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Cited by 81Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychological Treatments and AssessmentsPsychotherapy Techniques and Applications

Metacognitive Theory and Therapy for Worry and Generalized Anxiety Disorder: Review and Status

Open access
Wells, Adrian·2010·Journal of Experimental Psychopathology
DOI 10.5127/jep.007910
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Abstract

The metacognitive model of pathological worry and Generalized Anxiety Disorder (GAD) makes a crucial distinction between two types of worry and explains the persistence and uncontrollability of negative thinking as an effect of specific metacognitions. The negative appraisal of worry (meta-worry) and negative beliefs about worry are central to the development of GAD. Furthermore, GAD is associated with paradoxes in mental control such as the use of extended thinking to reduce thinking. Evidence is reviewed that supports major tenets of the model. A specific treatment, metacognitive therapy is described that focuses on modifying metacognitive beliefs and reducing the use of worry to cope with thoughts. The empirical status of the model is reviewed and evidence from recent trials of this treatment is summarized. The treatment appears to be effective and initial trials suggest it is associated with greater levels of recovery than approaches comprised of applied relaxation or cognitive-behavioural treatment focused on intolerance of uncertainty. © 2010 SAGE Publications Ltd.

Integrity signals

Registry

Crossref · 10.5127/jep.007910

Cites

47 of 49 references verified0 citation errors · 2 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 71 cited sources checked · 0 supported · 0 flagged

  • Interpretationreasoning

    It follows from the metacognitive model that successful treatment of GAD should depend on the modification of metacognitions, especially meta-worry (type 2 worry) and negative metacognitive beliefs.

    “It follows from the metacognitive model that successful treatment of GAD should depend on the modification of metacognitions, especially meta-worry (type 2 worry) and negative metacognitive beliefs.”
    Quote in the paperSubstantial claim
  • Premisereasoning

    Anxiety symptoms reinforce 'worry about worry' (type 2 worry) because the person negatively interprets symptoms associated with worry as a sign of mental or physical harm.

    “Anxiety symptoms reinforce 'worry about worry' (type 2 worry) because the person negatively interprets symptoms associated with worry as a sign of mental or physical harm.”
    Quote in the paperSubstantial claim
  • Premisereasoning

    Ordinary (Type 1) worrying in itself is not sufficient to cause GAD.

    “But ordinary (Type 1) worrying in itself is not sufficient to cause GAD.”
    Quote in the paperSubstantial claim
  • Premisecitation

    The metacognitive model of general psychopathology proposes that extended and recycled thinking of emotional disorder is a generic causal factor.

    “The metacognitive model of general psychopathology (Wells & Matthews, 1994;Wells, 2008) proposes that this style of thinking is a generic causal factor.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Wells & Matthews, 1994

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Wells, 2008

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Premisecitation

    The metacognitive model of GAD proposes that pathological worry is the specific result of negative beliefs about worrying and counterproductive strategies of mental control.

    “In contrast, the metacognitive model of GAD (Wells, 1995) proposes that pathological worry is the specific result of negative beliefs about worrying and counterproductive strategies of mental control.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wells, 1995

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims. 42
  • Classified as probably not a substantial claim. 8

  • May combine two claims.

    Premisenone given

    Worrying is a covert coping response that is linked to positive metacognitive beliefs.

    “Worrying is a covert coping response that is linked to positive metacognitive beliefs.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    Two other factors involved in maintaining GAD are coping behaviours and thought control strategies.

    “Two other factors are involved in maintaining the problem: coping behaviours and thought control strategies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    Metacognitive therapy appears to be effective and initial trials suggest it is associated with greater levels of recovery than approaches comprised of applied relaxation or cognitive-behavioural treatment focused on intolerance of uncertainty.

    “The treatment appears to be effective and initial trials suggest it is associated with greater levels of recovery than approaches comprised of applied relaxation or cognitive-behavioural treatment focused on intolerance of uncertainty.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The process of extended and recycled thinking is comprised largely of perseveration in the form of worry and/or rumination and results from metacognition.

