| 1. |
- Månsson, Kristoffer N. T.
(författare)
-
Restructuring the socially anxious brain : Using magnetic resonance imaging to advance our understanding of effective cognitive behaviour therapy for social anxiety disorder
- 2016
-
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.
|
|
| 2. |
- Nieminen, Katri, 1965-
(författare)
-
Clinical aspects of childbirth-related anxiety
- 2016
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses a risk for a negative delivery experience. This thesis focuses on the mental and health-economic effects of severe FOC, and explores new treatment options for childbirth-related anxiety.Aims: (i) to investigate the prevalence of and variables associated with severe FOC, (ii) to estimate the cost of illness of severe FOC and (iii) to explore whether Internetbased cognitive behaviour therapy (ICBT) is feasible for treating pregnant women with severe FOC and those with childbirth-related symptoms of posttraumatic stress disorder (PTSD).Design and Results: Study 1: In a cross-sectional study 1635 pregnant women were asked about their FOC via the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), and provided socio-demographic data and information of their preferred mode of delivery. It was found that 15.6% of the participants had a severe FOC, which also strongly correlated with the preference of a caesarean section. Study 2: In a prospective case-control cohort study we mapped all visits, in-patient care, sick leave and delivery variables from medical records and estimated the societal costs in two groups of women; one group with severe FOC and one with low FOC. The costs for the group with severe FOC were 38% higher than for the low FOC group. Study 3: Twenty-eight nulliparous women with severe FOC were self-recruited to an eight weeks ICBT program for severe FOC. Fifteen women followed the entire program. Their FOC decreased significantly after treatment (Cohen’s d=0.95, p<0.0001), which means that ICBT is feasible and an option for treating women with severe FOC. Study 4: Fifteen participants in Study 3 wrote narratives of the imminent delivery before as well as after therapy. After treatment, the women had a more realistic attitude towards childbirth, more self-confidence and more active coping strategies. Partners and staff were perceived as more helpful, and the women were more aware of the child they were bearing. Study 5: Fifty-six women with a traumatic delivery experience were included in a randomized wait-list controlled study (RCT) of the effects of an eight week long ICBT program for childbirth-related PTSD symptoms. These symptoms decreased in both groups during active therapy, while the between-group effect size varied depending on measurements. Psychiatric comorbidity decreased in both groups after active treatment.Conclusion: Severe FOC is prevalent among Swedish pregnant women, and the cost of illness of this marker of peripartum psychological vulnerability is considerable when treated using standard care. A new treatment option for this group with ICBT seems feasible and is associated with more realistic attitudes towards the imminent delivery. An RCT with eight weeks of ICBT for parous women with PTSD symptoms also had promising results.As severe FOC is prevalent and associated with mental and economic burdens for the individual and the society, there is an urgent need to expand the research field. It is important to find feasible and effective treatments that can be applied on a large scale.
|
|
| 3. |
- Biliunaite, Ieva, 1992-
(författare)
-
Care for the Caregiver : Internet intervention for informal caregivers in Lithuania
- 2022
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Informal caregivers are individuals who provide care for significant others in need of support due to frailty or illness. Being able to support a family member can be a very rewarding but at the same time a demanding task. Consequently, informal caregivers are known to experience not only positive but also negative psychological health outcomes and should be offered appropriate support. The main goal of this thesis was to evaluate if Internet-based Cognitive Behavioural Therapy (ICBT) can be suited to provide Lithuanian informal caregivers with psychological support. In addition, a secondary aim was to collect information regarding Lithuanian informal caregiver characteristics, their experienced burden and support needs.The results showed that Lithuanian informal caregivers experience unmet support needs and a high caregiver burden. The findings also show that ICBT can be an effective and acceptable support option for Lithuanian informal caregivers in reducing their burden, depression, anxiety, stress and increasing the perceived quality of life. In conclusion, ICBT should be considered a promising psychological support option for Lithuanian informal caregivers. Further research is needed to evaluate the suitability of ICBT in regular care.
|
|
| 4. |
- Johansson, Robert
(författare)
-
Treating depression and its comorbidity : From individualized Internet-delivered cognitive behavior therapy to affect-focused psychodynamic psychotherapy
- 2013
-
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.
