Journal of Anxiety Disorders 50 (2017) 103–112

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Journal of Anxiety Disorders

journal homepage: www.elsevier.com/locate/janxdis

Metacognitive therapy versus disorder-specific CBT for comorbid anxiety MARK

disorders: A randomized controlled trial☆
⁎
Sverre Urnes Johnsona,b, , Asle Hoffarta,b, Hans M. Nordahlc,d, Bruce E. Wampolda,e
a
Modum Bad Psychiatric Center, Vikersund, Norway
b
University of Oslo, Department of Psychology, Norway
c
Norwegian University of Science and Technology, Institute of Mental Health, Norway
d
St. Olavs Hospital, Div of Psychiatry, Nidaros DPS, 7006 Trondheim
e
University of Wisconsin-Madison, USA

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
Cognitive behavioral therapy (CBT) has grown into a collection of
treatments for specific disorders and problems that have one key aspect
in common − changing maladaptive thoughts and behaviours (Beck,
1976). Meta-analyses have indicated that CBT has solid empirical evi-
dence and works well for a wide range of different disorders (Butler,
Chapman, Forman, & Beck, 2006; Tolin, 2010). CBT has developed by
designing specific variants of CBT for particular disorders (e.g., Clark,
1986). The use of a treatment for a single disorder may be problematic
because comorbidity is common in psychiatric patients, especially for
anxiety disorders (Kessler et al., 2012). Further, comorbidity is associated
with higher level of disease burden (Gadermann, Alonso, Vilagut,
Zaslavsky, & Kessler, 2012) and lowers the likelihood of recovery from
anxiety disorders (Bruce et al., 2008). To address comorbidity, trans-
diagnostic treatment models have been emerging and clinical theory and
research have shifted towards processes that are common across psy-
chological disorders (Aldao & Nolen-Hoeksema, 2010; Harvey, Watkins,
Mansell, & Shafran, 2004; Moses & Barlow, 2006; Wells & Matthews,
1994).
Several transdiagnostic processes have been discussed, each with a
different treatment model, such as Metacognitive therapy (Wells, 2009)
and the Unified Protocol (Barlow et al., 2011). However, few studies
have evaluated the effect of transdiagnostic treatment models com-
pared to a gold standard of disorder-specific treatments, such as CBT
(Norton & Paulus, 2015 Reinholt & Krogh, 2014). A study by Norton
and Barrera (2012) compared a transdiagnostic cognitive-behavioral
group treatment to 12-week disorder-specific CBT protocols for panic
disorder, social phobia, and generalized anxiety disorder, and failed to
find differences between transdiagnostic and the disorder-specific CBTs.
Moreover, no differences were found between disorder-specific 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.
2015), panic disorder with and without agoraphobia (Fogliati et al.,
2016) and depression (Titov et al., 2015). There is some evidence that
transdiagnostic CBT may reduce comorbid symptoms more than dis-
order-specific CBT (Norton et al., 2013). However, this pattern was not
found in a trial comparing acceptance and commitment therapy (ACT)
with disorder-specific CBT for mixed anxiety disorders (Arch et al.,
2012). Thus, it seems preliminarily that transdiagnostic CBT produces
similar results as disorder-specific CBT, and there is inconclusive evi-
dence regarding the differential effect on comorbid diagnoses and
symptoms.
An innovative transdiagnostic treatment model is Metacognitive
therapy (MCT). MCT is based on the transdiagnostic S-REF model
(Wells & Matthews, 1994, 1996). According to this theory, psycholo-
gical disorders are linked to the activation of self-regulatory strategies
called the cognitive attentional syndrome (CAS). CAS consists of ex-
tended thinking in the form of worry and rumination, threat monitoring
and unhelpful coping behaviours, and is maintained by positive and
negative metacognitions. Positive metacognitions are positive beliefs
about using the CAS (e.g., “If I worry I will be prepared.”) while ne-
gative metacognitions are related to the subjective feeling of lack of
control or dangers of the CAS-processes (e.g., “My worrying is un-
controllable.”). In the MCT-treatment the therapist focuses on enhan-
cing flexible thinking by explicitly challenging metacognitions (Wells,
2009). MCT models have shown promising results for specific disorders
like generalized anxiety disorder (GAD; McEvoy et al., 2015; Van der
Heiden, Muris, & van der Molen, 2012), major depressive disorder
(MDD; Hagen et al., 2017, Wells et al., 2012), post traumatic stress
disorder (PTSD; Wells, Walton, Lovell, & Proctor, 2015) and comorbid
and complex anxiety disorders (Johnson & Hoffart, 2016). A recent
meta-analysis indicated that MCT was superior to both waitlist and CBT
(Normann, van Emmerik, & Morina, 2014). Further, a small study
(N = 30) comparing individual MCT with individual CBT found that
MCT had a significantly better effect on anxiety and worry at post-
treatment than CBT (Nordahl, 2009). However, to our knowledge no
other studies have investigated the effect of MCT across several dis-
orders in a randomized controlled trial. A comparison of MCT with
disorder-specific treatments in samples with high degree of comorbidity
is needed.
The current study was designed to compare the best documented and
recommended treatments of CBT for post traumatic stress disorder
