| 1. |
- Månsson, Kristoffer N. T.
(författare)
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Restructuring the socially anxious brain : Using magnetic resonance imaging to advance our understanding of effective cognitive behaviour therapy for social anxiety disorder
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Social anxiety disorder (SAD) is a common psychiatric disorder associated with considerable suffering. Cognitive behaviour therapy (CBT) has been shown to be effective but a significant proportion does not respond or relapses, stressing the need of augmenting treatment. Using neuroimaging could elucidate the psychological and neurobiological interaction and may help to improve current therapeutics. To address this issue, functional and structural magnetic resonance imaging (MRI) were repeatedly conducted on individuals with SAD randomised to receive CBT or an active control condition. MRI was performed pre-, and post-treatment, as well as at one-year follow-up. Matched healthy controls were also scanned to be able to evaluate disorder-specific neural responsivity and structural morphology. This thesis aimed at answering three major questions. I) Does the brain’s fear circuitry (e.g., the amygdala) change, with regard to neural response and structural morphology, immediately after CBT? II) Are the immediate changes in the brain still present at long-term follow-up? III) Can neural responsivity in the fear circuitry predict long-term treatment outcome at the level of the individual? Thus, different analytic methods were performed. Firstly, multimodal neuroimaging addressed questions on concomitant changes in neural response and grey matter volume. Secondly, two different experimental functional MRI tasks captured both neural response to emotional faces and self-referential criticism. Thirdly, support vector machine learning (SVM) was used to evaluate neural predictors at the level of the individual.Amygdala responsivity to self-referential criticism was found to be elevated in individuals with SAD, as compared to matched healthy controls, and the neural response was attenuated after effective CBT. In individuals with SAD, amygdala grey matter volume was positively correlated with symptoms of anticipatory speech anxiety, and CBT-induced symptom reduction was associated with decreased grey matter volume of the amygdala. Also, CBT-induced reduction of amygdala grey matter volume was evident both at short- and long-term follow-up. In contrast, the amygdala neural response was weakened immediately after treatment, but not at one-year follow-up. In extension to treatment effects on the brain, pre-treatment connectivity between the amygdala and the dorsal anterior cingulate cortex (dACC) was stronger in long-term CBT non-responders, as compared to long-term CBT responders. Importantly, by use of an SVM algorithm, pre-treatment neural response to self-referential criticism in the dACC accurately predicted (>90%) the clinical response to CBT.In conclusion, modifying the amygdala is a likely mechanism of action in CBT, underlying the anxiolytic effects of this treatment, and the brain’s neural activity during self-referential criticism may be an accurate and clinically relevant predictor of the long-term response to CBT. Along these lines, neuroimaging is a vital tool in clinical psychiatry that could potentially improve clinical decision-making based on an individual’s neural characteristics.
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| 2. |
- Johansson, Robert
(författare)
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Treating depression and its comorbidity : From individualized Internet-delivered cognitive behavior therapy to affect-focused psychodynamic psychotherapy
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overarching goal of this thesis has been to enhance Internet-delivered psychological treatments for depression and its comorbidity. To this end, three randomized controlled trials (Study II, III and IV) with a total of 313 participants were conducted. A prevalence study (Study I) was also conducted to provide an up-to-date estimate of the prevalence of depression, anxiety disorders, and their comorbidity in the Swedish general population.Study I showed that more than every sixth individual in Sweden suffers from symptoms of depression and/or anxiety. Comorbidity between depression and anxiety was substantial and associated with higher symptom burden and lower health-related quality of life. Study II showed that a tailored Internet-based CBT protocol (ICBT) was effective in reducing symptoms of depression when compared to a control group. Among individuals with more severe depression and comorbidities, the tailored ICBT treatment worked better than standardized ICBT. Study III showed that a psychodynamic Internet-based psychotherapy was highly effective in the treatment of depression, when compared to a group who received psychoeducation and online support. In Study IV, an Internet-delivered affect-focused psychodynamic psychotherapy proved to have a large effect on depression and a moderately large effect on anxiety disorders.In conclusion, this thesis shows that in the context of treating depression and its comorbidity, Internet-delivered psychological treatments can be potentially enhanced by psychodynamic psychotherapy and by individualization.