    “The process is comprised largely of perseveration in the form of worry and/or rumination and results from metacognition.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Wells & Matthews, 1994

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Wells, 2008

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisereasoning

    Often, however, they encounter negative information or generate further questions which acts to trigger new bouts of worrying.

    “Often, however, they encounter negative information or generate further questions which acts to trigger new bouts of worrying.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Reassurance seeking transfers the control of worrying to someone else and the individual fails to discover that they have internal control.

    “The problem with reassurance seeking is that it transfers the control of worrying to someone else and the individual fails to discover that they have internal control.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Suppression of thoughts that might trigger worrying and failure to let go of the thinking process produce paradoxical effects such as thought rebound or are simply ineffective for reducing worry.

    “Suppression of thoughts that might trigger worrying and failure to let go of the thinking process produce paradoxical effects such as thought rebound or are simply ineffective for reducing worry.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Suppression of worry-triggering thoughts is rarely entirely effective and contributes another form of perseveration on a topic.

    “This is rarely entirely effective (e.g.Wegner, 1994;Wegner, Schneider, Carter, & White 1987) and contributes another form of perseveration on a topic.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Wegner, 1994 source
    • cites Wegner, Schneider, Carter, & White 1987 source

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisereasoning

    This is because of lack of knowledge of alternative strategies, because positive beliefs about the need to engage in sustained worrying and negative beliefs about worrying are inconsistent with the concept of 'letting thoughts go'.

    “This is because of lack of knowledge of alternative strategies, because positive beliefs about the need to engage in sustained worrying and negative beliefs about worrying are inconsistent with the concept of 'letting thoughts go'.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    In some cases there is a strategy of 'information search' where the person monitors information in the news or on the Internet to find facts that will 'put their mind at rest.'

    “In some cases there is a strategy of 'information search'.Here the person monitors information in the news or on the Internet in order to try and find facts that will 'put their mind at rest.'”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    The metacognitive model of pathological worry and GAD distinguishes two types of worry and explains the persistence and uncontrollability of negative thinking as an effect of specific metacognitions.

    “The metacognitive model of pathological worry and Generalized Anxiety Disorder (GAD) makes a crucial distinction between two types of worry and explains the persistence and uncontrollability of negative thinking as an effect of specific metacognitions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    In addition, the patient's over-reliance on worry and sustained thinking as a coping strategy should be addressed.

    “In addition, the patient's over-reliance on worry and sustained thinking as a coping strategy should be addressed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Negative appraisal of worry (meta-worry) and negative beliefs about worry are central to the development of GAD.

    “The negative appraisal of worry (meta-worry) and negative beliefs about worry are central to the development of GAD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Common attempts to prevent worrying or the dangers believed to be associated with it consist of asking for reassurance or avoiding information that could trigger worry.

    “Common attempts to prevent worrying or the dangers believed to be associated with it consist of asking for reassurance or avoiding information that could trigger worry.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    When a thought cannot be suppressed the person with GAD does not interrupt or stop the worry process; instead greater thinking is used as a means of reducing thinking, creating a paradox in mental regulation.

    “When a thought cannot be suppressed the person with GAD does not interrupt or stop the worry process.Instead greater thinking is used as a means of reducing thinking, creating a paradox in mental regulation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Negative beliefs about the uncontrollability and danger of worry measured at time 1 predicted the later development of GAD and this effect remained when trait-anxiety and type 1 worry frequency assessed at time 1 were partialled-out.

    “Furthermore, negative beliefs about the uncontrollability and danger of worry measured at time 1 predicted the later development of GAD and this effect remained when trait-anxiety and type 1 worry frequency assessed at time 1 were partialled-out.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Nassif (1999, study 2)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisereasoning

    This bi-directional effect in the model occurs as type 1 worry increases emotion and it is decreased or maintained by emotion depending on goals being met.

