Skip to main content
SpringerLink
Log in

Metacognitive Therapy for Anxiety Disorders: a Review of Recent Advances and Future Research Directions

  • Anxiety Disorders (A Pelissolo, Section Editor)
  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review describes (a) key features of the metacognitive model as they relate to anxiety and related disorders, (b) central components of metacognitive therapy (MCT), (c) the current empirical status of MCT, (d) recent developments, (e) controversies and (f) future research directions.

Recent Findings

Evidence is accumulating that MCT is effective for anxiety and related disorders. Emerging evidence suggests that MCT may be effective with children and adolescents and compares well to other evidence-supported treatments such as cognitive behaviour therapy and mindfulness-based approaches. Evidence for distinct mechanisms across therapies is mixed.

Summary

While MCT appears to be effective for anxiety and related disorders, more research is required to evaluate (a) efficacy and unique (vs. common) mechanisms of change compared to other therapies, (b) effectiveness for children and adolescents, (c) alternative delivery methods (e.g., via internet, group vs. individual), (d) transdiagnostic impacts and (e) applications to a broader array of disorders.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bijl RV, Ravelli A, van Zessen G. Prevalence of psychiatric disorder in the general population: results of the Netherlands mental health survey and incidence study (NEMESIS). Soc Psychiatry Psychiatr Epidemiol. 1998;33:587–95.

    Article  CAS  PubMed  Google Scholar 

  2. Jacobi F, Wittchen H-U, Holting C, et al. Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German health interview and examination survey (GHS). Psychol Med. 2004;34:597–611.

    Article  CAS  PubMed  Google Scholar 

  3. Grant BF, Stinson FS, Dawson DA, Chou SP, Dufour MC, Compton W, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on alcohol and related conditions. Arch Gen Psychiatry. 2004;61:807–16.

    Article  PubMed  Google Scholar 

  4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. https://doi.org/10.1001/archpsyc.62.6.593.

    Article  PubMed  Google Scholar 

  5. McEvoy PM, Grove R, Slade T. Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of mental health and wellbeing. Aust N Z J Psychiatry. 2011;45:957–67. https://doi.org/10.3109/00048674.2011.624083.

    Article  PubMed  Google Scholar 

  6. Baxter AJ, Vos T, Scott KM, Ferrari AJ, Whiteford HA. The global burden of anxiety disorders in 2010. Psychol Med. 2010;44:2363–74.

    Article  Google Scholar 

  7. Teesson M, Slade T, Mills K. Comorbidity in Australia: findings of the 2007 National Survey of mental health and wellbeing. Aust N Z J Psychiatry. 2009;43:606–14.

    Article  PubMed  Google Scholar 

  8. Slade T, McEvoy PM, Chapman C, Grove R, Teesson M. Sex differences in the temporal sequencing of anxiety, mood and substance use disorders in the general population: findings from the 2007 Australian National Survey of mental health and wellbeing. Epidemiol Psychiatr Sci. 2015;24:45–53. https://doi.org/10.1017/S2045796013000577.

    Article  CAS  PubMed  Google Scholar 

  9. Roy-Byrne PP, Stang P, Wittchen H–U, Ustun B, Walters EE, Kessler RC. Lifetime panic-depression comorbidity in the National Comorbidity Survey: association with symptoms, impairment, course and help-seeking. Br J Psychiatry. 2000;176:229–35.

    Article  CAS  PubMed  Google Scholar 

  10. Brown TA, Campbell LA, Lehman CL, Grisham JR, Mancill RB. Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. J Abnorm Psychol. 2001;110:585–99.

    Article  CAS  PubMed  Google Scholar 

  11. Clark DM, Ehlers A. An overview of the cognitive theory and treatment of panic disorder. Appl Prev Psychol. 1993;2:131–9.

    Article  Google Scholar 

  12. Heimberg RG. Cognitive-behavioral therapy for social anxiety disorder: current status and future directions. Biol Psychiatry. 2002;51:101–8.

    Article  PubMed  Google Scholar 

  13. McEvoy PM, Erceg-Hurn DM, Saulsman LM, Thibodeau MA. Imagery enhancements increase the effectiveness of cognitive behavioural group therapy for social anxiety disorder: a benchmarking study. Behav Res Ther. 2015;65:42–51. https://doi.org/10.1016/j.brat.2014.12.011.