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| 3. |
- Nyström, Markus B. T., 1973-
(författare)
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Treating depression with activation
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to evaluate and compare four therapist-supported Internet-administered treatments for depression. Three studies were conducted. The first was a systematic review to determine the most effective mode and dose of physical activity (PA) for treating major depressive disorders (MDDs), and to suggest guidelines and recommendations for clinicians. These recommendations included that the PA needs to be individually customized, performed for at least 30 minutes, preferably under supervision, and with a frequency of at least three times per week to be effective for treating MDDs. Recommendations, however, must be viewed in light of the relatively few studies that match the inclusion criteria. The second study aimed to empirically evaluate and compare the effect of four therapist-supported Internet-administered treatments for mild to moderate depression. Two of the treatments were based on PA and two on behavioural activation (BA). One PA group was provided with a rationale; whereas, the other was not. The treatment in one BA group was based on Lewinsohn’s model and the other on Martell’s model. Results showed that all groups (including the control group) significantly reduced their depressive symptoms. Group comparisons revealed that three of the four treatment groups (all except the PA group that did not receive a rationale) had a significantly greater symptom reduction than the control group. This suggests that some sort of rationale is important for symptom reduction. The third study aimed to examine if a relapse prevention program would affect symptom change during a 24-month follow-up. We also examined if symptom change during the acute phase (AP) treatment period predicted symptom change during the follow-up period. A third and final aim was to examine if the number of symptoms post-AP treatment predicted symptom change during the follow-up period. The initial analysis indicated that the introduction of a relapse prevention program did not affect symptom change during follow-up. The symptom change during AP treatment did predict symptom change during follow-up for three of the four treatment groups (all except one of the BA groups). The number of symptoms post-AP treatment, however, did not predict symptom change during follow-up for any of the treatment groups. The main conclusion from this thesis is that PA seems to be effective for treating and preventing depressive symptoms. PA with a rationale is more effective than without one, and an understanding of the person’s situation is important for a treatment outcome. If a symptom change can be achieved during the acute phase, the likelihood for symptom change during the follow-up increases.
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| 4. |
- Sunnhed, Rikard, 1979-
(författare)
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Cognitive therapy and behavioral therapy for insomnia disorder : efficacy, moderators and mediators
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Insomnia disorder is the second most prevalent mental disorder and the most prevalent sleep disorder. Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the treatment of choice with well-documented effects. Nevertheless, a significant proportion of patients fail to respond, and an even larger proportion fail to remit from the condition. In addition, very little is known about the effects of CBT-I's separate components or about what moderates and mediates their effect. Gaining knowledge about components, predictors, and mediators could be one route for optimizing and tailoring CBT-I and ultimately enhancing outcomes.The overall aim of this thesis was to advance our theoretical and clinical knowledge about CBT-I by exploring Cognitive Therapy (CT) and Behavior Therapy's (BT) comparative efficacy and their potential moderators and mediators.To pursue the study aims, one large randomized controlled trial was performed that involved 219 individuals with insomnia disorder randomized to CT, BT, or a waitlist control group. Study 1 examined CT and BT's comparative efficacy against a waitlist control on a broad range of outcomes. Study 2 examined theoretically derived constructs from both therapy models, and insomnia-associated correlates as potential predictors and moderators of outcome for the two therapies. Study 3 examined theoretically driven process variables from the cognitive model as mediators of outcome in both CT and BT.Study I showed that both therapies outperformed the waitlist and turned out as comparably effective treatments on the majority of outcomes. BT was associated with significantly more adverse events, whereas CT received significantly more minutes of telephone support.Study II showed that early morning waketime and bedtime variability