    “This bi-directional effect in the model occurs as type 1 worry increases emotion and it is decreased or maintained by emotion depending on goals being met.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Johnston and Davey (1997) measured the number of catastrophising steps following mood induction; subjects who experienced increased anxious and sad mood produced significantly more steps in their worry.

    “Johnston and Davey (1997) measured the number of catastrophising steps following mood induction.Subjects who experienced increased anxious and sad mood produced significantly more steps in their worry.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Johnston and Davey (1997) source

  • May combine two claims.

    Interpretationcitation

    These results suggest mood can contribute to perseveration of worry and mood state is not just a result of worrying.

    “These results suggest mood can contribute to perseveration of worry and mood state is not just a result of worrying.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    There should be evidence that negative beliefs about worrying are positively associated with GAD and should distinguish GAD from other disorders.

    “Thus, there should be evidence that negative beliefs about worrying are positively associated with GAD and should distinguish GAD from other disorders.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The aforementioned studies of appraisal of worrying are cross-sectional and cannot address the possible causal role of meta-worry in GAD.

    “The aforementioned studies of appraisal of worrying are cross-sectional and cannot address the possible causal role of meta-worry in GAD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Nuevo, Montorio and Borkovec (2004) replicated the study of Wells and Carter (1999) and extended it by examining the relationship between meta-worry and worry severity in an elderly Spanish sample.

    “Nuevo, Montorio and Borkovec (2004) replicated the study of Wells and Carter (1999) and extended it by examining the relationship between meta-worry and worry severity in an elderly Spanish sample.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Nuevo, Montorio and Borkovec (2004) source

  • May combine two claims.

    Premisecitation

    The GAD group could be distinguished from the other groups in endorsing significantly higher negative metacognitive beliefs in two domains: (1) uncontrollability and danger, and (2) need for control focusing on negative consequences of not controlling thoughts.

    “The GAD group could be distinguished from the other groups in endorsing significantly higher negative metacognitive beliefs in two domains: (1) uncontrollability and danger, and (2) need for control focusing on negative consequences of not controlling thoughts.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wells and Carter (2001) source

  • May combine two claims.

    Premisecitation

    Davis and Valentiner (2000) showed that subjects meeting criteria for GAD had higher scores than non-worried subjects on two dimension of metacognitions: uncontrollability and danger, and also beliefs about the need to control thoughts and the harmful consequences of not doing so.

    “Subsequently, Davis and Valentiner (2000) showed that subjects meeting criteria for GAD had higher scores than non-worried subjects on two dimension of metacognitions: uncontrollability and danger, and also beliefs about the need to control thoughts and the harmful consequences of not doing so.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Davis and Valentiner (2000) source

  • May combine two claims.

    Study design and conductown data

    The data from mediation analysis is cross-sectional limiting its validity in evaluating the model and further tests of causal mediation pathways are needed.

    “Whilst this is consistent with a causal pathway the data is cross-sectional limiting its validity in evaluating the model and further tests of causal mediation pathways are needed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Metaworry consistently emerged as a significant positive correlate of pathological worry and the amount of interference from worrying, relationships that persisted even when trait-anxiety and type 1 worry frequency were statistically controlled.

    “Metaworry consistently emerged as a significant positive correlate of pathological worry and the amount of interference from worrying, relationships that persisted even when trait-anxiety and type 1 worry frequency were statistically controlled.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Nuevo, Montorio and Borkovec (2004) source

  • May combine two claims.

    Premisecitation

    Cognitive behavioural treatments for GAD show high variability in outcome, with substantial room for improvement.

    “Summary quantitative analyses of these approaches show a high degree of variability in outcome with substantial room for improvements to be made.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Fisher, 2006 source

  • May combine two claims.

    Premisecitation

    The results showed that worry was similar across both groups but significant differences emerged in two separate negative belief domains: beliefs about the uncontrollability of worry and beliefs about the dangers of worrying.