(PTSD), social phobia (SAD) and panic disorder with and without agor-
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-
orders (Brady, Killeen, Brewerton & Lucerini, 2000). Furthermore, social
phobia and PTSD symptoms are often comorbid (Collimore, Carleton,
Hofmann, Asmundson, 2010; McMillan, Sareen, & Asmundson, 2014),
and panic attacks often occur together with PTSD and SAD (Cougle,
Feldner, Keough, Hawkins, & Fitch, 2010; Kessler et al., 2005). The me-
tacognitive model is also based on a theory (S-REF model) in which
common processes (i.e., worry, rumination and threat monitoring) be-
tween the different disorders is highlighted, and thus it is possible to
conceptualize a transdiagnostic case-formulation for PD/A, SAD and
PTSD.
Based on previous studies, it was hypothesized that MCT would
have larger effects on the anxiety and primary diagnoses than would the
disorder-specific CBT. Further, due to the more general focus of trans-
diagnostic processes it was hypothesized that MCT would have a larger
effect on comorbid diagnoses and other symptoms compared to dis-
order-specific CBT.
2. Method
2.1. Participants
Participants were referred to treatment at the Department of
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Journal of Anxiety Disorders 50 (2017) 103–112
Anxiety Disorder at Modum Bad Psychiatric Center in Norway in 2013.
Modum Bad is a specialist hospital conducting, which includes an in-
patient program for treatment resistant patients with anxiety disorders.
Before admission all patients received treatment in their local com-
munity and had not responded to previous treatments. The patients
were admitted to the hospital in groups of eight, but were treated in-
dividually. Treatment took place from the autumn of 2013 to the au-
tumn of 2014 and one-year follow up was finished in the autumn of
2015. Recruitment was designed to be liberal using the clinical criteria
for treatment used at the department. We used the Anxiety Disorders
Interview Schedule (IV) (ADIS IV; Brown, Di Nardo, & Barlow, 1994) for
diagnostic evaluation. To be eligible for participation in the study,
participants had to meet criteria for a principal DSM-IV disorder, ex-
ceeding above four on the clinical severity rating (CSR) on the ADIS IV
of PTSD, SAD or PD/A. Further, participants had to have failed to
benefit from at least one structured psychological treatment, be 18
years or older, able to speak Norwegian, and provide informed consent.
Exclusion criteria followed the intake-procedures at the department of
Anxiety Disorders at Modum Bad, which excluded patients who (a) in a
clinical context would have required immediate treatment or simulta-
neous treatment that could interact with the treatment in unknown
ways, (b) had current DSM-IV diagnoses of organic mental disorders, (c)
had clear and current suicidal risk or (d) had evidence of current sub-
stance abuse. All participants had to terminate the use of psychotropic
medications before treatment. The patients were contacted before
treatment to ensure that medications were terminated or was being
reduced. The study was approved by the Norwegian regional ethical
committee (2013/209/REK South-East).
Participants who were included in the trial (N = 90) were rando-
mized to treatment stratified on their principal disorder. There were six
participants who did not arrive at the hospital or complete the first
assessment. The participants did not have any knowledge of their
treatment-group before arrival. After diagnostic screening six patients
had a loss of eligibility and at start of treatment four patients were
excluded due to a new therapist arriving at the hospital who was not
formally trained. The remaining 74 participants who started treatment
(n = 38 CBT, n = 36 MCT) were included in the final analysis. Of the
participants starting treatment, seven did not complete the treatment
program, leaving 67 who completed all the treatment sessions (n = 33
in CBT, n = 34 in MCT). See Table 1 for final sample characteristics and
Fig. 1 for flowchart.
2.2. Baseline scores
The participants had on average 3.7 diagnoses at the start of
treatment with 90.5% having a comorbid disorder and 30 (41%) a
personality disorder. Only four participants (5%) had been working full
time when entering treatment (see Tables 1 and 3). That few partici-
pants were working regularly, which in combination with long duration
of the anxiety disorder (M = 16.1 years, SD = 11.8) indicates a sample
of chronic and dysfunctional patients.
2.3. Study design
Participants in the study were randomized to two different treatment
modalities, generic MCT and disorder-specific CBT. Patients in both MCT
and CBT were assessed at evaluation, pre-treatment, at the end of
treatment, and after a one-year follow-up period. At evaluation the
participants were assessed by clinicians in the department who con-
firmed the presence of an anxiety disorder before randomization, and a
new formal assessment including two diagnostic interviews (ADIS IV and
SCID II) and self report questionnaires were conducted at the start of
treatment. Assessors were blind to treatment conditions.
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.

Pre treatment 1YFW

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.