    Article  PubMed  Google Scholar 

  14. Rapee RM, Gaston JE, Abbott MJ. Testing the efficacy of theoretically derived improvements in the treatment of social phobia. J Consult Clin Psychol. 2009;77:317–27. https://doi.org/10.1016/j.brat.2014.12.011.

    Article  PubMed  Google Scholar 

  15. Ollendick TH, Davis TE. One-session treatment for specific phobias: a review of Öst’s single-session exposure with children and adolescents. Cogn Behav Ther. 2013;42:275–83. https://doi.org/10.1080/16506073.2013.773062.

    Article  PubMed  Google Scholar 

  16. Banneyer KN, Bonin L, Price K, Goodman WK, Storch EA. Cognitive behavioural therapy for childhood anxiety disorders: a review of recent advances. Curr Psychiatry Rep. 2018;20:65. https://doi.org/10.1007/s11920-018-0924-9.

    Article  PubMed  Google Scholar 

  17. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;26:17–31.

    Article  Google Scholar 

  18. Wang Z, Whiteside SPH, Sim L, Farah W, Morrow AS, Alsawas M, et al. Comparative effectiveness and safety of cognitive behavioural therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis. JAMA Pediatr. 2017;171(11):1049–56. https://doi.org/10.1001/jamapediatrics.2017.3036.

    Article  PubMed  PubMed Central  Google Scholar 

  19. McEvoy PM, Nathan P, Norton PJ. Efficacy of transdiagnostic treatments: a review of published outcome studies and future research directions. J Cogn Psychother. 2009;23:20–33.

    Article  Google Scholar 

  20. Wells A. Metacognitive therapy for anxiety and depression. New York: Guilford; 2009.

    Google Scholar 

  21. Wells A, Matthews G. Modelling cognition in emotional disorder: the S-REF model. Behav Res Ther. 1996;34:881–8. https://doi.org/10.1016/S0005-7967(96)00050-2.

    Article  CAS  PubMed  Google Scholar 

  22. Wells A. A metacognitive model and therapy for generalized anxiety disorder. Clin Psychol Psychother. 1999;6:86–95.

    Article  Google Scholar 

  23. •• Fergus TA, Bardeen JR. The attention training technique: a review of a neurobehavioral therapy for emotional disorders. Cogn Behav Pract. 2016;23:502–16. https://doi.org/10.1016/j.cbpra.2015.11.001 This article provides a comprehensive review of the attention training technique.

    Article  Google Scholar 

  24. • Sun X, Zhu C, So SHW. Dysfunctional metacognition across psychopathologies: a meta-analytic review. Eur Psychiatry. 2017;45:139–53 This meta-analysis reviews evidence that metacognitive beliefs are elevated in clinical versus non-clinical samples and across disorders.

    Article  CAS  PubMed  Google Scholar 

  25. • Rochat L, Manolov R, Billieux J. Efficacy of metacognitive therapy in improving mental health: a meta-analysis of single-case studies. J Clin Psychol. 2018;74:896–915. https://doi.org/10.1002/jclp.22567 This article provides an up-to-date meta-analysis of case studies of metacognitive therapy.

    Article  PubMed  Google Scholar 

  26. • Knowles MM, Foden P, El-Deredy W, Wells A. A systematic review of efficacy of the attention training technique in clinical and nonclinical samples. J Clin Psychol. 2016;72:999–1025. https://doi.org/10.1002/jclp.22312 This article systematically reviews evidence for the attention training technique.

    Article  PubMed  Google Scholar 

  27. Fergus TA, Wheless NE, Wright LC. The attention training technique, self-focused attention, and anxiety: a laboratory-based component study. Behav Res Ther. 2014;61:150–5.

    Article  PubMed  Google Scholar 

  28. Sharpe L, Perry KN, Rogers P, Dear BF, Nicholas MK, Refshauge K. A comparison of the effect of attention training and relaxation on responses to pain. Pain. 2010;150:469–76.

    Article  CAS  PubMed  Google Scholar 

  29. Nassif Y, Wells A. Attention training reduces intrusive thoughts cued by a narrative of stressful life events: a controlled study. J Clin Psychol. 2014;70:510–7.

