| 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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| 11. |
- Miloff, Alexander, 1982-
(författare)
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Virtual reality exposure therapy for spider phobia
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Exposure therapy for specific phobia involving systematic and repeated presentation of an aversive stimuli or situation is a highly effective treatment for reducing fear and anxiety. Dissemination of this evidence-based treatment has proved challenging, however, and for over 20 years an alternative method of delivery using virtual reality technology has been explored with positive results. This thesis consists of three empirical studies examining a new generation of virtual reality exposure therapy (VRET) that by using automation, inexpensive hardware, and downloadable software aims to ensure that a highly efficacious exposure therapy can be made available to almost anyone. Study I evaluated the efficacy of this novel automated VRET for spider phobia as compared to gold-standard in-vivo one-session treatment (OST) using a randomized non-inferiority design. Results indicated that large effect size reductions in self-reported fear were evident at post-assessment in both treatments and the automated VRET was not inferior to OST at 3- and 12-months follow-up according to behavioral approach test, but was significantly worse until 12-month follow-up. No significant difference was noted on a questionnaire measuring negative effects of treatment. Study II conducted a process measure evaluation of patient alliance towards the virtual therapist used in the VRET treatment with a purpose-built questionnaire entitled the Virtual Therapist Alliance Scale (VTAS). Exploratory factor analysis indicated a sound two-factor solution composed of a primary task, goal and co-presence factor and a secondary bond and empathy factor. Psychometric evaluation of the VTAS suggested good internal consistency, and a moderate correlation between the VTAS and change in self-reported fear over follow-up. Study III assessed what individuals with a fear of spiders found most frightening about spiders. Both quantitative ratings and qualitative descriptions indicated that movement characteristics were reported as most fear provoking and to a lesser extent appearance characteristics, however factor analysis of scores in these categories did not find a correlation with participant baseline self-reported fear. Overall, the above findings suggest that VRET is a potential alternative to OST for the treatment of spider phobia also with respect to therapist alliance, and spider movement characteristics should be emphasized in future VRET treatments.
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| 12. |
- Rafi, Jonas, 1985-
(författare)
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A Workplace Prevention Program for Problem Gambling
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Gambling is an activity that may involve harm for the gambler and others close to the gambler. Since workplaces may be negatively affected by employees who gamble during work or are at-risk problem gamblers, this setting has been proposed as a suitable arena for prevention. However, the potential effects of such initiatives have not been evaluated. This thesis explored the effects of a workplace prevention program for problem gambling. The program comprised gambling policy development and skill development training for managers.Study I used pre-intervention measures to explore gambling characteristics of employees (n=3629) in ten organizations, including both private and public sector organizations, and blue- and white-collar workers. About one in 20 employees knew someone who gambled during work, and this proportion was similar for both managers and subordinates. Another finding was that 3.5% of respondents were categorized as at-risk problem gamblers, with a higher prevalence among subordinates (3.8%) than managers (1.3%). A third finding was that 11.4% of employees stated that the organization had a gambling policy, and that this did not differ between managers and subordinates. Gambling policy knowledge was considerably lower than alcohol policy knowledge, as an alcohol policy was believed to exist by 94.3% of managers and 63.3% of subordinates. Lastly, in regression analyses, the two outcomes “knowing about a colleague who gambles during work” and “at-risk/problem gambling” were associated with each other, male gender, and young age. Taken together, the findings offer evidence that gambling may be an important topic to target in workplace settings, although more research is needed to pinpoint specific workplace harms and whether certain gambling types are associated with more workplace harms than others.Study II used a cluster-randomized design to investigate the effects of a prevention program. Ten organizations were randomized to an intervention group or a waitlist group. Individuals who were employed on any of three measurement occasions were eligible to participate. A total of n=490 (response rate 73%) managers and n = 4146 (response rate 43.3%) subordinates participated in the study by providing informed consent and responding to the survey at least once. The prevention program included two main components: policy development and skill development training for managers. The main outcome was managers’ inclination to act when worried about an employee regarding gambling or other harmful use (e.g., alcohol), together with a range of secondary outcome measures. The results showed that managers who participated in the skill development training significantly increased their inclination to act compared to the waitlist group, but this finding was not generalized to the whole intervention group. Thus, including managers in the intervention group who did not participate in the skill development training when calculating intervention effects resulted in non-significant effects. The results of secondary outcome measures showed that there were significant intervention effects regarding managers’ knowledge of a gambling policy, their confidence in how to act when concerned about an employee’s possible problem gambling or other harmful use, and the proportion of managers who had acted to provide support. Study III included semi-structured interviews with skill development participants (n=23) to inquire about their experiences of the prevention program. Interviews were transcribed and analyzed using qualitative content analysis, which yielded six distinct themes related to the participants, namely: 1) their expectations, 2) aspects of the skill development training they appreciated, 3) their experiences of PG, 4) their proposed areas of improvement, 5) whether they felt they had received a good basis for PG and other harmful use, and 6) their thoughts about the so-called “difficult conversation”. Taken together, the findings provide ideas for improving gambling-specific interventions for the workplace and corroborate earlier research findings on workplace interventions in general.To conclude, the thesis shows that a workplace preventive intervention for gambling can have positive effects on managers’ intended and performed actions to help an employee who they suspect has a problem with gambling or other harmful use. However, further program improvements and in-depth studies are needed to draw conclusions on explanations, robustness, and mechanisms of change.