2.4. Random assignment 2.5.2. Cognitive behavioral therapy

Following diagnostic assessment at evaluation, participants were
randomly assigned using a randomization sequence generated by www.
random.org. Patients were stratified individually on primary diagnosis
prior to randomization (i.e., SAD, PD/A or PTSD) and randomly as-
signed to either MCT or CBT. The randomization was conducted four
weeks before the start of treatment because the patients needed time to
plan travel and prepare for the treatment. Pragmatic considerations at
the hospital dictated that one treatment group began 3 weeks before the
other (viz., the MCT group started their treatment 3 weeks before the
CBT group). To avoid possible confounding related to order-effects the
intake of the patients was switched in the middle of the trial so that the
MCT group started three weeks after the CBT group.
2.5. Treatments
The number of sessions for completers were M = 9.4 (SD = 1.7).
The number of sessions were equivalent in both conditions. However
the sessions in CBT lasted longer, due to the protocols for SAD and
PTSD, which lasted 90 min. Standard session time for MCT was 50 min.
In the CBT group, actual session time in minutes was M = 71.5 (SD
18.8). In the MCT group the actual session time was 51.8 (SD = 13.3).
The patients received individual treatment in a ward for eight weeks
with other anxiety patients. The patients participated in the ward’s
common activity, consisting of one ward meeting and one physical
exercise session per week. The patients in the study were requested not
to talk about the treatment outside the therapy-room and instead focus
on other aspects of the inpatient setting.
2.5.1. Metacognitive therapy
The MCT treatment consisted of a manualized treatment protocol
for the generic MCT model (Wells, 2009). The protocol deemphasizes
disorder-specific aspects, and focuses instead on challenging positive
and negative metacognitions that drive the use of worry, rumination,
threat-monitoring and coping behaviours to regulate emotions.
Treatments in the disorder-specific CBT condition were the most
extensively documented cognitive treatments of panic disorder with
and without agoraphobia (Clark, 1986; Wells, 1997), of social phobia
(Clark & Wells, 1995; Wells, 1997), and of PTSD by using prolonged
exposure (PE) therapy (Foa, Hembree, & Rothbaum, 2007). The proto-
cols where chosen because of wide use and strong documentation over
the past two decades (see NICE, 2013). The treatments followed their
respective manuals. However, due to the length of the program the
number of sessions was adjusted to 7–9 in PE.
2.5.3. Comparison of MCT and CBT
MCT and CBT are used by therapists to change various aspects of
cognitions, and both treatments are goal directed, short term and
structured. However, CBT is focuses mainly on the content of cogni-
tions, whereas MCT focuses on the meta-level (cognitions about cog-
nitions). In MCT the goal is to change how patients respond to thoughts
by changing metacognitions that drive the CAS. Furthermore, in MCT
exposure to trauma is not a part of the treatment.
2.6. Therapists and supervision
Two clinical psychologists served as therapists in MCT and one
clinical psychologist and two psychiatrists served as therapists in CBT.
The therapists worked at the department at the time of the trial and had
at least two years of formal clinical training in MCT or CBT or were in
progress of completing their training in the respective treatments. One
of the psychiatrists in CBT was included during the trial. She received
intensive supervision from the CBT expert and the first author, and had
two training-cases documenting competency and adherence in CBT
prior to inclusion. Each therapist in the dataset treated 14.8 patients on
average (SD = 5.5, Range = 5 − 18). In the CBT group the average
years of clinical experience was 10.0 (SD = 10.8), and in the MCT
group the average years of experience was 2.5(SD = 0.7). An expert in
MCT (the third author) and an expert in CBT (the second author) su-
pervised the therapist groups weekly and ensured the therapists’ fide-
lity.