moderated the effect of both CT and BT. Those experiencing lower early morning waketime and bedtime variability achieved greater insomnia severity reductions in CT. In contrast, those experiencing greater early morning waketime and bedtime variability achieved larger insomnia severity reductions in BT. The findings also showed that greater insomnia severity, waketime after sleep onset, and lower sleep efficiency at baseline predicted greater insomnia severity at posttreatment.Study III provided evidence that reductions in dysfunctional beliefs and monitoring for sleep during treatment acted as drivers of the reduction in insomnia severity in CT. The results also indicated that reductions in safety behaviors and dysfunctional beliefs mediated reductions in insomnia severity in BT, although not as clear as the drivers of change for CT since they were also reciprocally predicted by reductions in insomnia severity.Study I indicate that CT and BT achieve similar effects and that both therapies are effective as standalone therapies for insomnia disorder. Study II provided evidence that the two therapies in CBT-I can depend on different patient characteristics at baseline to be effective. The results from study II thus suggest that the therapies in CBT-I could be tailored based on patient's characteristics before treatment to optimize outcomes. Study III provided support for the role of cognitive processes as important routes to remediate insomnia and underscore the value of assessing and targeting dysfunctional beliefs, monitoring, and safety behaviors to achieve reductions in insomnia severity and emphasize the importance of these concepts in understanding insomnia.
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| 5. |
- Bergman Nordgren, Lise, 1983-
(författare)
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Individually tailored internet-based cognitive behavioural therapy for anxiety disorders
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Fear is an innate emotion and an adaptive response to provide protection from potential harm. When fear is excessive and out of proportion in relation to the confronted situation, it can lead to the development of an anxiety disorder. Many individuals feel anxious at some point, but not all experience clinical anxiety or meet the diagnostic criteria of an anxiety disorder. Still, anxiety disorders are the most prevalent form of psychiatric disorder in the general population. More often than not people suffering from one anxiety disorder also present other psychiatric conditions. As of today, cognitive and behavioural treatments have been tested and found to positively affect anxiety disorders, making them the treatment of choice. Nevertheless, many patients do not seek or receive adequate treatment.One common critique of the research trials from which the recommendations for treatments stem is the use of a single protocol targeting only one diagnosis. This is because many people suffer from comorbidities. Another problem connected to the recommendation that cognitive behavioural therapy (CBT) should be the treatment of choice for anxiety disorders is the lack of therapists with adequate training. One possible way of dealing both with the shortcoming of therapists and making CBT more accessible is the use of the Internet. Internet-based CBT (ICBT) has been tested in numerous trials during the last 15 years, showing positive outcomes for a large variety of disorders. Many ICBT trials also make use of a single protocol. Another way of dealing with comorbidities might be to tailor the treatment to let characteristics and preferences of the patient guide the design of the protocol. Little is known about possible effects of tailoring the ICBT, the effects of therapeutic relationships in ICBT, and the effectiveness and cost-effectiveness of these treatments. This thesis is based on three studies on two separate randomized controlled trials (RCTs) using the same set of modules accessible for the tailored protocol.Study I was an RCT investigating treatment effects up to two-year after completion, showing favourable outcomes of the treatment in a self-recruited sample at all measure points. Study II was a secondary analysis exploring possible relations between working alliance and treatment outcome for participants in the treatment group recruited for Study I indicating that working alliance predict outcome in this tailored treatment. The second RCT was an effectiveness trial (Study III) analysing treatment effects and cost-effectiveness of the treatment up to one year post treatment in a primary-care population. This study showed positive treatment effects both regarding symptom reduction and cost-effectiveness, and that effects were sustained at one year post treatment. Conclusions drawn from these studies are that individually tailored ICBT seems to be a feasible approach for patients with anxiety disorders regardless of comorbidities, and a responsible choice in terms of societal costs.