    “The results showed that worry was similar across both groups but significant differences emerged in two separate negative belief domains: beliefs about the uncontrollability of worry and beliefs about the dangers of worrying.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Ruscio and Borkovec (2004) source

  • May combine two claims.

    Interpretationnone given

    These relationships extend to differentiating people with GAD from other patients and distinguish high worriers without GAD from individuals with GAD.

    “These relationships extend to differentiating people with GAD from other patients and distinguish high worriers without GAD from individuals with GAD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In that study, at follow-up the MCT group maintained this rate but the IUT group had narrowed the difference somewhat.

    “At follow-up the MCT group maintained this rate but the IUT group had narrowed the difference somewhat.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites van den Heiden, Muris and van der Molen (submitted)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Worry is a significant process involved in psychopathology and is a dominant diagnostic feature of GAD.

    “Worry is a significant process involved in psychopathology and is a dominant diagnostic feature of GAD.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    The metacognitive approach presents worry as a coping process aimed at mental control, a way of responding to negative thoughts about danger, and controlled by metacognition.

    “It presents worry as a coping process aimed at mental control.It is a way of responding to negative thoughts about danger and is controlled by metacognition.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Patients with GAD are locked in the mode of using an all-or-nothing strategy of trying to avoid thoughts that might trigger worrying or using worry to control worry.

    “Our patients are locked in the mode of using an all-or-nothing strategy of trying to avoid thoughts that might trigger worrying or using worry to control worry.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    MCT and other effective treatments such as AR and IUT appear to modify metacognitive beliefs but MCT was found to be associated with significantly greater change in negative beliefs about worry than these other approaches.

    “MCT and other effective treatments such as AR and IUT appear to modify metacognitive beliefs but MCT was found to be associated with significantly greater change in negative beliefs about worry than these other approaches.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In the uncontrolled trial, post-treatment effect sizes were 2.78 (trait-anxiety), 1.82 (Beck Anxiety Inventory), and 1.41 (Beck Depression Inventory).

    “Post-treatment effect sizes were 2.78 (trait-anxiety), 1.82 (Beck Anxiety Inventory), and 1.41 (Beck depression Inventory).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wells & King, 2006 source

  • May combine two claims.

    Premisecitation

    In that trial, post treatment effect sizes were: PSWQ MCT=3.4, AR=0.9; Trait Anxiety MCT=2.3, AR=0.6; BDI MCT=1.24, AR=0.3; Negative metacognitive beliefs MCT=2.0, AR=1.6.

    “Post treatment effect sizes were as follows: (PSWQ: MCT = 3.4,AR = 0.9; Trait Anxiety: MCT = 2.3, AR = 0.6; Beck Depression Inventory: MCT = 1.24,AR = 0.3; Negative metacognitive beliefs: MCT = 2.0, AR = 1.6).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wells et al., 2010 source

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Worry has negative consequences that might in some circumstances increase vulnerability to psychological symptoms.

    “It appears that worry has negative consequences that might in some circumstances increase vulnerability to psychological symptoms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Treatment effects appear to be stable and have been maintained over periods of 6-12 months.

    “Treatment effects appear to be stable and have been maintained over periods of 6-12 months.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In the uncontrolled trial, 87% of patients were recovered at post treatment as assessed by trait-anxiety and 75% remained recovered at 6 and 12 month follow-up.

    “Jacobson & Truax (1991) criteria for defining reliable improvement and recovery demonstrated that 87% of patients were recovered at post treatment as assessed by trait-anxiety and 75% remained recovered at 6 and 12 month follow-up.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Wells & King, 2006 source
    • cites Jacobson & Truax (1991) source

  • May combine two claims.

    Interpretationreasoning

    Worry can be controlled but it is necessary to choose a non-worry strategy to control it.

    “Worry can be controlled but it is necessary to choose a non-worry strategy to control it.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    The individual with GAD appraises their worry as uncontrollable and dangerous.