105
S.U. Johnson et al.
2.7. Treatment fidelity
Therapist competency for CBT was assessed using the Cognitive
Therapy Scale (CTS; Young & Beck, 1980) and for MCT the Meta Cog-
nitive Therapy Competency Scale (MCT-CS; Nordahl & Wells, 2009).
CTS has shown good psychometric properties (Vallis, Shaw & Dobson,
1986), while MCT-CS has not undergone psychometric investigation
(see supplementary A), but was developed to directly mirror the items
in the CTS. Competence was evaluated on a scale from 0 to 6 in both
MCT and CBT, and trial target for competence ratings was four or
above. Adherence to the treatment protocols was calculated based on
six items: setting agenda, checking homework, following the structure
of the treatment protocol, using CBT/MCT interventions, giving
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
106
Journal of Anxiety Disorders 50 (2017) 103–112
Fig. 1. Consort diagram of participant flow. MCT =
Metacognitive Therapy, CBT = Cognitive Behavioral
Therapy.
clinical psychology students trained by the MCT and CBT experts and
the first author. The two MCT trained students rated 313 MCT videos
(across 33 patients) and the two CBT trained students rated 281 CBT
(across 34 patients). Patients’ average competence and adherence rat-
ings across sessions were calculated. Every 15th to 18th video, chosen
at random, was coded independently by the first author for inter-rater
reliability, and for giving necessary supervision to avoid rater drift.
Inter-rater reliability using a one-way random intraclass correlation
(ICC [1,1]) was 0.88 for MCT competence (N = 17) and 0.76 for ad-
herence. The ICC (1, 1) for the CBT competence ratings (N = 18) was
0.93 and 0.83 for adherence.
2.8. Measures
Measures that were not specific to a particular anxiety disorder, but
S.U. Johnson et al.
assessed anxiety as a generalized condition, were selected. The Beck
Anxiety Inventory (BAI) and Anxiety Disorder Interview Schedule for
DSM-IV (ADIS-IV) were used as primary outcomes of the trial.
Secondary outcomes1 included the Structured Clinical Interview for
Diagnosis of DSM-IV Axis II (SCID II), Symptom Check List-90 (SCL-90),
IIP-64, BDI, Penn State Worry Questionnaire (PSWQ) and use of the
ADIS IV CSR-scores. To cover those diagnoses not measured by ADIS IV,
the patients were screened for eating disorder and body dysmorphic
disorder using the Mini-International Neuropsychiatric Interview
(M.I.N.I.; Sheehan et al., 1998), both at pre-treatment and one-year
follow up.
2.8.1. Beck anxiety inventory (BAI; Beck, Epstein, Brown & Steer, 1988)
BAI is an instrument with 21 items, measuring anxiety symptoms
during the prior week. The items are rated on a Likert scale from 0 to 3,
and the total score ranges from 0 to 63. BAI has been found reliable and
valid for measuring anxiety symptoms (Steer, Ranieri, Beck, & Clark,
1993). We used the BAI as the primary self-report outcome because it
was necessary to have a measure of anxiety that was appropriate across
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
follow-up were 0.89, 0.92 and 0.91, respectively.
2.8.2. ADIS −IV (Brown, DiNardo & Barlow, 1994)
ADIS-IV is a semi structured diagnostic interview designed to assess
the presence, nature and severity of DSM-IV anxiety and mood dis-
orders. Clinical Severity Ratings (CSR) are conducted for each disorder
on a scale from 0 to 8. ADIS-IV interviewers were advanced clinical
psychology students, trained to reliability standards, who had demon-
strated adequate diagnostic reliability on three consecutive interviews.
All interviewers were blind to treatment condition. Reliability assessors
who were blind to the original diagnosis coded videos of 15 percent of
randomly chosen diagnostic interviews (N = 20). Inter-rater reliability
on the principal diagnosis, PD/A, SAD and PTSD, was 100%. Inter-rater
agreement on dimensional CSR ratings for the primary diagnosis, using
a one-way random intraclass correlation (ICC [1,1]) was 0.96 with a
single-measure,. The ICC (1, 1) across all the anxiety and mood dis-
orders (met DSM IV criteria vs subclinical vs. none) was 0.85 and the
ICC (1, 1) for the sum score of dimensional CSR rating was 0.89.
2.8.3. SCID-II (First, Gibbon, Spitzer, Williams, & Benjamin, 1997)
SCID-II is a semi structured diagnostic interview designed to assess
the presence, nature, and severity of DSM-IV Axis II disorders.
Interviews were conducted by advanced clinical psychology students
early in treatment, and at one-year follow-up. To assess interrater re-
liability, blind raters coded 25 of the videos. Cohen’s kappa was 1.0 for
the personality disorder, reflecting 100% agreement about the presence
of personality disorder or not. The ICC (1, 1) for the total score of all
criteria (scoring 3 or not) was 0.97.
2.8.4. The symptom checklist-90 (SCL-90; Derogatis, 1983)
SCL-90 is one of the most widely used measures of multiple aspects
of psychological distress in clinical practice and research. The measure
consists of 90 items, and gives a GSI score of general distress. The items
are rated on a Likert scale from 0 to 5, and the total GSI score varies
from 0 to 5. SCL 90 has shown good psychometric properties (Schmitz