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| 13. |
- Rozental, Alexander, 1985-
(författare)
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Negative effects of Internet-based cognitive behavior therapy : Monitoring and reporting deterioration and adverse and unwanted events
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Internet-based cognitive behavior therapy (ICBT) has the potential of providing many patients with an effective form of psychological treatment. However, despite helping to improve mental health and well-being, far from everyone seem to benefit. In some cases, negative effects may also emerge. The overall aim of the present thesis was to establish the occurrence and characteristics of such incidents in ICBT using a combination of quantitative and qualitative methods. Study I determined deterioration, non-response, and adverse and unwanted events in a sample of 133 patients undergoing ICBT for social anxiety disorder. The results indicated that up to 6.8% fared worse during the treatment period, depending on the self-report measure and time point, as determined using the Reliable Change Index (RCI), while the non-response rate was between 29.3 to 86.5% at post treatment assessment, and 12.9% experienced other negative effects. Study II investigated the responses to open-ended questions on adverse and unwanted events among 556 patients in four separate clinical trials of ICBT; social anxiety disorder, panic disorder, major depressive disorder, and procrastination. In total, 9.3% reported negative effects, with a qualitative content analysis revealing two categories and four subcategories; patient-related, i.e., gaining insight and experiencing new symptoms, and treatment-related, i.e., difficulties applying the treatment interventions and problems related to the treatment format. Study III explored the number of patients achieving reliable deterioration, as determined using the RCI on the individual raw scores of 2866 patients from 29 clinical trials of ICBT. The results showed that the deterioration rate was higher among patients in a control condition, 17.4%, in comparison to treatment, 5.8%. Predictors were related to decreased odds of deterioration for patients receiving treatment; clinical severity at pre treatment assessment, being in a relationship, having a university degree, and being older. As for the control condition, only clinical severity at pre treatment assessment was associated with decreased odds of deterioration. Study IV examined a newly developed self-report measure for monitoring and reporting adverse and unwanted events, the Negative Effects Questionnaire. The results suggested a six-factor solution with 32 items; symptoms, quality, dependency, stigma, hopelessness, and failure. One-third of the patients reported experiencing unpleasant memories, stress, and anxiety, with novel symptoms and a lack of quality in the treatment and therapeutic relationship having the greatest negative impact. The general finding of the present thesis is that negative effects do occur in ICBT and that they are characterized by deterioration, non-response, and adverse and unwanted events, similar to psychological treatments delivered face-to-face. Researchers and clinicians in ICBT are recommended to monitor and report negative effects to prevent a negative treatment trend and further the understanding of what might contribute to their incidents. Future research should investigate the relationship between negative effects and treatment outcome, especially at follow-up, to examine if they are transient or enduring. Also, interviews could be conducted with those achieving reliable deterioration to explore if and how it is experienced by the patients and to see if it is attributed to the treatment interventions or other circumstances.
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| 14. |
- Zetterqvist (f.d. Westin), Vendela, 1980-
(författare)
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Tinnitus – an acceptance-based approach
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Tinnitus is a highly prevalent health condition creating moderate or severe interference on mood, sleep and daily functioning for a group of those affected. The aims of this thesis were 1) to explore the role of acceptance and psychological flexibility in understanding tinnitus interference both experimentally and with a longitudinal design 2) to evaluate the immediate and long-term outcomes of an acceptance based behaviour therapy (Acceptance and Commitment Therapy; ACT) in the treatment of people with tinnitus and, 3) to investigate the relationship between treatment outcome and processes assumed to be the active ingredients of treatment (acceptance and cognitive defusion).Study I (n=47) was an experiment comparing the impact of acceptance to that of thought suppression or a neutral instruction on the ability to maintain attention on an imagery task. Results indicated that participants could benefit from an acceptance strategy when performing the task. Study II (n=47) was a longitudinal trial studying the mediating role of acceptance on the relationship between tinnitus interference at baseline and tinnitus interference, anxiety, life quality, and depression at a seven-month follow-up. Full mediation was found for life quality and depression, and partial mediation for tinnitus interference. Study IV (n=64) was a randomised controlled trial evaluating the immediate and long-term effects of ACT in comparison to those of Tinnitus Retraining Therapy (TRT) and to a wait list control. Results showed that ACT had large immediate effects on tinnitus interference in comparison to wait list, and medium long-term effects in comparison to TRT. Results were also seen on secondary outcome. Self-reported tinnitus acceptance significantly mediated the immediate outcome of ACT. Study III (n=24) was a process study where the video recorded sessions of ACT from study IV were observed and rated with regard to client behaviour. Results showed that in-session acceptance and defusion behaviours rated early in therapy were predictors of sustained positive treatment effects of ACT. These associations continued to be substantial even when controlling for the prior improvement in outcome. This whereas prior symptom change could not predict process variables rated late in therapy. Participants in all trials were chronic tinnitus patients, mainly from different departments of audiology. These findings implicate that 1) acceptance and psychological flexibility may contribute to the understanding of tinnitus interference 2) ACT can reduce tinnitus interference in a group of normal hearing tinnitus patients and 3) acceptance and cognitive defusion are important processes in ACT, related to outcome.