    Article  PubMed  Google Scholar 

  30. Callinan S, Johnson D, Wells A. A randomised controlled study of the effects of the attention training technique on traumatic stress symptoms, emotional attention set shifting and flexibility. Cogn Ther Res. 2015;39:4–13. https://doi.org/10.1007/s10608-014-9634-8.

    Article  Google Scholar 

  31. Chambless DL, Hollon SD. Defining empirically supported therapies. J Consult Clin Psychol. 1998;66:7–18. https://doi.org/10.1037/0022-006X.66.1.7.

    Article  CAS  PubMed  Google Scholar 

  32. •• Normann N, van Emmerik AAP, Morina N. The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review. Depress Anxiety. 2014;31:402–11. https://doi.org/10.1002/da.22273 This article provides a meta-analytic review of meta-cognitive therapy.

    Article  PubMed  Google Scholar 

  33. Nordahl N, Wells A. Metacognitive therapy for social anxiety disorder: an A-B replication series across social anxiety subtypes. Front Psychol. 2018;8:540. https://doi.org/10.3389/fpsyg.2018.00540.

    Article  Google Scholar 

  34. van der Heiden C, van Rossen K, Dekker A, Damstra M, Deen M. Metacognitive therapy for obsessive-compulsive disorder: a pilot study. J Obsessive Compuls Relat Disord. 2016;9:24–9.

    Article  Google Scholar 

  35. McEvoy PM, Erceg-Hurn DM, Anderson RA, Campbell BNC, Swan A, Saulsman LM, et al. Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: an effectiveness trial. J Affect Disord. 2015;175:124–32. https://doi.org/10.1016/j.jad.2014.12.046.

    Article  PubMed  Google Scholar 

  36. McEvoy PM, Erceg-Hurn DM, Anderson RA, Campbell BNC, Nathan PR. Mechanisms of change during group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder. J Anxiety Disord. 2015;35:19–26. https://doi.org/10.1016/j.brat.2014.12.011.

    Article  PubMed  Google Scholar 

  37. Johnson SU, Hoffart A. Metacognitive therapy for comorbid anxiety disorders: a case study. Front Psychol. 2016;7:1515. https://doi.org/10.3389/fpsyg.2016.01515.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Vogel PA, Hagen R, Hjemdal O, Solem S, Smeby MCB, Strand ER, et al. Metacognitive therapy applications in social anxiety disorder: an exploratory study of the individual and combined effects of the attention training technique and situational attentional refocusing. J Exp Psychopathol. 2016;7:608–18. https://doi.org/10.5127/jep.054716.

    Article  Google Scholar 

  39. Bacow TL, May JE, Brody LR, Pincus DB. Are there specific metacognitive processes associated with anxiety disorders in youth? Psychol Res Behav Manag. 2010;3:81. https://doi.org/10.2147/prbm.s11785.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Bacow TL, Pincus DB, Ehrenreich JT, Brody LR. The metacognitions questionnaire for children: development and validation in a clinical sample of children and adolescents with anxiety disorders. J Anxiety Disord. 2009;23(6):727–36. https://doi.org/10.1016/j.janxdis.2009.02.013.

    Article  PubMed  Google Scholar 

  41. Cartwright-Hatton S, Mather A, Illingworth V, Brocki J, Harrington R, Wells A. Development and preliminary validation of the meta-cognitions questionnaire—adolescent version. J Anxiety Disord. 2004;18(3):411–22. https://doi.org/10.1016/S0887-6185(02)00294-3.

    Article  PubMed  Google Scholar 

  42. Ellis DM, Hudson JL. The metacognitive model of generalized anxiety disorder in children and adolescents. Clin Child Fam Psychol Rev. 2010;13:151–63. https://doi.org/10.1007/s10567-010-0065-0.

    Article  PubMed  Google Scholar 

  43. Ellis DM, Hudson JL. Test of the metacognitive model of generalized anxiety disorder in anxiety-disordered adolescents. J Exp Psychopathol. 2011;2(1):28–43. https://doi.org/10.5127/jep.011910.

    Article  Google Scholar 

  44. Esbjørn BH, Sømhovd MJ, Holm JM, Lønfeldt NN, Bender PK, Nielsen SK, et al. A structural assessment of the 30-item metacognitions questionnaire for children and its relations to anxiety symptoms. Psychol Assess. 2013;25(4):1211–9. https://doi.org/10.1037/a0033793.