et al., 2000). The Cronbach’s alpha coefficient for SCL-90 for this study
at start of treatment, at the end of treatment, and at one-year follow-up
was 0.96, 0.98 and 0.98, respectively.
1
This Trial was registered with 16 measures (ClinicalTrials.gov identifier:
NCT01889342). We chose a selection of the secondary outcomes of the trial in advance of
conducting any analysis, because the other measures were process-measures or disorder-
specific measures that will be reported elsewhere.
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Journal of Anxiety Disorders 50 (2017) 103–112
2.8.5. The inventory of interpersonal problems-64-circumplex (IIP-64-C;
Horowitz, Alden, Wiggins, & Pincus, 2000; Horowitz, Rosenberg, Baer,
Ureño, & Villaseñor, 1988)
IIP-64-C is a self-report measure of maladaptive relationship beha-
vior. The scale consisted of 64 items of which 8 subscales are con-
ceptually organized in a circumplex manner and the patients are asked
to rate interpersonal behavior on a 5-point Likert scale. The IIP 64C has
shown good psychometric properties (Horowitz et al., 1988). The
Cronbach’s alpha coefficient for the IIP-64-C for this study at start of
treatment, at the end of treatment and at one-year follow-up was 0.96,
0.98 and 0.96, respectively.
2.8.6. Beck depression inventory II (BDI II; Beck, Steer & Brown, 1996)
BDI-II is a 21-item self-report scale assessing current level of de-
pression. The range of scores is from 0 to 63, and the items are scored
on a Likert scale from 0 to 4. The psychometric properties of BDI are
adequate (Beck, Steer, & Garbin, 1988). The Cronbach’s alpha coeffi-
cient for the BDI II for this study at start of treatment, at the end of
treatment and at one-year follow-up was 87, 0.93 and 0.93, respec-
tively.
2.8.7. Penn state worry questionnaire (PSWQ; Meyer, Miller,
Metzger, & Borkovec, 1990)
PSWQ is a widely used 16- item self-report inventory assessing the
pervasiveness, excessiveness, and uncontrollability of worry. Total
scores on the PSWQ range from 16 to 80 and the items are scored on a
Likert scale from 1 to 5. The PSWQ is a reliable and valid instrument for
measuring worry (Meyer et al., 1990). The Cronbach’s alpha coefficient
for the PSWQ for this study at start of treatment, at the end of treatment
and at one-year follow-up was 0.92, 0.94 and 0.92, respectively.
2.8.8. Generalization of treatment effects
Co-occurring mood and anxiety disorders (with CSR of 4 or more) at
post-treatment and one-year follow-up were analysed as an index of
generalization of treatment effects. We used number of diagnoses and
the total score of CSR for each patient as the measure of generalization
of treatment effects. The procedure was similar to the one used in a
recently published RCT (Arch et al., 2012). Further, we used total
number of 3 criteria (SCID II) as a marker for the effect on personality
problems.
2.9. Common factors: treatment credibility and working alliance
We wanted to make sure that the two treatments were comparable
on common factors, such as treatment credibility and working alliance,
which are essential for psychotherapy outcome (Wampold & Imel,
2015). A shortened three-item version of the five-item Credibility Scale
(CS-3) was used (Borkovec & Nau, 1972) to assess on 0–10 point scales
how logical participants find the treatment, how successful participants
think the treatment would be to reduce symptoms, and how much the
participants would recommend the treatment to a friend. The measure
has been used in several trials to assess the credibility of competing
treatments and psychological placebos, and has sound psychometric
properties (Devilly & Borkovec, 2000). Cronbach’s alpha coefficient for
the CS-3 at session three was 0.80. Working Alliance Inventory − Short
Revised (WAI-SR) (Hatcher & Gillaspy, 2006) is a shortened 12-item
version of the original 36-item WAI (Horvath & Greenberg, 1989),
which measures the quality of the therapeutic alliance. Items are rated
on a 1–7 Likert scale, and the total score is the average of the twelve
items. The WAI-SR has demonstrated good psychometric properties
(Hatcher & Gillaspy, 2006). The Cronbach’s alpha coefficient for the
WAI-SR at session three was 0.92.
2.10. Clinical significance
The patient improvement was evaluated using the clinical
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
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.
(1988) were used to calculate the standard error of the difference be-
tween the two scores and the reliable change index (RCI). Using the cut
off point and the RCI, each patient could be classified as recovered
(passed both criteria), improved (passed only the RCI criterion in the
positive direction), unchanged (did not pass the RCI criterion), or de-
teriorated (passed the RCI criterion in the negative direction).
2.12. Power estimation
Power analysis, conducted with Optimal Design (Raudenbush & Liu,
2000), indicated that to reach 80% power with an effect size of d = 0.6,
required 78 participants. Therefore our total sample size (N = 90) was
expected to be sufficient to detect between group differences of mod-
erate size at each assessment point as found in previous research by
Nordahl (2009) and Normann et al. (2014).
3. Results