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| 15. |
- Forsström, David, 1981-
(författare)
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The use and experience of responsible gambling tools : An explorative analysis of user behavior regarding a responsible gambling tool and the consequences of use
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Responsible gambling tools are an intervention that is designed to decrease gambling among individuals with an at-risk gambling behavior. Studies have indicated that responsible gambling tools can decrease gambling behavior, but little is known about how this intervention is used by gamblers. The aim of the present thesis was to explore different facets of the use, experience and functions of these tools. Study I used descriptive statistics and latent class analysis (LCA) combined with multinomial regression to explore the use of the responsible gambling tool Playscan among 9528 gamblers (regular and at-risk gamblers). The participants had volunteered to use the tool. The functions of the tool had a high rate of initial use but a low rate of repeated use. The LCA identified five user classes. Two of the classes (self-testers and multifunctional users) were defined as high users of the tool and had a higher risk of developing gambling problems according to multinomial regression. The multifunctional users were characterized by an extensive use of all the functions while the other high usage class had an extensive use of the self-test. The three other classes were as follows: those who did not use the tool, those who visited the tool but did not engage in any of the functions, and those who only used the tool’s advice on how to decrease their gambling. Participants’ reasons for use and non-use of the tool were attributed to their degree of need of the tool and its functions. The tool’s most widely used function was the self-test that investigated the level of negative consequences faced by a user due to his or her gambling. Study II was a qualitative study investigating participants’ views, experiences and their reasons for using the tool. The study was conducted by interviewing 20 volunteer users of the tool. These semi-structured interviews were analyzed by thematic analysis. The results showed that the users had a positive attitude towards the tool and understood its purpose. The self-test was the most widely used function in this sample as well. However, the participants’ positive attitude toward the tool did not effectively encourage them to use it; they displayed low use of the tool’s functions. This paradox was explained by lack of feedback and the fact that some participants did not understand that they had registered to use the tool. Providing more feedback and tailoring the feedback to individual users were seen as ways of bridging the paradox. Study II also found that participants used the gambling website (which Playscan was linked to) in an analogue way, preparing their bets before placing them online. This limited the time they spent on the site and inhibited their use of Playscan. Study III was motivated by the extensive use of the self-test among users in Study I and Study II. The aim of Study III was to investigate the psychometric properties of the self-test (known as GamTest) to better understand how it could be used with Playscan in the most efficient way. Two thousand two hundred and thirty four respondents answered the questionnaire, along with instruments measuring depression, anxiety and another instrument measuring problems due to gambling. Factor analysis, parallel analysis, Cronbach’s alpha, and correlations were used to establish the tool’s psychometric properties. The results yielded a three-factor model, excellent reliability, and high correlation with the Problem Gambling Severity Index (PGSI), endorsing the validity of the self-test. The results also indicated that the questionnaire could be effectively shortened. Overall, the studies show that the tool has an initial high use, low repeated use and that the self-test is the most used feature. In addition, the self-test had good psychometric properties.
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| 16. |
- Ivanova, Ekaterina, 1987-
(författare)
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Responsible provision of online gambling : Effects, usability and gamblers’ experiences of protective measures implemented in online gambling environments
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Problem gambling is considered a public health problem in many countries and is associated with serious financial and health-related harms for both problem gamblers and significant others. It is possible to create gambling environments that would promote sustainable gambling behaviors and prevent excessive gambling. However, research on the effectiveness of tools for responsible provision of gambling is scarce and the quality of the research is low. Also, there exists a conflict of interest between making a profit when providing gambling and protecting vulnerable customers. The general aim of the project was to study the effects, usability and gamblers’ experiences of tools for responsible provision of online gambling. Study I evaluated the effects of a prompt to set voluntary deposit-limit of optional size among 4,328 customers of an online gambling platform. During the data collection period, all customers from Finland registering an account on the gambling platform were randomized into being prompted to set a deposit-limit either 1) at-registration, 2) before their first deposit, 3) after their first deposit or 4) to an unprompted control group. Gambling intensity, measured with aggregated net loss, was tracked during 90 days after registration. No differences in gambling intensity between the intervention and control groups were found neither on the whole-group level (B (95% CI) =-0.080 (-0.229-0.069), p=.291), nor in the subgroup of the most involved gamblers (B (95% CI) =0.042(-0.359-0.442), p=.838). Study II aimed at predicting gaming freeze (as a proxy parameter for problem gambling) in online gamblers. For the sample of N=2,618 (N=1,309 freezers), a total of 105 predictors were created based on the data tracked by the gambling platform. The analysis was carried out using the machine learning method Random Forest. The predictive accuracy of the model applied to the dataset was 0.615, with a specificity of 0.686 and a sensitivity of 0.543. Study III aimed at investigating non-problem gamblers’ experiences of protective measures. A total of N=10,200 active customers of an online gambling platform were asked to rate their previous experiences of protective tools, their inclination to abandon a gambling service due to perceived overexposure to protective measures and answer questions on their symptoms of problem gambling. N=1,223 responded to the questionnaire, with the majority of the sample being moderate-risk gamblers (38.5%), followed by low-risk gamblers (26.8%), non-problem gamblers (18.9%) and problem gamblers (15.8%). In general, non-problem gamblers were not more disturbed by protective measures than other categories of gamblers. More problem gamblers have previously abandoned a gambling service due to perceived overexposure to protective measures compared to non-problem gamblers (OR(95% CI)= 7.17(3.61-14.23), p<.001). In conclusion, a prompt to set a voluntary deposit-limit of optional size did not appear to be effective in decreasing gambling intensity in online gamblers, indicating the need of evaluating alternative designs. Predicting gaming freezes in the current project resulted in a low accuracy, indicating that gaming freeze is not suitable as a proxy measurement for problem gambling and suggesting the need for collecting subjective data on symptoms of problem gambling. The results of Study III suggest that protective measures can be tested and implemented without the risk of disturbing recreational gamblers.
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| 17. |
- Silfvernagel, Kristin
(författare)
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Individually tailored internet-based cognitive behavioural therapy for adolescents, young adults and older adults with anxiety
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Anxiety disorders share the feature of excessive fear, anxiety and related behavioural disturbances. Fear is defined as the emotional response to a real or a perceived imminent threat and anxiety is the anticipation of a future threat. The anxiety disorders covered in this thesis are panic disorder with or without agoraphobia, social phobia, post-traumatic stress disorder, generalized anxiety disorder and anxiety disorder not otherwise specified.Cognitive behavioural treatment protocols are typically designed to target one specific disorder and falls under the definition of disorder-specific cognitive behavioural therapy. It is however unclear if this is the most optimal approach in regards to the high comorbidity between anxiety disorders and depressive disorders. Internet-based cognitive behavioural therapy has in the past generally been disorder-specific and from above mentioned predicament two alternative treatment approaches emerged, the tailored and the transdiagnostic approach that aims to simultaneously treat both principal and comorbid disorders. Previous trials on internet-based cognitive behavioural therapy have targeted adults in general and relatively few target adolescents, young adults and older adults.The aims of this thesis were to further develop and test the effects of tailored internet-based cognitive behavioural therapy on the basis of age, for adolescents, young adults and older adults. Specifically by developing and testing the effects of individually tailored internet-based cognitive behavioural therapy for adolescents with anxiety and comorbid depressive symptoms and by adapting and testing the effects of individually tailored internet-based cognitive behavioural therapy for young adults and older adults with anxiety and comorbid depressive symptoms. These aims were tested in two pilot effectiveness studies (Paper I and III) and two efficacy randomised controlled trials (Paper II and IV). The results from these four trials showed significant results across all outcome measures with overall moderate to large effect sizes. The tentative conclusion based on these results is that tailoring internet-based cognitive behavioural therapy can be a feasible approach in the treatment of anxiety symptoms and comorbid depressive symptoms for adolescents, young adults and older adults. Despite the positive findings of the studies in this thesis, there is a need for more research examining the acceptability and effectiveness of internet-based cognitive behavioural therapy for adolescents, young adults and older adults with anxiety and depression before implementation on a larger scale.