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| 6. |
- Dahlin, Mats, 1975-
(författare)
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Development and evaluation of an internet-based treatment for generalized anxiety disorder : An acceptance-based approach
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Generalized anxiety disorder (GAD) is a chronic condition characterized by an excessive and uncontrollable worry. GAD has a highly negative impact on all aspects of life, and the costs for society are considerable. Cognitive behaviour therapy (CBT), delivered face-to- face or online, has been shown to be effective in treating GAD. However, there are still room for improvement, with treatment content and format of delivery being two areas to further investigate. Internet-based treatments are often based on a generic CBT model of GAD and include treatment strategies such as cognitive restructuring and relaxation. Furthermore, the impact of therapist support has shown inconclusive results.Overall, this thesis aimed to evaluate the effects of a new internet-based treatment for GAD, based on acceptance, mindfulness, and valued action, delivered with different types of support. Study I was a small pilot trial with a within-group design. The study included 16 participants diagnosed with GAD who received the newly developed treatment program with weekly therapist support. Statistically significant and large effect sizes were observed on self-rated worry at post-treatment, and the effects were maintained at a three-months follow-up. Study II included 103 participants diagnosed with GAD who were randomized to nine weeks of treatment with the treatment program and weekly support, or a waiting-list control group. Statistically significant moderate to large effects were observed on primary and secondary outcomes in favour of the treatment. The exception was a measure of quality of life, with no significant difference between the two groups. The treatment effects were maintained at a six-months follow-up. Study III was a pilot trial including 33 participants diagnosed with GAD. A within-group design was used to investigate the effects of the treatment program delivered with automated messages and support on demand. Significant and large within-group effects were observed on all outcome measures at post-treatment with the exception of quality of life, for which there was a small effect. Study IV was a pilot factorial design trial that compared the acceptance-based treatment program against a self-tailored treatment, as well as two types of support: scheduled support and support on demand. The study included 85 participants with GAD randomized to four different treatment groups. Significant moderate to large effects were observed in all treatment groups, with no statistically significant differences between the groups on self-rated outcome measures. Receiving scheduled support was rated as more positive than support on demand, and self-tailored treatment was rated as more positive than the acceptance-based treatment. Treatment satisfaction was high in all studies.In conclusion, the studies indicate that an internet-based treatment based on acceptance, mindfulness, and valued action is a viable option in the treatment of GAD.
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| 7. |
- Jonsson, Jakob, 1968-
(författare)
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Preventing problem gambling: Focus on overconsumption
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A proportion of gamblers experience problems. The role of overconsumption in developing gambling problems is sparsely described in the literature and there is little scientific knowledge about the prevention of gambling problems. There are some promising results regarding personalized feedback on gambling habits, and there is a need for more research. The overall aim of this thesis was to explore the role of overconsumption in problem gambling and target it in a preventive intervention. The preventive intervention was to give gambling consumption feedback to high consumers in order to make them reflect upon their gambling habits and enhance their motivation for change. Study I aimed to explore the dimensionality of GamTest, an online test of gambling behaviour, and validate it against PGSI and the gambler’s own perceived problems. Data came from four Nordic gambling sites, n = 10,402. In an ESEM analyses, GamTest had a high degree of correspondence with the players’ own perceived problems and with the PGSI. In an EFA, GamTest captured five dimensions of problematic gambling (i.e. overconsumption of money and time, and negative financial, social and emotional consequences). A bifactor approach showed a general factor and four specific residual factors, negative emotional consequences contribute to the dominant part of the general factor. Study II aimed to examine both the psychometric properties of the Jonsson-Abbot Scale (JAS) and its predictive validity with