2.11. Statistical methods 3.1. Characteristics of the patients

The data from all patients who started treatment were analysed. Chi
square tests and t-tests (two-tailed) were conducted to check for dif-
ferences at pre-treatment. Treatment differences were analysed using
Hierarchical Linear Modelling (HLM; Raudenbush & Bryk, 2002). In
HLM all available data is used. Thus, a research participant with only
baseline data can be included in an analysis and contribute to the es-
timation of model parameters (Kwok et al., 2008). The models were
built by starting with a model with only fixed intercept and no random
effects. Random intercepts and random slope were then added if they
significantly increased model fit. The data was modelled for hetero-
scedastic residual variance over time. A diagonal covariance structure
of the residuals gave the best model fit. Maximum likelihood (ML) was
used as the estimation method (Fitzmaurice, Laird, & Ware, 2004). All
models were tested for model fit using log likelihood tests, and the most
parsimonious model was selected. Since a non-linear relationship was
expected, with a larger decrease from pre-treatment to post-treatment,
we used a piecewise HLM with two different time variables.
The MCAR (Missing Completely at Random) test (Little, 1988) was
not significant on the BAI (χ2 = 3,2, p = 0.669) or the other measures,
indicating that the data could be considered to be missing at random.
Multiple imputations with twenty-five datasets were used on all the
self-report measures (Graham, Olchowski, & Gilreath, 2007; Graham,
2009; Rubin, 1996). Pre-treatment scores were used as predictors, and
the pooled estimates used in the calculation of clinical significant
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-
cedure (Benjamini & Hochberg, 1995) was applied to determine sig-
nificance. Effect sizes (Cohen’s d) for HLM-analysis are calculated based
on Feingold (2009). Interpretations were based on the classifications of
Cohen (1988). SPSS version 21.0 was used.
Table 1 gives an overview of the characteristics of the patients at
pre-treatment and one-year follow-up. The patients’ did not differ on
key variables at pre-treatment, including number of diagnoses, former
treatment, use of medications, age and gender (p > 0.05 for all vari-
ables). Further, no significant pre-treatment differences between con-
ditions emerged on the outcome variables (p > 0.05 for all variables;
see supplementary material B). The sample analysed included 74 pa-
tients, of whom 72 were Norwegians (Caucasian), 1 was African and 1
was Asian. The mean age was 42.0 (SD = 12.8), mean duration of ill-
ness was 16.1 years (SD = 11.8), 45 (60.8%) were female and 29
(39.2%) were male, 39 (52.7%) lived alone. Only 9 (12.2%) had a
university degree, while the majority had only upper secondary school
28 (37.8%). Of the 74 patients entering treatment, seven patients
(9.5%) terminated treatment prematurely. Two patients dropped out of
MCT late in therapy (i.e.,after 4 weeks), and five patients dropped out
of CBT early (i.e., before 4 weeks). Drop out rate in the two conditions
did not significantly differ (p = 0.159; Fisher’s exact test). The reasons
for drop out in MCT were loss of motivation (n = 1) and use of alcohol
(n = 1). In CBT the reasons were lack of motivation (n = 4) and use of
alcohol (n = 1). In total, sixty-seven patients (MCT, N = 34; CBT,
N = 33) completed the post-treatment assessment. See Fig. 1 for par-
ticipant flow.
3.2. Treatment effects
3.2.1. Primary and secondary outcomes
The means and standard deviations for patients in the two treat-
ments across outcome assessment are reported in Table 2 (self-report
measures) and Table 3 (interview-based ADIS). To test for treatment
differences we conducted HLM with linear splines on all outcome