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| 18. |
- Tyrberg, Mårten, 1981-
(författare)
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Bringing psychological treatment to the psychiatric ward : Affecting patients, staff, and the milieu
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The psychiatric ward is a complex setting. This has to do partly with the severity of the patients’ suffering. Often, they present with such diagnoses as psychosis, self-harm, substance abuse, and suicidality. In fact, they often present with a combination of these. This renders the delivery of effective treatment a challenging task. Partly, the complexity of the ward has to do with aspects of the context itself. Admissions and discharges often happen fast and unexpectedly, staff members are expected to handle various challenging behaviors, they display quite high levels of burnout and work dissatisfaction, and the wards are often staffed by bank staff, leading to a lack of continuity of care. This adds to the challenge of delivering effective treatment. In the typical Swedish ward, treatment consists of medication, nursing, observation, and management of risk behaviors. Psychological treatment is seldom a routine part of inpatient care. However, there are sound arguments for adding psychological treatment in the form of cognitive behavior therapy (CBT) of various modalities. Further, there is promise in psychosocial interventions delivered by the nursing staff after appropriate training, and in providing supervision to the staff.The aim of the present thesis was to investigate the feasibility and potential efficacy of acceptance and commitment therapy (ACT), a CBT based psychotherapy model, as a broadly applied intervention in the context of psychiatric inpatient care. In three studies, ACT was evaluated as a brief individual psychotherapy intervention, and as a psychologically informed approach to dealing with patients performed by the nursing staff group in a psychiatric ward for psychosis patients.In study I, an average of two sessions of ACT was delivered to patients (n = 11) with a diagnosis of psychosis. Compared to a control group (n = 10), the risk for rehospitalization during a four-month follow-up period was significantly smaller for patients in the experimental group. There was also a trend toward increased values-based living scores in the experimental group, compared to controls.Study II evaluated the effects on staff members (n = 20) and patients (n = 9) of a brief ACT training intervention tailored to the staff group, the aim of which was to introduce ACT as a day-to-day approach to dealing with patients. After a total of 12 hours of ACT training, the staff group displayed a slight increase in work-related psychological flexibility, compared to before, while a non-randomized control group (n = 18) displayed a slight decrease. Patients being treated on the ward after the staff training displayed a slight increase in psychological flexibility during ward treatment, while patients being treated before displayed a slight decrease. In both cases, however, the differences were considered quite small (non-significant in statistical terms). Further, the study investigated ACT-consistent behavior changes among staff members following ACT training, using a multiple baseline single-subject design. Results revealed both expected and unexpected patterns of behavior.In study III, the usefulness of the ACT model was investigated using a qualitative content analysis. Staff members (n = 10) experienced ACT as useful in terms of dealing with patients’ struggles, enriching typical duties, and dealing with their own stress. Difficulties in using the model related to time restraints, complexities of the model itself, and the severity of patients’ illnesses.In summary, the present thesis adds to the research basis for ACT as a treatment for psychosis, delivered in an inpatient setting. It shows that the introduction of ACT as an add-on to traditional ward treatment in Sweden is for the most part feasible and acceptable. However, the thesis also discusses various challenges in the implementation of psychological treatment in such a complex context as the inpatient ward, both in terms of delivery of the treatment itself and the evaluation of its effectiveness.
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| 19. |
- Vernmark, Kristofer, 1976-
(författare)
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Therapeutic alliance and different treatment formats when delivering internet-based CBT for depression
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Depression är en funktionsnedsättande problematik som påverkar en stor del av den vuxna populationen varje år. Trots ett omfattande behov av hjälp så råder det brist på tillgång till effektiv behandling. Kognitiv Beteendeterapi (KBT) är en evidensbaserad metod som har stöd vid behandling av depression och förmedlad via internet skulle metoden kunna tillgängliggöras för fler. Dock är det i dagsläget oklart vilka format och vilket innehåll som kan användas när behandlingen förmedlas via internet, samt vilken betydelse den terapeutiska alliansen har för en behandling som till största del sker på distans. Syftet med denna avhandling var att undersöka effekterna för olika format av internetbehandling (epostterapi, guidad självhjälp och blended treatment) vid depression, samt alliansens roll i dessa format.Studiernas resultat visar på att epostterapi och internetförmedlade självhjälpsprogram med behandlarstöd var effektiva metoder för att behandla depression. Alliansskattningar var höga, vilket visar att en positiv terapeutisk allians kan uppnås i internetbehandling. Patientskattningar av allians kunde inte predicera utfallet i någon av behandlingarna, men behandlarskattad allians predicerade förbättring på depressionsskattningar i blended treatment. Den här avhandlingen innehåller den första randomiserade kontrollerade studien på KBT-baserad epostterapi vid depression, samt det första internet-förmedlade självhjälpsprogrammet baserat på beteendeaktivering och ACT.