respect to increased gambling risk and problem gambling onset. The results are based on repeated interviews with 3,818 participants within the Swedish longitudinal gambling study. The results indicate an acceptable fit of a three-factor solution in a CFA, with ‘Overconsumption (OC),’ ‘Gambling fallacies (GF),’ and ‘Reinforcers (RI)’ as factors. When controlled for risk potential measured at baseline, GF and RI were significant predictors of gambling risk potential, and GF and OC were significant predictors of problem gambling onset at 12-month follow up. Study III’s primary objective was to investigate the effects of providing personalized feedback on gambling intensity among high consumers in Norway. An RCT design was used to evaluate how behavioural feedback by telephone or letters affects subsequent gambling expenditure. A sample of 1,003 statistical matched triplets, from the top 0.5 % of customers, were randomly assigned to telephone, letter, or a no-contact control condition. Over 12 weeks, theoretical loss decreased 29 % for the telephone, and 15 % for the letter, conditions, compared with 3 % for the control group. Study IV was a 12-month follow-up of Study III, aimed to investigate the relative effects over twelve months. The telephone group showed a 30 % reduction in theoretical loss, the letter group 13 %, both outperforming the control group with a 7 % reduction. Less than 1% in all groups stopped playing at Norsk Tipping. These four studies indicate that overconsumption of gambling plays different roles in problem gambling. The role of overconsumption in preventing gambling problems is discussed. Contacting high consumers about their gambling expenditure appears to be an effective method for gambling companies to meet their duty of care for customers. Technical evolution has made it possible for gambling companies to fulfil their duty of care, but this has to be regulated and mandatory if it is to be effective.
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| 8. |
- Lindqvist, Karin, 1987-
(författare)
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Making Connections : Outcomes and the Role of the Therapeutic Relationship in Internet-Delivered Psychodynamic Treatment for Adolescent Depression
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Major depressive disorder (MDD) is ranked one of the most burdensome disorders for adolescents worldwide. There is an urgent need for accessible interventions, as many adolescents suffering from MDD do not receive treatment. Internet-delivered interventions remove barriers to seeking and receiving treatment, and internet-delivered cognitive behavioural therapy (ICBT) has been found to be effective for adolescent MDD. However, not all are helped by ICBT and treatment alternatives are needed. Internet-delivered psychodynamic therapy (IPDT) has previously been tested with promising effects in adults, but no studies have assessed its efficacy for adolescents. Furthermore, little is known about mechanisms of change in internet interventions targeting adolescent MDD and how adolescents experience the therapeutic relationship in IPDT. This thesis aims to evaluate efficacy as well as processes and experiences of IPDT, from different perspectives.Study I investigated effects of IPDT for adolescents aged 15–18 (n = 76) suffering from MDD, compared to control condition. IPDT was found to be significantly more effective than a supportive control condition on reducing depression (d = 0.82). Furthermore, moderate to large significant effects in favour of IPDT were found for comorbid anxiety, emotion regulation and self-compassion.Study II explored participants’ (n = 18) experiences of the psychotherapeutic relationship in IPDT. Semi-structured interviews were analysed using thematic analysis. Four themes were created: “a meaningful and significant relationship with someone who cared”, “a helping relationship with someone who guided and motivated me through therapy”; “a relationship made safer and more open by the fact that we didn’t have to meet”; and “a nonsignificant relationship with someone I didn’t really know and who didn’t know me”.Study III examined the relationship between therapeutic alliance, emotion regulation and outcome week-by-week in IPDT and ICBT for adolescent depression (n = 272). Results showed that therapeutic alliance, as rated by both therapist and participant, predicted outcome in depressive symptoms week-by-week in both treatments. Furthermore, this relationship was mediated by emotion regulation, again in both treatments.In conclusion, results from this thesis indicate that IPDT may be a viable treatment option for adolescent depression. Furthermore, it is possible to form a close and safe relationship between therapist and participant, experienced as important for the psychotherapeutic process by many participants. Lastly, therapeutic alliance plays an important role in both IPDT and ICBT for adolescent depression, partly through its effect on emotion regulation.