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S.U. Johnson et al. Journal of Anxiety Disorders 50 (2017) 103–112

Table 3 treatments at one-year follow-up as evident in Table 2 (see supple-

Number of diagnoses and CSR from pre treatment to 1-year-follow-up (1YFW). mentary materials C and Table S6 for data on the HLM-analysis at one-
year follow-up). Subanalyses based on diagnosis revealed that the lar-
Pre treatment IYFW
gest difference between MCT and CBT at post-treatment was found for
Diagnosis CBT (38) MCT (36) CBT (30) MCT (29) PD/A. Details concerning analyses on the three specific diagnoses are
Diag (SD) 3.7 (1.6) 3.7 (1.6) 2.1 (1.6) 2.3 (1.6) presented in supplementary materials D.
CSR (SD) 22.0 (10.6) 22.6 (9.5) 14.4 (9.4) 14.0 (9.5)
PTSD (%) 25 (65.8) 15 (41.7) 10 (33.3) 13 (44.8)
PD/A (%) 23 (60.5) 28 (77.8) 6 (20.0) 10 (34.5)
3.2.2. Generalization of treatments effect
SAD (%) 21 (55.3) 24 (66.7) 11 (36.7) 13 (44.8) Treatments effect on comorbid diagnosis was established with the
GAD (%) 23 (60.5) 22 (61.1) 12 (40.0) 11 (37.9) use of three separate HLMs: number of diagnoses, CSR for all diagnoses,
MDD (current) (%) 16 (42.1) 13 (36.1) 9 (30.0) 6 (20.7) and number of 3 criteria on the SCID II. The analysis revealed no sig-
Dysthymia (%) 11 (28.9) 17 (47.2) 3 (10.0) 7 (24.1)
nificant interaction with group, for number of diagnoses (p = 0.57,
OCD (%) 4 (10.5) 1 (2.8) 2 (6.7) 1 (3.4)
SF (%) 5 (13.2) 6 (16.7) 3 (10.0) 2 (6.9) d = 0.1), or CSR total (p = 0.35, d = 0.2). However there was a sig-
BP (%) 2 (5.3) 1 (2.8) 1 (3.3) 0 (0) nificant interaction between slope and group for SCID II total criteria,
Cyclothymia (%) 0 (0) 0 (0) 1 (3.3) 0 (0) (p = 0.03, d = 0.3), indicating that from pre-treatment to one-year
Hypoch. (%) 4 (10.5) 1 (2.8) 2 (6.7) 1 (3.4) follow-up, MCT produced larger change in personality disorder pro-
SD (%) 4 (10.5) 1 (2.8) 1 (3.3) 2 (6.9)
Drug abuse (%) 2 (5.3) 0 (0) 0 (0) 0 (0)
blems. See Table S8 in supplementary material for estimates of random
Alcohol abuse (%) 1 (2.6) 2 (5.6) 1 (3.3) 1 (3.4) and fixed effects.
Alcohol dep. (%) 1 (2.6) 1 (2.8) 0 (0) 1 (3.4)
PD (%) 15 (39.5) 15 (41.7) 8 (26.7) 4 (13.8) 3.3. Common factor threats to validity
PD 3 Criteria (SD) 8.3 (7.7) 9.2 (9.8) 5.6 (6.1) 4.6 (6.0)
Cluster C PD (SD) 10 (27.8) 15 (41.7) 5 (16.7) 3 (10.3)
Cluster B PD (SD) 5 (13.9) 5 (13.9) 3 (10.0) 2 (6.9) There were no significant differences between MCT (M = 23.3,
Cluster A PD (SD) 3 (8.3) 2 (5.6) 1 (3.3) 1 (3.4) SD = 6.4) and CBT (M = 24.0, SD = 4.9) in treatment credibility at the
start of treatment using an independent sample t-test (t(1, 68) = 0.51,
Note. Diag = Number of diagnoses, CSR = Clinical severity rating (ADIS IV total score), p = 0.613, d = −0.1) or at session three between MCT (M = 24.2,
PTSD = Post traumatic stress disorder, PD/A = Panic disorder with and without agor-
SD = 4.8) and CBT (M = 23.6, SD = 4.4) (t(1, 66) = −0.69,
aphobia, SAD = Social phobia, GAD = Generalized Anxiety Disorder, MDD = Major
p = 0.496, d = 0.1). Further, there was no significant difference in the
depressive disorder, OCD = Obsessive compulsive disorder, SF = specific phobia,
BP = Bipolar disorder, Hypoch. = Hypochondriasis, SD = Somatization disorder, working alliance at session three: MCT (M = 5.9, SD = 0.9) and CBT
Alcohol dep.= Alcohol dependence, PD = Personality disorder, PD 3 Criteria = Number (M = 5.8, SD = 0.9) (t(1, 68) = −0.60, p = 0.549, d = 0.1).
of 3 criteria on SCID I, SD = Standard deviation. Accordingly, differences between treatment credibility and alliance did
not appear to compromise internal validity.
measures. Thus, there were two time-sequences, from pre-treatment to
post-treatment (slope) and from post-treatment to one-year follow-up 3.4. Therapist competence and treatment adherence
(slope2). As evident in Table 4, there was an interaction between slope
and treatment from pre-treatment to post-treatment in favour of MCT The mean overall competency rating was 4.39 (SD = 0.56) and 4.00
on BAI (p = 0.01, d = 0.7), BDI (p = 0.008, d = 0.7), SCL-90, (SD = 0.70) for MCT and CBT, respectively. Treatment adherence was
(p = 0.03, d = 0.6) and PSWQ (p = 0.002, d = 0.6), but not on ADIS 4.69 (SD = 0.60) and 4.28 (SD = 0.64) for MCT and CBT, respectively.
IV CSR primary diagnosis (p = 0.5, d = 0.3) and IIP 64 (p = 0.6, As stated previously, these values reflect adequate adherence and
d = 0.2). As indicated by Table 4 there was also a significant interac- competence (i.e., ratings > 4) for both MCT and CBT. Therapist effects
tion between slope2 and group on the same measures in the opposite were assessed with an ICC (1,1) for BAI and was found to be negligible
direction, indicating that CBT had larger gains from post-treatment to ( < 0.1). Thus, therapist effects are not likely to influence the statis-
one-year follow-up. There were no differences in effect between the tical results.