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| 20. |
- Carlbring, Per, 1972-
(författare)
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Panic! Its Prevalence, Diagnosis and Treatment via the Internet
- 2004
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- As evidenced by several trials, cognitive behavior therapy (CBT) is a highly effective treatment for Panic disorder with or without agoraphobia (PD). However, therapists are short in supply, and patients with agoraphobia may not seek therapy due to fear of leaving their homes or traveling certain distances. A major challenge therefore is to increase the accessibility and affordability of evidence-based psychological treatments.This thesis is based on five studies; three treatment studies set up as randomized controlled trails (RCT), one prevalence study, and one study testing the equivalence of an Internet-administered diagnostic assessment tool with a clinician-administered interview.Study I showed that the Swedish 12-month PD prevalence is consistent with findings in most other parts of the Western world (2.2%; CI 95% 1.0%-3.4%). There was a significant sex difference, with a greater prevalence for women (3.6%) compared to men (0.7%).Study II showed that the validity of the computerized diagnostic interview (CIDI-SF) was generally low. However, the agoraphobia and obsessive-compulsive disorder modules had good specificity and sensitivity, respectively.The three RCTs showed, directly or indirectly, that Internet-based self-help is superior to a waiting-list. When 10 individual weekly sessions of CBT for PD was compared with a 10-module self-help program on the Internet, the results suggest that Internet-administered self-help, plus minimal therapist contact via e-mail, is as effective as traditional individual CBT (80% vs. 67% no longer met criteria for panic disorder; composite within-group effect size was Cohen’s d= 0.78 vs. 0.99). One-year follow-up confirmed the results (92% vs. 88% no longer met criteria for panic disorder; d= 0.80 vs. 0.93). The results generally provide evidence to support the continued use and development of Internet-distributed self-help programs.
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| 21. |
- Furukawa, Toshi A., et al.
(författare)
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Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression : a systematic review and component network meta-analysis using individual data
- 2021
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Ingår i: Lancet psychiatry. - London, United Kingdom : Elsevier. - 2215-0374 .- 2215-0366. ; 8:6, s. 500-511
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Forskningsöversikt (refereegranskat)abstract
- Findings We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42.0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1.83 [95% credible interval (CrI) -2.90 to -0.80]) and that relaxation might be harmful (1.20 [95% CrI 0.17 to 2.27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0.32 [95% CrI 0.13 to 0.93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. 511
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| 22. |
- Hedman‐Lagerlöf, Erik, et al.
(författare)
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Therapist‐supported Internet‐based cognitive behaviour therapy yields similar effects as face‐to‐face therapy for psychiatric and somatic disorders : an updated systematic review and meta‐analysis
- 2023
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Ingår i: World Psychiatry. - : John Wiley & Sons. - 1723-8617 .- 2051-5545. ; 22:2, s. 305-314
-
Tidskriftsartikel (refereegranskat)abstract
- Providing therapist-guided cognitive behaviour therapy via the Internet (ICBT) has advantages, but a central research question is to what extent similar clinical effects can be obtained as with gold-standard face-to-face cognitive behaviour therapy (CBT). In a previous meta-analysis published in this journal, which was updated in 2018, we found evidence that the pooled effects for the two formats were equivalent in the treatment of psychiatric and somatic disorders, but the number of published randomized trials was relatively low (n=20). As this is a field that moves rapidly, the aim of the current study was to conduct an update of our systematic review and meta-analysis of the clinical effects of ICBT vs. face-to-face CBT for psychiatric and somatic disorders in adults. We searched the PubMed database for relevant studies published from 2016 to 2022. The main inclusion criteria were that studies had to compare ICBT to face-to-face CBT using a randomized controlled design and targeting adult populations. Quality assessment was made using the Cochrane risk of bias criteria (Version 1), and the main outcome estimate was the pooled standardized effect size (Hedges’ g) using a random effects model. We screened 5,601 records and included 11 new randomized trials, adding them to the 20 previously identified ones (total n=31). Sixteen different clinical conditions were targeted in the included studies. Half of the trials were in the fields of depression/depressive symptoms or some form of anxiety disorder. The pooled effect size across all disorders was g=0.02 (95% CI: –0.09 to 0.14) and the quality of the included studies was acceptable. This meta-analysis further supports the notion that therapist-supported ICBT yields similar effects as face-to-face CBT.
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| 23. |
- Hjorth, Olof, et al.
(författare)
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Serotonin and dopamine transporter availability in social anxiety disorder after combined treatment with escitalopram and cognitive-behavioral therapy
- 2022
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Ingår i: Translational Psychiatry. - : Springer Science and Business Media LLC. - 2158-3188. ; 12:1
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Tidskriftsartikel (refereegranskat)abstract
- Selective serotonin reuptake inhibitors (SSRIs) and internet-based cognitive behavioral therapy (ICBT) are recommended treatments of social anxiety disorder (SAD), and often combined, but their effects on monoaminergic signaling are not well understood. In this multi-tracer positron emission tomography (PET) study, 24 patients with SAD were randomized to treatment with escitalopram+ICBT or placebo+ICBT under double-blind conditions. Before and after 9 weeks of treatment, patients were examined with positron emission tomography and the radioligands [11C]DASB and [11C]PE2I, probing the serotonin (SERT) and dopamine (DAT) transporter proteins respectively. Both treatment combinations resulted in significant improvement as measured by the Liebowitz Social Anxiety Scale (LSAS). At baseline, SERT-DAT co-expression was high and, in the putamen and thalamus, co-expression showed positive associations with symptom severity. SERT-DAT co-expression was also predictive of treatment success, but predictor-outcome associations differed in direction between the treatments. After treatment, average SERT occupancy in the SSRI + ICBT group was >80%, with positive associations between symptom improvement and occupancy in the nucleus accumbens, putamen and anterior cingulate cortex. Following placebo+ICBT, SERT binding increased in the raphe nuclei. DAT binding increased in both groups in limbic and striatal areas, but relations with symptom improvement differed, being negative for SSRI + ICBT and positive for placebo + ICBT. Thus, serotonin-dopamine transporter co-expression exerts influence on symptom severity and remission rate in the treatment of social anxiety disorder. However, the monoamine transporters are modulated in dissimilar ways when cognitive-behavioral treatment is given concomitantly with either SSRI-medication or pill placebo.