|
|
| 5. |
- Molander, Peter, 1983-
(författare)
-
From Detection to Intervention Psychological Aspects of Online Hearing Rehabilitation
- 2018
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Hearing problems are among the most common causes of disability worldwide for adults. It is currently classified as one of the top five causes of years lived with disability. Between the years 2005 and 2015 the global prevalence of hearing loss increased with about 26 %. The negative impact of hearing loss on those affected is not limited to communication problems, as a range of other negative effects can be present, such as increased levels of social isolation, problems in the work-place and psychological distress.The different studies of the thesis can be summarized in three overall research questions. The first question was if hearing loss can be detected through automated online screening procedures, and what are the characteristics of those who participate in online screening (Study I and II)? The second question focused on development and testing of a measure dealing with psychological acceptance of hearing loss (Study III). Finally, the third research question concerned if online administered guided self-help based on Acceptance and Commitment Therapy could help persons with hearing loss and psychological distress (Study IV)?In the screening studies (Study I and II) an online speech-in-noise hearing test was initially developed and later updated. Screening for hearing problems with this test was found to be feasible, and 16.7 (Study I) and 19% (Study II) of the participants were recommended to seek professional care for their potential hearing loss. These participants had more cognitive problems, were more likely to be of male gender, and had lower levels of education than those without measured hearing problems. Study III showed that it was possible to measure hearing-related acceptance with a new questionnaire and that this measure was a better predictor of disability than instruments measuring anxiety, depression, or measured hearing performance. In Study IV, people with hearing loss and comorbid psychological distress were offered an eight-week long internet-based therapist-guided self-help treatment inspired by ACT. After treatment ended, the intervention group had lower levels of perceived hearing disability, increased ratings of quality of life and reduced depressive symptoms in relation to the wait-list control group. This thesis suggests that the internet can be used to assist early detection, measuring acceptance of hearing loss and finally as a treatment modality for persons who experience distress in relation to their hearing loss.
|
|
| 6. |
- Bergman Nordgren, Lise, 1983-
(författare)
-
Individually tailored internet-based cognitive behavioural therapy for anxiety disorders
- 2013
-
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.
|
|
| 7. |
- Dahlin, Mats, 1975-
(författare)
-
Development and evaluation of an internet-based treatment for generalized anxiety disorder : An acceptance-based approach
- 2020
-
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.
|
|
| 8. |
- Hallin, Nathalie, 1990-
(författare)
-
Perceptions of and behaviour toward religious people and atheists in Sweden and the USA
- 2024
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Religiosity has been present in societies throughout history and several theories hold that religion serves to foster trust and a sense of community within the religious ingroup. In many societies today, it is not uncommon to lack religious beliefs and religion is no longer a natural part of everyday life. The studies included in this thesis investigated how religious groups perceive each other or how generous they are to each other, both in the more secular Sweden and in the more religious USA. Paper 1 examined Swedes’ perceptions of atheists and religious people. Specifically, how often they associated atheists or religious people with extreme immoral behaviour by making a conjunction error. Previous studies using the same methodological paradigm have found that more people associate atheists, rather than religious people, with immoral behaviour. We found no significant association between target (atheist or religious person) and conjunction errors, indicating that Swedes do not associate immoral behaviour with atheists to a greater degree than they associate immoral behaviour with religious people. We compared the results to those presented in a previous study and found that the Swedish participants in our study made significantly fewer conjunction errors when the target was an atheist than a sample from the USA. They also made significantly more conjunction errors when the target was a religious person than a Finnish sample and the American sample. The results suggests that anti-atheist bias is lower in Sweden compared to the USA, but anti-religious bias is higher than in both Finland and the USA. However, it is also possible that the type of sample used affected the results – we recruited participants from social media while the other two samples were solely or mainly student samples. The study shows that the clear anti-atheist bias found in similar studies is not universal. Paper 2 investigated Christians’ and atheists’ perceptions of Christian, Muslim, and atheist job applicants in four studies, two with Swedish samples (studies 1 and 3) and two with samples from the USA (studies 2 and 4). Participants rated the perceived competence and likeability of a target applicant (Christian, Muslim, or atheist) and a control applicant (with no information about religious affiliation). In the last two studies, participants also specified if they would have hired the target or control applicant. Participants generally rated the control applicant as being more competent (USA) and more likeable (Sweden and USA) than the target applicant. Both Christian and atheist participants rated targets with the same religious affiliation higher in likeability than targets from one or both religious outgroups in two of the studies. The only significant difference in competence ratings between the targets were in study 3, where Christians rated Muslims as less competent than Christians. However, Christians’ likeability ratings in study 3 did not differ between targets. More atheists in study 3 hired the control applicant than the Christian applicant, but no other group differed in which applicant they hired. In conclusion, when people perceived one religious group to be more likeable, it was their ingroup. However, these results do not translate to perceptions of competence and seldom to hiring decisions. Paper 3 investigated generosity toward religious ingroup and outgroup members in three studies conducted in Sweden (study 1), the USA (study 2), and Egypt and Lebanon (study 3), using an adapted Dictator Game. Participants allocated a sum of money between themselves and three potential recipients. In the most relevant round, these were a Christian, a Muslim, and an atheist. We found that in studies 1 and 2, there was no significant difference in overall generosity between religious people, agnostics, and atheists in the rounds where they did not know the religious affiliation of the recipients. In the round where they knew the affiliation of recipients, religious people gave significantly more than atheists (studies 1 and 2) and agnostics (study 2). Study 3 had too few agnostics and atheists to compare their generosity to that of religious people. Christians, Muslims, and atheists in all three studies gave significantly more money to their respective religious ingroups than to the outgroup that was given the largest amount. This ingroup generosity was found in the other rounds as well. However, the ingroup minus outgroup amount was larger in the religion round compared to most other rounds. The exceptions were the ideology round in study 1 and 2, which did not differ significantly from the religion round. In study 2, the difference between ingroup and outgroup generosity was larger for Muslim participants than for Christians and atheists. In conclusion, religious people seem to be more generous only when they know the religious affiliation of recipients, but atheists, Muslims, and Christians are all more generous toward religious ingroup members than toward outgroup members. The papers together show that religious affiliation is an important group category that affects perceived likeability and generosity in several contexts.
