Dysfunctional Attitudes Versus Metacognitive Beliefs as Within-Person Predictors of Depressive Symptoms Over Time.

Understanding within-person variation between theorized mechanisms of disorder and depressive symptoms can help identify targets for interventions. Cognitive models of depression hypothesize dysfunctional attitudes as underlying vulnerability factors, while the metacognitive model places emphasis on dysfunctional metacognitive beliefs. However, no previous study has tested the relative importance of change in dysfunctional attitudes and metacognitive beliefs as predictors of change in depressive symptoms within individuals. In a sample of 1,418 individuals measured at four time-points separated by 5-week intervals, a multilevel model approach was used to test the relative importance of change in dysfunctional attitudes and metacognitive beliefs as predictors of change in depressive symptoms. Change in dysfunctional attitudes and metacognitive beliefs predicted change in depressive symptoms over time. However, change in metacognitive beliefs and in particular negative metacognitive beliefs and judgements of cognitive confidence were significantly stronger predictors of change in depressive symptoms compared to dysfunctional attitudes. Furthermore, change in metacognitive beliefs predicted change in dysfunctional attitudes beyond change in depressive symptoms. These results suggest that metacognitive beliefs rather than dysfunctional attitudes might be more important for depressive symptoms over time within persons and that metacognitive change may also influence dysfunctional attitudes over time. Metacognitive beliefs are therefore a promising target for treatment and prevention aiming to reduce depressive symptoms, but replication of our results in clinical samples is warranted before more clear conclusions can be drawn.

Is meta-worry relevant to interpersonal problems? Testing the metacognitive model of generalized anxiety disorder in an analogue- and a clinical sample of GAD.

Interpersonal problems are common in individuals with generalized anxiety disorder (GAD) and improved interpersonal functioning is an important goal in treatment. In the metacognitive model of worry and generalized anxiety disorder, emotional distress and psychological dysfunction are related to two distinct types of worry. Particular emphasis is put on meta-worry which refers to "worry about worrying" or appraisal of worrying as threatening in itself. Meta-worry impairs effective mental regulation and might therefore be an important predisposition to self-regulate via others and thereof interpersonal problems. In the current study, we tested the prediction that meta-worry is uniquely associated with interpersonal problems in two samples. The first consisted of 135 individuals with analogue GAD and the second of 56 individuals with a diagnosis of GAD. Using hierarchical linear regressions controlling for anxiety, depression and worry, meta-worry showed a unique relationship with interpersonal problems in both samples. These findings indicate that meta-worry may be relevant to formulate and treat interpersonal problems in individuals with GAD.

School completion and progression to higher education in adolescents with social anxiety: a linkage between Young-HUNT3 and national educational data (2008-2019), Norway.

BACKGROUND: Social anxiety disorder (SAD) most commonly develops in adolescence-a period of life that includes a transition to upper secondary school. The aim of this study is to investigate the extent to which social anxiety in adolescence is associated with the completion of upper secondary school and progression to higher education. METHODS: This longitudinal study includes 8,192 adolescents aged 13-19 years who participated in the Norwegian Young-HUNT 3 population-based study. Social anxiety is measured employing (1) diagnostic interview screening questions (interview) and (2) a self-reported symptom index (questionnaire). Notably, we define the cohorts based on these two methods. Using national educational data (2008-2019), we follow educational attainment among the cohorts until they turn 25 years of age. RESULTS: We found that adolescents who screened positive (SP) for SAD had a predicted probability of upper secondary school completion at 21 years of age that was 14% points lower than those who screened negative (SN). Further, differences remained when looking at completion rates at age 25 years. Moreover, predicted probabilities for completion were inversely associated with increasing levels of self-reported social anxiety symptoms. Similarly, the proportion of the completers of an academic program in the SP group that were enrolled in higher education by 25 years of age, were lower than for the SN group (87 vs. 92%). CONCLUSION: Social anxiety in adolescence, both self-reported symptoms and diagnostic screening, has long-term negative impact on upper secondary school completion and to some extent enrollment to higher education.

Adverse Childhood Experiences Are Associated With Personality Disorder: A Prospective, Longitudinal Study.