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| 24. |
- Karyotaki, Eirini, et al.
(författare)
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Internet-Based Cognitive Behavioral Therapy for Depression : A Systematic Review and Individual Patient Data Network Meta-analysis
- 2021
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Ingår i: JAMA psychiatry. - : American Medical Association. - 2168-6238 .- 2168-622X. ; 78:4, s. 361-371
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Forskningsöversikt (refereegranskat)abstract
- IMPORTANCE: Personalized treatment choices would increase the effectiveness of internet-based cognitive behavioral therapy (iCBT) for depression to the extent that patients differ in interventions that better suit them.OBJECTIVE: To provide personalized estimates of short-term and long-term relative efficacy of guided and unguided iCBT for depression using patient-level information.DATA SOURCES: We searched PubMed, Embase, PsycInfo, and Cochrane Library to identify randomized clinical trials (RCTs) published up to January 1, 2019.STUDY SELECTION: Eligible RCTs were those comparing guided or unguided iCBT against each other or against any control intervention in individuals with depression. Available individual patient data (IPD) was collected from all eligible studies. Depression symptom severity was assessed after treatment, 6 months, and 12 months after randomization.DATA EXTRACTION AND SYNTHESIS: We conducted a systematic review and IPD network meta-analysis and estimated relative treatment effect sizes across different patient characteristics through IPD network meta-regression.MAIN OUTCOMES AND MEASURES: Patient Health Questionnaire-9 (PHQ-9) scores.RESULTS: Of 42 eligible RCTs, 39 studies comprising 9751 participants with depression contributed IPD to the IPD network meta-analysis, of which 8107 IPD were synthesized. Overall, both guided and unguided iCBT were associated with more effectiveness as measured by PHQ-9 scores than control treatments over the short term and the long term. Guided iCBT was associated with more effectiveness than unguided iCBT (mean difference [MD] in posttreatment PHQ-9 scores, -0.8; 95% CI, -1.4 to -0.2), but we found no evidence of a difference at 6 or 12 months following randomization. Baseline depression was found to be the most important modifier of the relative association for efficacy of guided vs unguided iCBT. Differences between unguided and guided iCBT in people with baseline symptoms of subthreshold depression (PHQ-9 scores 5-9) were small, while guided iCBT was associated with overall better outcomes in patients with baseline PHQ-9 greater than 9.CONCLUSIONS AND RELEVANCE: In this network meta-analysis with IPD, guided iCBT was associated with more effectiveness than unguided iCBT for individuals with depression, benefits were more substantial in individuals with moderate to severe depression. Unguided iCBT was associated with similar effectiveness among individuals with symptoms of mild/subthreshold depression. Personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression.
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| 25. |
- Käll, Anton, 1992-, et al.
(författare)
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Scheduled Support Versus Support on Demand in Internet-Delivered Cognitive Behavioral Therapy for Social Anxiety Disorder : Randomized Controlled Trial
- 2023
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Ingår i: Clinical Psychology in Europe. - : PsychOpen. - 2625-3410. ; 5:3
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Clinician-supported internet-delivered cognitive behavioral therapy (ICBT) can be an effective treatment option when treating social anxiety disorder (SAD). Unguided ICBT is often found to be less effective. One possible solution to reduce the costs of clinician support is to provide support on demand. In this format of guidance, participants have the option to contact their clinician if needed. In a few studies, this mode of support has been compared favorably to scheduled support.Method: Participants in a previously reported controlled trial on SAD who had been in a waitlist control group were randomly allocated to ICBT with either on-demand guidance or scheduled weekly therapist guidance. A total of 99 participants were included. Data were collected weekly on the primary outcome measure, the Liebowitz Social Anxiety Scale self-report (LSAS-SR), and at pre- and post-treatment for secondary measures. Data were analyzed in accordance with the intention-to-treat principle using mixed-effects models.Results: Both groups improved significantly during the treatment according to the LSAS-SR ratings. The groups did not differ in their estimated change during the treatment period, with a between-group effect of d = 0.02, 95% CI [-0.37, 0.43]. Both groups experienced similar improvement also on the secondary outcome measures, with small between-group effect sizes on all outcomes.Conclusions: The findings indicate that support on demand can be an effective way of providing guidance in ICBT for SAD, although more research on this topic is needed. A limitation of the study is that it was conducted in 2009, and the findings were in the file drawer. Subsequent published studies support our initial findings, but more research is needed.
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| 26. |
- Lindner, Philip, et al.
(författare)
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Is Continued Improvement After Automated Virtual Reality Exposure Therapy for Spider Phobia Explained by Subsequent in-vivo Exposure? : A First Test of the Lowered Threshold Hypothesis
- 2021
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Ingår i: Frontiers in Psychiatry. - : Frontiers Media SA. - 1664-0640. ; 12
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Tidskriftsartikel (refereegranskat)abstract
- Consumer Virtual Reality (VR) technology offers a powerful, immersive medium for scalable dissemination of mental health interventions. Decades of research has shown VR exposure therapy to be efficacious in the treatment of anxiety disorders and that the fear reduction generalizes to real-world stimuli. Many studies also report continued improvement over time, after discontinuing VR use. The lowered threshold hypothesis states that this continued improvement is moderated by lowering the threshold to conduct subsequent in-vivo exposure. The current study is the first to formally test this hypothesis, using data from a recent trial on automated VR exposure therapy for spider phobia, in which participants (n = 49) were followed for 1 year, completing assessments 1 week, 3 and 12 months post-treatment. The assessment included validated self-report of phobia symptoms, a standardized behavioral approach test featuring a real spider, and a questionnaire for self-reporting frequency of in-vivo exposures since last assessment. Number of in-vivo exposures was found to be independently associated with greater symptom decrease in longitudinal outcome models. In sequential structural equation models, immediate post-treatment symptom reduction was associated with subsequent in-vivo exposures, which in turn was associated with continued symptom reduction. However, this applied only to self-reported phobia symptoms (not behavioral avoidance) and no associations were found past 3 months. Our findings offer preliminary, partial support for the lowered threshold hypothesis, suggesting that VR exposure interventions may benefit from including explicit in-virtuo to in-vivotransitioning components.
