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- 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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| 2. |
- 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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| 3. |
- Danielsson, Katarina, 1983-
(författare)
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Delayed Sleep Phase Disorder : Prevalence, Diagnostic aspects, Associated factors and Treatment concepts
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Delayed sleep phase disorder (DSPD) is the most common circadian rhythm sleep disorder. Persons with DSPD have great difficulties falling asleep and waking up at conventional times. To diagnose DSPD this delayed sleep-wake rhythm should cause social impairment and distress for the individual. Evening melatonin and morning bright light are the recommended treatments. The overall aim of this thesis was to evaluate at-home treatment with Light therapy (LT) and the feasibility of adding cognitive behavior therapy (CBT) to LT in DSPD, furthermore prevalence, diagnostic aspects and associated factors were investigated.Study I included 673 randomly selected individuals aged 16–26 years. The prevalence of DSPD was 4.0%. Unemployment (defined as an absence of educational or work activities) and an elevated level of anxiety were associated with DSPD.In study II, dim light melatonin onset (DLMO) was measured in healthy adults. Time for DLMO DLMO (Mean±SD) was 20:58±55 minutes.Studies III, IV, and V present results from a randomized controlled trial examining the feasibility of CBT as an additive treatment to LT with scheduled rise times, in persons with DSPD. Sleep onset and sleep offset was significantly advanced from baseline (03:00±1:20; 10:22±2:02 respectively) to the end of LT (01:27±1:41; 08:05±1:29, p<0.001 respectively). This advancement was predicted by consistent daily usage of the LT-lamp. At the follow-ups after LT and CBT or LT alone, sleep onset remained stable, sleep offset was delayed, and sleep difficulties were further improved, but there was no significant group interaction over time. There was a significant group interaction over time in the severity of anxiety and depressive symptoms, both in favor of the LT+CBT group.Conclusively, DSPD was common among adolescents and young adults and it was associated with unemployment and elevated levels of anxiety. DLMO appeared in the expected time range in healthy working adults. At-home treatment with LT with scheduled rise times advanced sleep-wake rhythm and improved sleep difficulties in DSPD. Even though sleep-wake rhythm was not further advanced or better preserved in the participants that received LT+CBT compared to LT alone, the addition of CBT to the treatment regimen was feasible and well accepted.
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