Table 4
BAI, SCL-90, BDI, IIP-64, PSWQ and ADIS in HLM.

Parameter BAI BDI SCL-90 PSWQ IIP-64 ADIS

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).

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S.U. Johnson et al.
Table 5
Clinical significant change for MCT, CBT and the total sample at post-treatment and 1-
year-follow-up.
Post-treatment
Treatment Recovered Reliable Change Unchanged
MCT (n = 36) 15 (41.6) 5 (13.8) 14 (38.9)
CBT (n = 38) 7 (18.4) 7 (18.4) 20 (52.6)
Total (N = 74) 22 (29.7) 12 (16.2) 34 (45.9)
1-year-follow-up
MCT (n = 36) 10 (27.8) 6 (16.7) 17 (47.2)
CBT (n = 38) 14 (36.8) 5 (13.2) 16 (42.1)
Total (N = 74) 24 (32.4) 11 (14.9) 33 (44.6)
Note. Percentages given in parentheses.
3.5. Clinical significant change
At post-treatment, 55.4% and 36.8% of the patients in MCT and CBT
were either recovered or improved, respectively (see Table 5). At one-
year follow-up, 44.8% and 50.0% of the patients in MCT and CBT were
either recovered or improved.
4. Discussion
The main purpose of the study was to compare the effect of MCT
with a gold standard treatment for anxiety disorders, namely CBT. We
hypothesized that MCT as a transdiagnostic treatment would have
greater effect on anxiety and comorbid diagnoses and symptoms in a
mixed anxiety disorder sample than CBT. There was an interaction
between slope and treatment from pre-treatment to post-treatment in
favour of MCT on anxiety (BAI), depression (BDI), worry (PSWQ) and
general symptoms (SCL-90) but not on ADIS IV and interpersonal
functioning (IIP 64). From pre-treatment to one-year follow-up there
were no significant differences between the treatments. There were no
significant differences between MCT and CBT on treatment credibility
at session one or session three, indicating that both treatments had a
rationale that seemed plausible and that therapists form alliances in the
two treatments that were comparable. Moreover, the adherence and
competence ratings in both treatments were at a satisfactory level
(> 4), strengthening the internal validity of the study.
A conceivable reason for the more rapid effect of MCT at post-
treatment is that MCT directly challenges emotion regulation strategies
at the process level in the form of worry and rumination, while CBT
may have needed a longer time to work through the content of cogni-
tion. However, during the one-year follow-up period CBT patients
continued to improve, while the MCT patients remained stable. One
possible explanation is that the patients in the CBT group needed more
time to make use of the tools learned in therapy. For example, beha-
vioral experiments are a common practice in all three CBT manuals,
thus patients returning home and continuing exposure could have en-
hanced treatment effects. Notably, 67.8% of the sample (73% CBT and
62% MCT) had treatment in the follow-up period, which is normal for
this patient group. Of those receiving additional treatment, 33% had
CBT treatment, while the majority (49%) of participants could not tell
what kind of treatment they were given. The lack of continued im-
provement of MCT at one-year follow-up could be due to a shift in
treatment that was not compatible with MCT.
The effect sizes on the BAI from pre-treatment to one-year follow-up
were large, though smaller then found in other trials for MCT and CBT
(cf., Nordahl, 2009). However, in studies with highly comorbid anxiety
disorders the effect sizes were significantly lower than those in the
present study, and duration of illness had a significant negative asso-
ciation with the effect of treatment (cf., Sánchez-Meca, Rosa-Alcázar,
Marín-Martínez, & Gómez-Conesa, 2010). Our sample consisted of pa-
tients who all had failed previous treatments, were out of work and had
Journal of Anxiety Disorders 50 (2017) 103–112
high degrees of comorbidity. There is a negative correlation between
mental health and unemployment (Murphy & Athanasou, 1999) and
being out of work at the start of treatment has been found to predict
poorer long-term outcome (Durham et al., 2005; Hoffart, Øktedalen,
Svanøe, Hedley & Sexton, 2015). Thus, the effect sizes of the present
Detoriated study should be interpreted in this context. Furthermore, attrition rates,
9.5% from pre- to post- and 20.2% from pre- to one-year follow-up were
2 (5.6)
4 (10.5) modest and no group differences emerged. The attrition rates were
6 (8.1) lower than the weighted mean attrition (23%) reported in a meta-
analysis of CBT studies for anxiety disorders (Hofmann & Smits, 2008).
3 (8.3) The number of diagnoses was reduced from pre- to post-treatment
3 (7.9) and maintained at one-year follow-up with no significant differences
6 (8.1) between the treatment groups. The results replicate and extend pre-
vious work on the effect of CBT on comorbid symptoms and diagnosis
for anxiety disorders (Norton et al., 2013; Tsao, Lewin & Craske, 1998).
The results did not support our hypothesis that working on transdiag-
nostic processes, such as worry and rumination (MCT), would lead to
larger effects on comorbid symptoms and diagnoses. However, MCT
reduced personality-problems more then CBT, indicating a possible
broader effect of MCT on comorbid personality problems, a result that
needs further investigation.
4.1. Strengths and limitations
This study has several strengths. A new promising treatment was
compared to the best documented form of treatment for anxiety dis-
orders and the study was conducted in a naturalistic setting with
treatment resistant comorbid anxiety disorder patients.
Several limitations should also be noted. First, we did not include a
no-treatment control group, which prevents examination of whether
the two treatments were superior to no treatment. However, we know
that the level of spontaneous recovery in chronic, treatment resistant,
and comorbid anxiety disorder patients is low (Bruce et al., 2008). Also,
comparing established treatments does not typically require a no
treatment or waitlist control group, the use of which may then be
considered unethical (Devilly & McFarlane, 2009). Second, four pa-
tients were removed from the trial due to changes in the clinical staff,
damaging random assignment. Moreover, due to drop out before
treatment the patients analysed do not fit the strict definition of an
intent-to-treat sample. Third, the study was carried out at one clinic,
which suggests that there may have been contamination of the thera-
pies between the patients during the treatment phase, although an at-
tempt was made to minimise the likelihood of such contamination.
Fourth, we have not controlled for the ad hoc and additional treatments
that the patients received post-treatment, which might favour CBT as
many patients in both conditions received CBT in the follow-up period.
5. Conclusion
This is the first randomized controlled trial comparing MCT and
CBT for comorbid anxiety disorders, and both treatments produced
satisfactory effects, particularly for this treatment-resistant population.
There were significant differences in favour of MCT from pre-treatment
to post-treatment, but these differences disappeared at one-year follow-
up. The CBT group used the best-documented and widespread form of
CBT for each primary anxiety disorder, while the MCT group used a
generic model. There are advantages to having to learn only one
treatment for anxiety rather than several. Learning one model is less
time consuming than learning three specific ones, which has ad-
vantages for training of therapists. This study suggests that adoption of
MCT for patients with comorbid anxiety disorders may be warranted.
Acknowledgement
This study was supported by “The National Program for Integrated
Clinical Specialist and PhD-training for Psychologists” in Norway. We
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S.U. Johnson et al.
thank the individuals who participated in the study, the department of
anxiety disorder at Modum Bad for data collection and the research
assistants who assisted in data collection.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at http://dx.doi.org/10.1016/j.janxdis.2017.06.004.
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