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| 27. |
- Lindqvist, Karin, et al.
(författare)
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Therapeutic alliance is calming and curing - The interplay between alliance and emotion regulation as predictors of outcome in Internet-based treatments for adolescent depression
- 2023
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Ingår i: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 91:7, s. 426-437
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance–outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance–outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation.Method: Two hundred and seventy-two participants aged 15–19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling.Results: Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships.Conclusion: Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance.
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| 28. |
- Lundgren, Tobias
(författare)
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ACT Treatment of Epilepsy : Time for a behavioral model?
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The present dissertation contributes to the understanding of behavioral treatment of epilepsy and supports the integration of medical and behavioral science to develop a treatment model to help those who suffer from drug refractory epilepsy. There is a lack of well-designed randomized controlled trials evaluating behavioral therapy for epilepsy. Medical science has contributed significantly to the development of antiepileptic drugs for seizure control, yet despite these efforts approximately 1/3 of patients suffer from recurrent seizures. The comorbidity between epilepsy and psychiatric problems is significant and quality of life is lower for those who suffer from epilepsy compared to those who suffer from other chronic illnesses. The purpose of the present dissertation is to develop and evaluate a behavioral treatment model for those who suffer from recurrent epileptic seizures and associated problems. Acceptance and commitment therapy (ACT) is compared to supportive treatment and yoga. Outcome variables are seizure frequency, seizure index (frequency * duration) and quality of life. The dissertation consists of three studies; two studies with randomized controlled group designs to evaluate treatment effects and one mediational analysis study evaluating the effect of specific therapeutic processes. The mediational analysis examines specific ACT processes such as value attainment, epilepsy related psychological flexibility and persistency in overcoming barriers. The results of the two randomized controlled trials show a significant decrease in seizure frequency and seizure index in favor of the ACT group compared to the control groups and significant changes in life quality. The results of the mediational study indicate that the evaluated processes, alone or in combination, had a mediational role in three of the four outcome variables. In conclusion, the present dissertation supports the integration of behavior and medical science to help those who suffer from epilepsy and associated problems.
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| 29. |
- Ma, Lichen, 1988-
(författare)
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In search of the missing bias : Virtual reality based attentional bias modification for social anxiety
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Attentional bias modification (ABM) aims to attenuate social anxiety by directly modifying the underlying bias that generates and maintains problematic anxiety. Mixed results from previous ABM studies have spurred efforts to boost its effectiveness by introducing more robust bias modification protocols and new technologies. This thesis explored the effects of virtual reality (VR) based ABM training on attentional bias and social anxiety symptoms.Study I investigated the efficacy of a single-session, VR based dot-probe task in reducing attentional bias and social anxiety symptoms. The results showed no significant differences between active and mock ABM training. No attentional bias was observed at baseline, and the dot-probe training did not alter attentional bias. The use of two-dimensional or three-dimensional stimuli had no significant impact on anxiety symptom or bias. Although we found an overall reduction in anxiety symptoms over time, this reduction was not specific to active training and the magnitude of change was not clinically significant. Study II examined the efficacy of a single-session, VR based person-identity-matching (PIM) task. The results were practically identical to those found in Study I, with no bias observed at baseline and no correlation observed between bias and anxiety. No change in attentional bias was observed post-training. For anxiety symptoms, participants showed a general reduction in their anxiety scores over time. Once again, this reduction was nonspecific and clinically insignificant. Overall, the empirical studies of the current thesis indicated no substantial treatment gains from a single session of VR based ABM. More accurate, reliable, and precise measures of attentional bias are needed before we can properly assess the efficacy of any ABM procedure. Study III took on a broader perspective by compiling and synthesising contemporary expert opinions on the use of virtual reality and mixed reality technologies in the treatment of anxiety and stress-related disorders, with a focus on the current state of technology-assisted psychotherapies and their prospective development. The experts acknowledged that current VR psychotherapies still face some challenges, but the consensus was that the overall outlook for future use of VR psychotherapies remained positive.
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| 30. |
- Månsson, Viktor, et al.
(författare)
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Emotion regulation-enhanced group treatment for gambling disorder : a non-randomized pilot trial
- 2022
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Ingår i: BMC Psychiatry. - : Springer Science and Business Media LLC. - 1471-244X. ; 22:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Despite the association of Gambling Disorder (GD) with poor mental health, treatment options generally lack components targeting emotional difficulties. This study investigated the feasibility and acceptability of adding strategies of emotion regulation to an eight-session weekly group treatment.Method: This non-randomized pilot study recruited 21 treatment-seeking adults with GD, (mean age = 36.3, 19% females) from addiction care. In a mixed methods design, measures of within-group changes in self-reported symptoms of GD were complemented with thematic analysis of post-treatment interviews regarding the feasibility of the treatment.Results: Within-group scores on the Gambling Symptoms Assessment Scale (G-SAS) showed a 47% decrease (β: -0.1599, 95% CI: − 0.2526 to − 0.0500) from pre-treatment to 12-month follow-up, with Hedges’ g = 1.07 (CI: 0.57–1.60).The number of GD-symptoms according to the Structured Clinical Interview for Gambling Disorder (SCI-GD) decreased from 7.0 (SD = 1.60) at pre-treatment to 2.1 (SD = 2.36) at 12-month follow-up. Participants completed an average of 6.3 sessions and rated the intervention high in satisfaction and acceptability. Feasibility interviews showed no noticeable negative effects or ethical issues. Furthermore, helpful components in the treatment were: increased awareness of emotional processes and strategies to deal with difficult emotions.Conclusions: Adding emotion regulation strategies in the treatment of GD is feasible and acceptable and warrants further investigation in a controlled trial.Trial registration: This study was registered with ClinicalTrials.gov (Identifier NCT03725735).