There is a lack of studies that have prospectively examined adverse childhood experiences (ACEs) in association with a personality disorder (PD). Data from a sample of 8,199 adolescents first assessed for ACEs were linked with subsequent data from the Norwegian Patient Register in order to obtain diagnoses of a PD in adulthood (after a 14-year follow-up). We used logistic regression analysis. Any type of ACE gave a 3.8-fold higher risk of developing a PD. Abuse, more specifically emotional abuse, came out as one of the strongest predictors. Of the adolescents who developed a PD, approximately 90% had a history of ACE. The results of this study support the importance of assessing ACEs, such as abuse, neglect, and household dysfunction, in the diagnostic procedure and treatment for PD.

Metacognitive beliefs predict interpersonal problems in patients with social anxiety disorder.

Patients with Social Anxiety Disorder (SAD) typically report interpersonal problems, and these are important targets in treatment beyond social anxiety symptoms as they impair quality of life, maintain emotion symptoms and effect on social functioning. What factors contribute to interpersonal problems? In the current study we set out to explore the role of metacognitive beliefs as correlates of interpersonal problems in patients treated for SAD when controlling for the effect of social phobic cognitions and symptoms. The sample consisted of 52 patients with a primary diagnosis of SAD participating in a randomized controlled trial comparing cognitive therapy, paroxetine, pill placebo, or the combination of cognitive therapy and paroxetine in treating SAD. Two hierarchical multiple linear regression analyses were conducted to explore change in metacognitions as predictors of change in interpersonal problems when controlling for change in social phobic cognitions and social anxiety. Change in metacognitions accounted for unique variance in interpersonal problems improvement beyond change in cognitions. Furthermore, change in cognitions overlapped with change in social anxiety symptoms, and when controlling the overlap between these three predictors, only change in metacognitions was uniquely associated with improvement in interpersonal problems. This finding indicates that metacognitions are linked to interpersonal problems in patients with SAD with the implication that treatment should aim to modify metacognitive beliefs to alleviate interpersonal dysfunction.

Adverse childhood experiences and their association with substance use disorders in adulthood: A general population study (Young-HUNT).

Aim: To investigate the association of adverse childhood experiences (ACEs) and substance use disorders (alcohol and illicit drug use disorders), specifically by gender, in a large longitudinal non-clinical population study. Methods: Data from 8199 adolescents, first assessed for ACE (2006-2008), were linked with subsequent data from the Norwegian Patient Register to obtain diagnoses of a substance use disorder in adulthood (after 12-14 years' follow-up in March 2020). This study used logistic regression analysis to assess the associations between ACEs and substance use disorders with respect to gender. Results: Adults with any history of ACEs have a 4.3-fold higher likelihood of developing a substance use disorder. Female adults had a 5.9-fold higher likelihood of developing an alcohol use disorder. Emotional neglect, sexual abuse and physical abuse were the strongest individual ACE predictors for this association. Male adults had a 5.0-fold higher likelihood of developing an illicit drug use disorder (for example stimulants such as cocaine, inhibiter such as opioids, cannabinoids and multiple drugs). Physical abuse, parental divorce and witnessed violence were the strongest individual ACE predictors for this association. Conclusions: This study reinforces the association between ACEs and substance use disorders and exposes a gender-specific pattern. Increased attention should be paid to the meaning of individual ACEs as well as to the accumulation of ACEs in the development of a substance use disorder.

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.

Prevalence of adverse childhood experiences and their co-occurrence in a large population of adolescents: a Young HUNT 3 study.

PURPOSE: Studies of adverse childhood experiences (ACEs) undertaken at the time of adolescence in the general population are not common. The aim of this study was to determine the prevalence and co-occurrence of the individual ACEs and sub-types of ACEs in a large population of adolescents. METHODS: Data were used from the Young Nord-Trøndelag Health (Young HUNT 3) study, a population-based study of young adolescents. ACEs were operational defined as sexual, physical and/or emotional abuse; physical and/or emotional neglect; and/or household dysfunction. Co-occurrence was measured as the accumulation of ACEs and as an overlap analysis. RESULTS: Of the 8199 evaluable adolescents, 65.8% had experienced at least one ACE and 28% of those had experienced more than one ACE. Household dysfunction was the most prevalent ACE subtype. The biggest overlaps among the three ACE sub-types were seen in those reporting neglect or abuse. CONCLUSION: There was a high degree of overlap between the three ACE sub-types and the individual ACEs, indicating that ACEs should be assessed together as a whole rather than separately. This study provides an opportunity to assess ACEs and their co-occurrences in relation to outcomes later in life.