|
|
| 9. |
- Käll, Anton, 1992-
(författare)
-
Internet-based interventions for loneliness : Efficacy and latent psychopathological profiles of treatment seekers
- 2021
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Loneliness is an adverse emotional reaction thought to stem from an unwanted and impoverished social situation. Though it commonly makes brief appearances across the lifespan for most people, it has received increasing attention as a factor relevant to somatic and psychological well-being when assuming a more chronic form. For this reason, developing ways of alleviating loneliness is an important item on the research agenda tied to this phenomenon. Psychological interventions, and cognitive behavioural therapy (CBT) in particular, have been proposed to have potential for this. This thesis sought to evaluate the effects of two different kinds of internet-based interventions targeting loneliness: one based on CBT, and one based on interpersonal psychotherapy (IPT).In addition to this general aim, Study I also investigated the presence of different subgroups in the sample of people seeking help within the framework of projects. Using the statistical method known as Latent Profile Analysis we discovered five profiles consisting of symptoms of common psychiatric disorders and loneliness. The profiles mainly differed as a function of symptom severity, though one of the larger groups was also characterised primarily by their high ratings of social anxiety. The results suggest that the sample seeking help for their loneliness can exhibit both clinical and non-clinical levels of common mental health problems.Study II served as the pilot evaluation of an ICBT programme for loneliness. A total of 73 participants were included in a randomised controlled trial where the participants were randomised to either 8 weeks of active treatment or a wait-list control group. The results indicated significantly lower loneliness ratings after the treatment phase for the ICBT condition with a moderate-to-large effect size compared to the control group. Significant differences favouring the ICBT condition were also noted for two of the four secondary measures.Study III followed up on the participants two years after the conclusion of the initial treatment period. At this point, the control group had also received access to a version of the ICBT programme with therapist support on-demand. The results indicated that the decrease in loneliness was sustained, along with similarly lasting effects on the secondary outcomes of interest.Study IV aimed to replicate the findings from the second study with a similar ICBT programme. However, this study also employed an internet-based IPT intervention to allow for conclusions regarding the possibility of reducing loneliness by other means than CBT. A sample of 170 participants were recruited and randomised to one the treatment conditions or to a waitlist control group. The results indicated that the ICBT condition had a significantly steeper reduction in loneliness than both the waitlist and the IPT condition after the conclusion of the treatment. Both active conditions produced a significant increase in quality of life.In conclusion, internet-based psychological interventions can be efficacious for reducing loneliness, though the efficacy was only found for participants who received access to the ICBT condition in Study II and IV. The benefits from this treatment programme were sustained up to two years after the conclusion of the intervention. For these reasons, ICBT is proposed to be a good candidate for offering help to people experiencing distressing feelings of loneliness.
|
|
| 10. |
- Lech, Börje
(författare)
-
Consciousness about own and others’ affects
- 2012
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- It is essential for individuals’ well-being and relationships that they have the ability to consciously experience, express and respond to their own and others’ affects. The validity of a new conception of affect consciousness (AC), incorporating consciousness of both own and others’ affects, was investigated in this thesis. The clinical usefulness of the new conception was explored and an interview (affect consciousness interview – self/other; ACI-S/O) intended to capture this new definition was validated. In study I the interrater reliability and the concurrent validity of the ACI-S/O were assessed and found to be acceptable. There were significant differences in all variables of ACI-S/O between the four groups that participated in the study. Joy and interest had the highest ratings in all groups and guilt and shame had the lowest. By means of a factor analysis, two factors, labeled “general affect consciousness” and “consciousness about shame and guilt,” were obtained. General affect consciousness was related to different aspects of relational and emotional problems and possibly protection against them. In study II the clinical implications of AC were further explored in relation to eating disorders (ED). The level of AC in the ED group was compared with a comparable non-clinical group. The relation between AC and aspects of ED pathology were explored, as well as whether AC should be seen as a state or trait in patients diagnosed with ED. ACI-S/O was not significantly related to ED pathology or general psychological distress. There were no significant differences in AC between the different sub-diagnoses of ED but there were between the ED group and the non-clinical group. Significant pre-post correlations for both factors of ACI-S/O were found, indicating that AC could be seen as a stable dimension that might be important for ED pathology but is unrelated to ED symptoms. In study III the relationship between AC and self-reported attachment style (ASQ) was explored in a non-clinical group and three patient groups. There were significant correlations between all scores on ACI- S/O and the ASQ, with the exception of consciousness about guilt. Multiple regression analyses showed that AC, and especially others’ affects, contributed significantly to the ASQ subscales. AC and in particular own joy and others’ guilt and anger seem to be of importance for attachment style. In study IV the importance of AC for the treatment process was explored. Patients’ AC before therapy was significantly correlated with patients’ positive feelings towards their therapists but not with their alliance ratings. Patients’ warm and positive feelings were related to pre-therapy AC, whereas negative feelings were related to low alliance ratings in the previous sessions.
|
|