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| 31. |
- Persson Asplund, Robert, 1977-, et al.
(författare)
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Work-Focused Versus Generic Internet-Based Interventions for Employees With Stress-Related Disorders : Randomized Controlled Trial
- 2023
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Ingår i: Journal of Medical Internet Research. - : JMIR Publications. - 1438-8871. ; 25
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Tidskriftsartikel (refereegranskat)abstract
- Background: In recent decades, stress-related disorders have received more attention, with an increasing prevalence, especially within the working population. The internet provides new options for broad dissemination, and a growing body of evidence suggests that web-based interventions for stress might be effective. However, few studies have examined the efficacy of interventions in clinical samples and work-related outcomes.Objective: The aim of this study was to evaluate the efficacy of an internet-based cognitive behavioral intervention for stress-related disorders integrating work-related aspects (work-focused and internet-based cognitive behavioral therapy [W-iCBT]), compared with a generic internet-based cognitive behavioral therapy (iCBT) group and a waitlist control (WLC) group.Methods: In this trial, 182 employees, mainly employed in the health care, IT, or educational sector, who fulfilled the criteria for a stress-related disorder, were randomized to a 10-week W-iCBT (n=61, 33.5%), generic iCBT (n=61, 33.5%), or WLC (n=60, 33%). Self-rated questionnaires on perceived stress, burnout, exhaustion, and other mental health– and work-related outcomes were administered before and after the treatment and at 6- and 12-month follow-ups.Results: Compared with the WLC group, participants of the W-iCBT and iCBT groups showed an equal and significant reduction in the primary outcome (Shirom-Melamed Burnout Questionnaire [SMBQ]) from pretreatment to posttreatment assessment (Cohen d=1.00 and 0.83, respectively) and at the 6-month follow-up (Cohen d=0.74 and 0.74, respectively). Significant moderate-to-large effect sizes were also found in the secondary health- and work-related outcomes. The W-iCBT was the only group that exhibited significant effects on work ability and short-term sickness absence. Short-term sickness absence was 445 days lower than the WLC group and 324 days lower than the iCBT intervention group. However, no significant differences were found in terms of work experience or long-term sick leave.Conclusions: The work-focused and generic iCBT interventions proved to be superior compared with the control condition in reducing chronic stress and several other mental health–related symptoms. Interestingly, effects on work ability and short-term sickness absence were only seen between the W-iCBT intervention and the WLC groups. These preliminary results are promising, indicating that treatments that include work aspects may have the potential to accelerate recovery and reduce short-term sickness absence because of stress-related disorders.Trial Registration: ClinicalTrials.gov NCT05240495
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| 32. |
- Smoktunowicz, Ewelina, et al.
(författare)
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Consensus statement on the problem of terminology in psychological interventions using the internet or digital components
- 2020
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Ingår i: Internet Interventions. - : Elsevier. - 2214-7829. ; 21, s. 1-8
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Tidskriftsartikel (refereegranskat)abstract
- Since the emergence of psychological interventions delivered via the Internet they have differed in numerous ways. The wealth of formats, methods, and technological solutions has led to increased availability and cost-effectiveness of clinical care, however, it has simultaneously generated a multitude of terms. With this paper, we first aim to establish whether a terminology issue exists in the field of Internet-delivered psychological interventions. If so, we aim to determine its implications for research, education, and practice. Furthermore, we intend to discuss solutions to mitigate the problem; in particular, we propose the concept of a common glossary. We invited 23 experts in the field of Internet-delivered interventions to respond to four questions, and employed the Delphi method to facilitate a discussion. We found that experts overwhelmingly agreed that there were terminological challenges, and that it had significant consequences for conducting research, treating patients, educating students, and informing the general public about Internet-delivered interventions. A cautious agreement has been reached that formulating a common glossary would be beneficial for the field to address the terminology issue. We end with recommendations for the possible formats of the glossary and means to disseminate it in a way that maximizes the probability of broad acceptance for a variety of stakeholders.
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| 33. |
- Sunnhed, Rikard, 1979-, et al.
(författare)
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Mediators of Cognitive Therapy and Behavior Therapy for Insomnia Disorder : A Test of the Processes in the Cognitive Model
- 2022
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Ingår i: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 90:9, s. 696-708
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To examine if the processes in the cognitive model mediate cognitive therapy (CT) and behavior therapy (BT) for insomnia. Method: Individuals diagnosed with insomnia disorder (n = 219) were randomized to telephone-supported internet-delivered CT (n = 72), BT (n = 73), or a wait-list (WL; n = 74). Cognitive processes (worry, dysfunctional beliefs, monitoring, and safety behaviors) proposed to maintain insomnia and treatment outcome (insomnia severity index) were assessed biweekly. Criteria for evaluating mediators were assessed via parallel process growth modeling and cross-lagged panel models. Results: Parallel process growth modeling showed that dysfunctional beliefs, monitoring, and safety behaviors significantly mediated the effects of both CT and BT. Cross-lagged panel models confirmed that dysfunctional beliefs and monitoring (approaching significance) influenced subsequent within-individual change in insomnia severity in CT. In BT, however, prior changes in insomnia severity predicted subsequent changes in worry and monitoring, and reciprocal influences among processes and outcomes were observed for dysfunctional beliefs and safety behaviors. Furthermore, the effect of safety behaviors on outcome was significantly larger for BT compared to CT. Conclusion: Together, the findings support the role of dysfunctional beliefs and monitoring as processes of change in CT and safety behaviors as a specific mediator in BT. Limited evidence was provided for worry as a mediator. The findings could improve clinical management and increase our conceptual understanding of insomnia and its maintaining factors by underscoring the relevance of these three processes for insomnia, as well as indicate important routes for future research, such as investigating how baseline presentations might moderate these mediations, for example moderated mediation.
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