Social anxiety disorder in adolescents: Prevalence and subtypes in the Young-HUNT3 study.

BACKGROUND: Few studies have examined the prevalence of social anxiety disorder (SAD) among adolescents and the associated sex-specific fears. No previous studies have reported variance in SAD prevalence among adolescents based on a stepwise diagnostic approach. METHODS: Using various diagnostic thresholds from the Anxiety Disorders Interview Schedule child version, and the diagnostic criteria from both the 4th and 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), we explored the point prevalence of SAD among a population-based sample of 8216 adolescents aged 13-19 years. RESULTS: Overall, 2.6% of adolescents met the SAD diagnostic criteria. The prevalence varied from 2.0% to 5.7% depending on the criteria-set. Twice as many females met the overall SAD criteria. The DSM-IV generalized SAD subtype was assigned to 86.5% of the sample, while 3.5% met the DSM-5 performance-only subtype. Compared with males aged 16-19 years, significantly more of those aged 13-15 years met the SAD criteria; no significant age group differences were found among females. CONCLUSIONS: This is the first study to demonstrate variance in SAD prevalence among adolescents based on the diagnostic threshold method. Depending on the threshold applied, SAD prevalence among adolescents varied from 2.0% to 5.7%. Age and sex differences in social fear experiences highlight the importance of considering developmental heterogeneity in SAD, especially for adapting prevention and treatment interventions.

Processing speed and working memory are predicted by components of successful aging: a HUNT study.

BACKGROUND: Research has demonstrated that cognitive heterogeneity occurs with aging both within and between individuals. The purpose of this study was to explore whether the cognitive heterogeneity in aging was related to the subgroups of successful and usual aging. METHOD: Participants were a representative sample of normal older adults (n = 65, age range 70-89 years). All subjects had participated in the third phase of the Nord-Trøndelag Health Survey (HUNT3) and completed all subtests in the Wechsler Memory Scale (WMS-III) and Wechsler Adult Intelligence Scale (WAIS-III). Successful aging was defined in four ways in the study: as (1) absence of disease, (2) high functioning, (3) active engagement with life, or (4) all three components combined. Five domains of memory and intelligence functions were investigated using linear regression analysis, with group membership (successful versus usual aging) as predictors and age, sex and education as correlates. RESULTS: Processing speed performance was correlated with the successful aging component absence of disease, younger age and being of the female sex, while working memory performance was correlated with the successful aging component absence of disease and more years of education. Performance in other domains (verbal, visuospatial, and episodic memory) were not related to any successful aging definition. Age had a consistent negative effect on the processing speed domain for all successful aging definitions. Education was positively linked to cognitive performance on the verbal and working memory domains. Being female was positively linked to processing speed and episodic memory. CONCLUSIONS: Processing speed and working memory were linked to successful aging when it was defined as absence of disease, but not by other components of successful aging, i.e. domain-specific. In contrast, other cognitive domains were not related to any components of successful aging.

Metacognitive therapy and work-focused interventions for patients on sick leave due to anxiety and depression: study protocol for a randomised controlled wait-list trial.

BACKGROUND: Common mental disorders such as depression and anxiety are major contributors to the global burden of disease. Affected individuals suffer reduced quality of life, impaired functioning and reduced capacity to work. Maintaining employment is an important determinant for health and wellbeing, and the economic impact of depression and anxiety is a significant societal expense. Treatments providing effective symptom reduction and helping patients return to work (RTW) would thus have substantial public health benefits. The present study will explore the effectiveness of metacognitive therapy (MCT) and work-focused interventions on reducing symptoms and increasing RTW rates for patients on sick leave due to depression and anxiety. METHODS: The study is a randomised controlled wait-list trial (RCT; N = 240). The intervention group will receive protocol-based MCT and work-focused interventions immediately after inclusion. The control condition is a wait-list control group. All patients will receive up to 12 weekly sessions. The study context is a Norwegian outpatient clinic part of a national programme aimed at reducing sick leave. The co-primary outcomes are change in RTW and symptoms of depression and anxiety at the end of treatment. In addition to self-report, sick leave will also be collected from national registries from 2 years prior to intervention to 4 years after intervention. Symptoms of scores will be collected by self-report at pre- and post-treatment and at 6 and 12 months follow-up after treatment. A cost-effectiveness analysis will use total cost and quality-adjusted life-years as the secondary outcomes. DISCUSSION: There is broad consensus on the importance of identifying treatment that effectively reduces depression and anxiety symptoms and aids RTW. This study is an important contribution to the field as it is the first RCT on MCT and work-focused interventions for patients on sick leave due to anxiety and depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT03301922 . Registered on October 4, 2017.