    Article  PubMed  Google Scholar 

  45. Esbjørn BH, Lønfeldt NN, Nielsen SKK, Reinholdt-Dunne ML, Sømhovd MJ, Cartwright-Hatton S. Metaworry, worry, and anxiety in children and adolescents: relationships and interactions. J Clin Child Adolesc Psychol. 2015;44(1):145–56. https://doi.org/10.1080/15374416.2013.873980.

    Article  PubMed  Google Scholar 

  46. Lønfeldt NN, Silverman WK, Esbjørn BH. A systematic review and meta-analysis of the association between third-wave cognitive constructs and youth anxiety. Int J Cogn Ther. 2017;10:115–37.

    Article  Google Scholar 

  47. Smith KE, Hudson JL. Metacognitive beliefs and processes in clinical anxiety in children. J Clin Child Adolesc Psychol. 2013;42(5):590–602. https://doi.org/10.1080/15374416.2012.755925.

    Article  PubMed  Google Scholar 

  48. Esbjørn BH, Normann N, Lønfeldt NN, Tolstrup M, Reinholdt-Dunne ML. Exploring the relationships between maternal and child metacognitions and child anxiety. Scand J Psychol. 2016;57:201–6. https://doi.org/10.1111/sjop.12286.

    Article  PubMed  Google Scholar 

  49. Simons M, Schneider S, Herpetz-Dahlmann B. Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder: a case series with randomized allocation. Psychother Psychosom. 2006;75:257–64. https://doi.org/10.1159/000092897.

    Article  PubMed  Google Scholar 

  50. •• Esbjørn BH, Normann N, Reinholdt-Dunne ML. Adapting metacognitive therapy to children with generalised anxiety disorder: suggestions for a manual. J Contemp Psychother. 2015;45:159–66. https://doi.org/10.1007/s10879-015-9294-3 This article describes how metacognitive therapy can be adapted for children.

    Article  PubMed  PubMed Central  Google Scholar 

  51. •• Esbjørn BH, Normann N, Christiansen MC, Reinholdt-Dunne ML. The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: an open trial. J Anxiety Disord. 2018;53:16–21 This article reports on a recent evaluation of metacognitive therapy for children aged 7 to 13 years.

    Article  PubMed  Google Scholar 

  52. Thorslund J, McEvoy PM, Anderson RA. 2019. Group metacognitive therapy for adolescents with mixed anxiety and depressive disorders: a pilot study. Manuscript submitted for publication.

  53. •• Johnson SU, Hoffart A, Nordahl HM, Wampold BE. Metacognitive therapy versus disorder-specific CBT for comorbid anxiety disorders: a randomized controlled trial. J Anxiety Disord. 2017;50:103–12 This study reports a direct comparison of metacognitive therapy to CBT.

    Article  PubMed  Google Scholar 

  54. •• Hoffart A, Johnson SU, Nordahl HM, Wells A. Mechanisms of change in metacognitive and cognitive behavioural therapy for treatment-resistant anxiety: the role of metacognitive beliefs and coping strategies. J Exp Psychopathol. 2018;9:1–10. https://doi.org/10.1177/2043808718787414 . This study investigates mechanisms of change in metacognitive versus cognitive therapy.

    Article  Google Scholar 

  55. •• Johnson SU, Hoffart A, Hordahl HM, Ulvenes PG, Vrabel K, Wampold BE. Metacognition and cognition in inpatient MCT and CBT for comorbid anxiety disorders: a study of within-person effects. J Couns Psychol. 2018;65:86–97. https://doi.org/10.1037/cou0000226 . This study investigates mechanisms of change in metacognitive versus cognitive therapy.

    Article  PubMed  Google Scholar 

  56. •• Capobianco L, Reeves D, Morrison AP, Wells A. Group metacognitive therapy vs. mindfulness meditation therapy in a transdiagnostic patient sample: a randomised feasibility trial. Psychiatry Res. 2018;259:554–61. https://doi.org/10.1016/j.psychres.2017.11.045 This study investigates mechanisms of change in metacognitive therapy versus mindfulness meditation.

    Article  PubMed  Google Scholar 

  57. McEvoy PM, Erceg-Hurn DM. The search for universal transdiagnostic and trans-therapy change processes: evidence for intolerance of uncertainty. J Anxiety Disord. 2016;41:96–107. https://doi.org/10.1016/j.janxdis.2016.02.002.