    “The individual appraises their worry as uncontrollable and dangerous.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Neither of these strategies provides experiences that can correct erroneous beliefs about worry or provide experiences that strengthen new and more adaptive relationships with cognition.

    “Neither of these strategies provides experiences that can correct erroneous beliefs about worry or provide experiences that strengthen new and more adaptive relationships with cognition.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Each of these treatment studies demonstrates a significant and large effect associated with MCT, with consistent high standardized recovery rates.

    “Each of these treatment studies demonstrates a significant and large effect associated with MCT, with consistent high standardized recovery rates.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In the uncontrolled trial (Wells & King, 2006), all patients improved during treatment and gains were maintained across 12 month follow-up.

    “All patients improved during treatment and gains were maintained across 12 month follow-up.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wells & King, 2006 source

  • May combine two claims.

    Premisecitation

    In that trial, using Jacobson criteria, 80% of the MCT group were recovered at post-treatment and 12 month follow-up as measured by PSWQ, compared with 10% of patients who received relaxation.

    “Using Jacobson criteria for defining recovery, 80% of the MCT group were recovered at post-treatment and 12 month follow-up as measured by the Penn State Worry Questionnaire, compared with 10% of patients who had received relaxation.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Wells et al., 2010 source
    • cites Jacobson & Truax (1991) source

  • May combine two claims.

    Interpretationcitation

    MCT appears to be superior to applied relaxation and Intolerance of Uncertainty Treatment.

    “MCT appears to be superior to applied relaxation and Intolerance of Uncertainty Treatment.”
    Quote in the paperSubstantial claim
46 of 46

  • The paper relies on this without support.

    Thoughts of emotional disorder are extended and recycled and are difficult to control.

    “Unlike most thoughts, thoughts of emotional disorder are extended and recycled and are difficult to control.”

  • The paper relies on this without support.

    For most people a negative thought comes and goes without raising a sustained negative response.

    “For most people a negative thought (e.g.'What if I lose my job?') comes and goes without raising a sustained negative response.”

  • The paper relies on this without support.

    Most people have positive beliefs about worrying and most people worry occasionally.

    “Most people have positive beliefs about worrying and most people worry occasionally.”

  • The authors state this as an assumption.

    An over-reliance on worry or inflexibility in this style of responding to negative thoughts can lead to problems of emotional self-regulation.

    “However, the metacognitive model assumes that an over-reliance on worry or inflexibility in this style of responding to negative thoughts can lead to problems of emotional self-regulation.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Beck citation year differs from reference entry

    Minor

    The treatment section cites the Beck, Emery, and Greenberg work as published in 1995, but its reference entry gives 1985.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Nassif Y., 1999, Predictors of pathological worry.

Cited by

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Related

Authors
Wells, A.
Affiliations
School of Psychological Sciences, University of Manchester, UK, & Dept. of Psychology, NTNU, Norway
Venue
Journal of Experimental Psychopathology
Publisher
SAGE Publications
Published
2010-01
Volume
1
Issue
1
ISSN
2043-8087 (ISSN-L)
DOI
10.5127/jep.007910
OpenAlex
W2067486979
Semantic Scholar
23a9612d604dc6cb55a9e1b91e3003cfb9bdbcff
Cited by
81
References
44
Citations by year
2026: 6 · 2025: 13 · 2024: 13 · 2023: 9 · 2022: 8 · 2021: 5 · 2020: 7 · 2019: 4 · 2017: 1 · 2016: 3 · 2015: 3 · 2014: 5 · 2012: 1
FWCI
1.67
Type
journal article
Language
en
Open access
Licence
journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations
  • Journal of Experimental Psychopathology (publishedVersion)
  • Research Explorer (The University of Manchester) (submittedVersion)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
metacognitive model, metacognitive therapy, generalized anxiety disorder, pathological worry, meta-worry, metacognitive beliefs, mental control, intolerance of uncertainty, applied relaxation, cognitive behavioral therapy, treatment efficacy

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