ =Ā 33), around half had a university qualification (52%, nĀ =Ā 27), and one-quarter had completed high school or less (25%, nĀ =Ā 13), and a similar proportion had a technical or trade certificate (23%, nĀ =Ā 12). Half were married or

Cross-sectional associations

Scatterplots revealed that the relationships between the variables were linear. Cross-sectional correlations are displayed in Table 1. Consistent with the first hypothesis, negative metacognitions, RNT, and symptoms were strongly correlated at all time points. Contrary to the first hypothesis, relationships between positive metacognitions and the other constructs were weak and inconsistent. At pre-treatment, there were no associations between positive metacognitions and RNT, symptoms, or

Discussion

The main aim of this study was to investigate mechanisms of change during group metacognitive therapy for repetitive negative thinking (RNT) in a sample with primary and non-primary generalized anxiety disorder. The first hypothesis, that positive and negative metacognitive beliefs would be significantly and positively associated with RNT and psychological distress at pre-treatment, post-treatment, and follow-up, was partially supported. Consistent with metacognitive theory, negative

Acknowledgements

The authors wish to gratefully acknowledge Amanda Swan, Lisa Saulsman, and Mark Summers for facilitating groups.

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