    Article  PubMed  Google Scholar 

  58. Mennin DS, Ellard KK, Fresco DM, Gross JJ. United we stand: emphasizing commonalities across cognitive-behavioral therapies. Behav Ther. 2013;44:234–48.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Hayes SC, Levin ME, Plumb-Vilardaga J, Villatte JL, Pistorello J. Acceptance and commitment therapy and contextual behavioural science: examining the progress of a distinctive model of behavioural and cognitive therapy. Behav Ther. 2013;44:180–98.

    Article  PubMed  Google Scholar 

  60. • McEvoy PM, Graville R, Hayes S, Kane RT, Foster JK. Mechanisms of change during attention training and mindfulness in high trait anxious individuals: a randomized control study. Behav Ther. 2017;48:678–94. https://doi.org/10.1016/j.beth.2017.04.001 This study reports on common mechanisms across the attention training technique and mindfulness approaches.

    Article  PubMed  Google Scholar 

  61. Normann N, Lønfeldt NN, Reinholdt-Dunne ML, Esbjørn BH. Negative thoughts and metacognitions in anxious children following CBT. Cogn Ther Res. 2016;40:188–97. https://doi.org/10.1007/s10608-015-9740-2.

    Article  Google Scholar 

  62. McEvoy PM, Perini SJ. Cognitive behavioral group therapy for social phobia with or without attention training: a controlled trial. J Anxiety Disord. 2009;23:519–28. https://doi.org/10.1016/j.janxdis.2008.10.008.

    Article  PubMed  Google Scholar 

  63. van der Heiden C, Muris P, van der Molen HT. Randomized controlled trial on the effectiveness of metacognitive therapy and intolerance-of-uncertainty therapy for generalized anxiety disorder. Behav Res Ther. 2012;50(2):100–9. https://doi.org/10.1016/j.brat.2011.12.005.

    Article  PubMed  Google Scholar 

  64. Borkovec TD. The nature, functions, and origins of worry. In: Davey G, Tallis F, editors. Worrying: perspectives on theory assessment and treatment. Sussex: Wiley & Sons; 1994. p. 5–33.

    Google Scholar 

  65. Borkovec TD, Alcaine OM, Behar E. Avoidance theory of worry and generalized anxiety disorder. In: Heimberg R, Turk C, Mennin D, editors. Generalized anxiety disorder: advances in research and practice. New York: Guilford Press; 2004. p. 77–108.

    Google Scholar 

  66. Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, et al. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: an updated meta-analysis. J Anxiety Disord. 2018;55:70–8. https://doi.org/10.1016/j.janxdis.2018.01.001.

    Article  CAS  PubMed  Google Scholar 

  67. Nordahl HM, Halvorsen JØ, Hjemdal O, Ternava MR, Wells A. Metacognitive therapy vs. eye movement desensitization and reprocessing for posttraumatic stress disorder: study protocol for a randomized superiority trial. Trials. 2018;19:16. https://doi.org/10.1186/s13063-017-2404-7.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Wells A, McNicol K, Reeves D, Salmon P, Davies L, Heagerty A, et al. Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY group MCT): study protocol for a randomised controlled trial. Trials. 2018;19:215. https://doi.org/10.1186/s13063-018-2593-8.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Wells A, McNicol K, Reeves D, Salmon P, Davies L, Heagerty A, et al. Metacognitive therapy home-based self-help for cardiac rehabilitation patients experiencing anxiety and depressive symptoms: study protocol for a feasibility randomised controlled trial (PATHWAY home-MCT). Trials. 2018;19:444. https://doi.org/10.1186/s13063-018-2826-x.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. School of Psychology, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia

    Peter M. McEvoy

  2. Centre for Clinical Interventions, Perth, Australia

    Peter M. McEvoy

Authors
  1. Peter M. McEvoy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter M. McEvoy.

Ethics declarations

Conflict of Interest

The author declares that there are no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Anxiety Disorders

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

McEvoy, P.M. Metacognitive Therapy for Anxiety Disorders: a Review of Recent Advances and Future Research Directions. Curr Psychiatry Rep 21, 29 (2019). https://doi.org/10.1007/s11920-019-1014-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11920-019-1014-3

Keywords

Search

Navigation