Change talk and sustain talk in treatment of generalized anxiety disorder: A secondary analysis of cognitive behavioral therapy and metacognitive therapy in adult outpatients.

BACKGROUND AND OBJECTIVES: Measures of patient motivation have proven elusive, showing inconsistent results in relation to psychotherapy outcome. How patients talk about change is an alternative measure of motivation, with potential value in predicting treatment outcome. This study had two aims: (1) to examine if change talk and sustain talk (including its subcategories) predicted reduction in worry levels at post-treatment and 2-year follow-up, and (2) if there were differences between the cognitive behavioral therapy (CBT) and metacognitive therapy (MCT) conditions with respect to change talk. METHODS: This study investigated 24 patients receiving CBT and 27 patients receiving MCT for generalized anxiety disorder (GAD), and coded patients' utterances in sessions 1 and 4. RESULTS: Change talk was significantly associated with lower worry levels at post-treatment and 2-year follow-up, beyond initial worry severity and treatment condition. Change talk in session 4, and reduction in sustain talk from session 1 to 4, was positively associated with improvement, whilst sustain talk in session 4 showed a negative relationship. More specifically, commitment statements in session 1 and expressing signs of taking steps at session 4 were associated with reduction in worry levels. Moreover, patients in the MCT condition argued more both for and against change during session 1, but not session 4. LIMITATIONS: The sample size was relatively small. CONCLUSIONS: These results indicate that change talk sustain talk could be important in the treatment of GAD.

Mitigating adolescent social anxiety symptoms: the effects of social support and social self-efficacy in findings from the Young-HUNT 3 study.

Adolescents' exposure to negative life events (NLEs) and potentially traumatic events is highly prevalent and increases their risk of developing psychological disorders considerably. NLE exposure has also been linked to the development of social anxiety disorder (SAD) among older children and young adolescents. Despite the relatively low treatment efficacy reported for children and adolescents suffering from SAD, few studies have addressed the extent to which resilience factors, such as social support and social self-efficacy, are associated with SAD symptoms. This study examined whether social support and social self-efficacy predict, and buffer against SAD symptoms using a large, population-based sample of adolescents, among whom a large proportion have experienced NLEs. The results reveal that NLEs are significantly associated with SAD symptoms, while social support and social self-efficacy are both negatively associated with SAD symptoms. Only the NLEs × social support interaction significantly predicted SAD symptoms, with social support attenuating the association between NLEs and SAD symptoms. Moreover, increases in both social self-efficacy and social support were associated with reduced SAD symptoms, over and above variance explained by social support alone. Our cumulative results suggest that interventions that can modify both social support and social self-efficacy may help reduce SAD symptoms in at-risk adolescents.

Correction to: Physical exercise augmented cognitive behaviour therapy for older adults with generalised anxiety disorder (PEXACOG): study protocol for a randomized controlled trial.

Following the publication of our article [1], we have become aware of one error in the exclusion criteria, inconsistencies in Figure 1 and Figure 2, and a typo in the reference list.

A Randomized Controlled Trial of Metacognitive Therapy for Depression: Analysis of 1-Year Follow-Up.