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| 9. |
- Ly, Kien Hoa
(författare)
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Use of a Smartphone Application in the Treatment of Depression : The New Wave of Digital Tools in Psychological Treatment
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Internet-delivered programs based on cognitive behavior therapy (CBT) have during the past decade shown to work in an effective way for the treatment of depression. Due to its accessibility and independence of time and location, smartphone-based CBT might represent the next generation of digital interventions. Depression is an affective disorder that affects as many as 350 million people worldwide. However, with CBT, depression can be treated, but access to this treatment is scarce due to limited health care resources and trained therapists. As a result of this, health care could highly benefit from the use of smartphones for delivering cost-effective treatment that can be made available to a large part of the population who suffer from depression. One treatment that should be especially suitable for the smartphone format is behavioral activation (BA), since it has strong empirical support as well as the benefits of being flexible and rather simple.The overall aim of the thesis was to test and further develop a BA smartphone application, as well as to build a method for how this smartphone application could be used in a comprehensive and effective way in depression treatment. To fulfill this aim, four studies were conducted. The results showed that smartphones have the ability to be used in an effective way in the treatment of depression, including as an add-on to traditional face-to-face sessions. The results also showed that the smartphone format was experienced as a portable and flexible way of accessing the treatment – and thus could be more present in everyday life.In conclusion, there is reason to believe that smartphones will be integrated even further in society and therefore may serve an important role in future mental health care. Since the first indications reveal that depression can be treated by means of a supported smartphone application, it is highly possible that applications for other mental health problems will follow. Furthermore, in this thesis, the same smartphone application has been tested in three different ways and there is potential to apply smartphones in a range of other formats, such as in relapse prevention and as a way to intensify treatment during periods when needed. From a psychiatric research point of view, as my research group has been doing trials on guided internet treatment for more than 15 years, it is now time to move to the next generation of information technology – smartphones.
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| 10. |
- Mechler, Jakob, 1983-
(författare)
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Beyond the Blank Screen : Internet-Delivered Psychodynamic Therapy for Adolescent Depression: Evaluating Non-Inferiority, the Role of Emotion Regulation, and Sudden Gains
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Adolescent major depressive disorder (MDD) is a common and debilitating disorder, associated with clinically significant distress and impairment in functioning. A vast array of negative consequences of adolescent MDD have also been found to extend into adulthood. Still, the majority of affected youths do not receive adequate treatment. Internet-delivered interventions address many barriers to treatment, for instance stigma and lack of qualified psychiatric care. However, the most studied internet-delivered treatment, internet-delivered cognitive behavioural therapy (ICBT), leads to clinically meaningful change in somewhat less than 50% of participants. These results indicate the need for treatment alternatives. This thesis consists of three empirical studies examining a newly developed such alternative, internet-delivered psychodynamic treatment (IPDT). Study 1 (n = 272) was a randomised controlled trial, testing whether IPDT was non-inferior to ICBT for depressed adolescents (15–19 years). Results indicated that both treatments were effective, with large within-group effects, and that IPDT was non-inferior to ICBT. No significant differences were noted on primary or secondary outcomes in the intent-to-treat analyses. Study 2 (n = 67) tested emotion regulation as a baseline predictor of rate of change, and whether intra-individual change in emotion regulation was a mechanism of change in IPDT. Results indicated that patients with relatively more severe deficits in emotion regulation had a steeper trajectory towards improvement. Intra-individual changes in emotion regulation also predicted improvements in the subsequent week, indicating that emotion regulation acted as a mechanism of change in IPDT. Study 3 (n = 66) tested whether sudden gains (SGs) and large intersession improvements (LIIs; defined as SGs without demanding symptom stability pre- and post-gain) were associated with superior outcome. LIIs were associated with improved outcome at post-treatment and at follow-up, whilst SGs were not. Overall, the above findings suggest that IPDT is a viable alternative to ICBT for depressed adolescents, that IPDT partly works through increases in emotion regulation and that patients who improve suddenly, between consecutive weeks in IPDT, are more likely to benefit from treatment.
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