This paper reports the 1-year follow-up results from a randomized controlled trial (RCT), which examined the efficacy of metacognitive therapy (MCT) for unipolar depression compared to a waiting condition. Thirty-nine patients with major depression were offered MCT and were divided into two conditions; immediate MCT with 10 weekly sessions or a waiting period that had a 10-week delayed MCT start. Two participants dropped out during the waiting condition. Thirty-four patients participated in the follow-up assessment. Based on the intent-to-treat sample and all patients, 67% were classified as recovered, 13% improved, and 20% were unchanged at 1-year follow-up. For the completers sample 73% recovered, 12% improved, and 15% were unchanged. Five of the 31 patients (13%) that were in remission at post-treatment experienced relapse at 1-year follow-up. Within-group effect sizes were large for reductions in symptoms of depression (d = 2.09) and anxiety (d = 1.16) at 1-year. Treatment response was associated with reductions in rumination, worry, and metacognitive beliefs as predicted by the metacognitive model, but reductions in metacognitions independently predicted reductions in depression scores from pre-treatment to 1-year follow-up. The results suggest that treatment gains are stable at 1-year follow-up. The study sets the stage for future research, which should evaluate MCT over a longer term and compare it with active treatments using suitably powered RCTs.

Metacognitive Therapy of Early Traumatized Patients With Borderline Personality Disorder: A Phase-II Baseline Controlled Trial.

Metacognitive therapy (MCT) is proving to be an effective and brief treatment for anxiety disorders and depression, but there are no investigations of its feasibility and effect on primary personality disorders. We conducted a baseline controlled phase II trial of MCT on a group of patients with Borderline personality disorder all reporting early trauma history with sexual or physical abuse. All had been referred to our study after hospitalization and subsequently treated at the university outpatient clinic at NTNU. Twelve patients referred for severe long-term trauma and emotional instability were offered participation in the program. All gave their consent and were included in the trial. We aimed to examine retention over treatment and follow-up, if the treatment can be delivered in a standardized way across complex and heterogeneous patients and any evidence associated with treatment effects on a range of measures to inform subsequent trials. We measured change in mood, borderline-related symptoms, interpersonal problems, trauma symptoms, suicidal thoughts and self-harming behaviors across pre- post-treatment and by 1- and 2-year follow-up. Treatment appeared feasible with all patients completing the course and 11 out of 12 completing all follow-up assessments. All outcome measures showed a high retention rate and no drop-outs from the treatment. Large improvements over time and treatment gains were maintained at 2 years. There was significant reduction of borderline symptom severity, interpersonal problems and trauma symptoms from pre to 2-year follow-up. The results indicate that MCT may be applied to Borderline personality disorder and that future more definitive trials are warranted.

Physical exercise augmented cognitive behaviour therapy for older adults with generalised anxiety disorder (PEXACOG): study protocol for a randomized controlled trial.

BACKGROUND: Generalised anxiety disorder (GAD) is a frequent and severe anxiety disorder among older adults. GAD increases the risk of developing other disorders such as depression and coronary heart disease. Older adults with GAD exhibit a poorer response to cognitive behaviour therapy (CBT) compared to younger patients with GAD. The normal age-related cognitive decline can be a contributor to reduced treatment efficacy. One strategy for improving treatment efficacy is to combine CBT with adjunctive interventions targeted at improving cognitive functions. Physical exercise is a viable intervention in this regard. Increased levels of brain-derived neurotrophic factor may mediate improvement in cognitive function. The present study aims to investigate the proposed effects and mechanisms related to concomitant physical exercise. METHODS: The sample comprises 70 participants aged 60-75 years, who have GAD. Exclusion criteria comprise substance abuse and unstable medication; inability to participate in physical exercise; and conditions which precludes GAD as primary diagnosis. The interventions are individual treatment in the outpatient clinic at the local psychiatric hospital, with two experimental arms: (1) CBT + physical exercise and (2) CBT + telephone calls. The primary outcome measure is symptom reduction on the Penn State Worry Questionnaire. Other measures include questionnaires, clinical interviews, physiological, biological and neuropsychological tests. A subset of 40 participants will undergo magnetic resonance imaging (MRI). After inclusion, participants undergo baseline testing, and are subsequently randomized to a treatment condition. Participants attend five sessions of the add-on treatment in the pre-treatment phase, and move on to interim testing. After interim testing, participants attend 10 sessions of CBT in parallel with continued add-on treatment. Participants are tested post-intervention within 2 weeks of completing treatment, with follow-up testing 6 and 12 months later. DISCUSSION: This study aims to develop better treatment for GAD in older adults. Enhancing treatment response will be valuable from both individual and societal perspectives, especially taking the aging of the general population into account. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02690441 . Registered on 24 February 2016.

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.