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- Sunnhed, Rikard, 1979-
(författare)
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Cognitive therapy and behavioral therapy for insomnia disorder : efficacy, moderators and mediators
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Insomnia disorder is the second most prevalent mental disorder and the most prevalent sleep disorder. Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the treatment of choice with well-documented effects. Nevertheless, a significant proportion of patients fail to respond, and an even larger proportion fail to remit from the condition. In addition, very little is known about the effects of CBT-I's separate components or about what moderates and mediates their effect. Gaining knowledge about components, predictors, and mediators could be one route for optimizing and tailoring CBT-I and ultimately enhancing outcomes.The overall aim of this thesis was to advance our theoretical and clinical knowledge about CBT-I by exploring Cognitive Therapy (CT) and Behavior Therapy's (BT) comparative efficacy and their potential moderators and mediators.To pursue the study aims, one large randomized controlled trial was performed that involved 219 individuals with insomnia disorder randomized to CT, BT, or a waitlist control group. Study 1 examined CT and BT's comparative efficacy against a waitlist control on a broad range of outcomes. Study 2 examined theoretically derived constructs from both therapy models, and insomnia-associated correlates as potential predictors and moderators of outcome for the two therapies. Study 3 examined theoretically driven process variables from the cognitive model as mediators of outcome in both CT and BT.Study I showed that both therapies outperformed the waitlist and turned out as comparably effective treatments on the majority of outcomes. BT was associated with significantly more adverse events, whereas CT received significantly more minutes of telephone support.Study II showed that early morning waketime and bedtime variability moderated the effect of both CT and BT. Those experiencing lower early morning waketime and bedtime variability achieved greater insomnia severity reductions in CT. In contrast, those experiencing greater early morning waketime and bedtime variability achieved larger insomnia severity reductions in BT. The findings also showed that greater insomnia severity, waketime after sleep onset, and lower sleep efficiency at baseline predicted greater insomnia severity at posttreatment.Study III provided evidence that reductions in dysfunctional beliefs and monitoring for sleep during treatment acted as drivers of the reduction in insomnia severity in CT. The results also indicated that reductions in safety behaviors and dysfunctional beliefs mediated reductions in insomnia severity in BT, although not as clear as the drivers of change for CT since they were also reciprocally predicted by reductions in insomnia severity.Study I indicate that CT and BT achieve similar effects and that both therapies are effective as standalone therapies for insomnia disorder. Study II provided evidence that the two therapies in CBT-I can depend on different patient characteristics at baseline to be effective. The results from study II thus suggest that the therapies in CBT-I could be tailored based on patient's characteristics before treatment to optimize outcomes. Study III provided support for the role of cognitive processes as important routes to remediate insomnia and underscore the value of assessing and targeting dysfunctional beliefs, monitoring, and safety behaviors to achieve reductions in insomnia severity and emphasize the importance of these concepts in understanding insomnia.
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| 2. |
- Danielsson, Nanette S.
(författare)
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Disturbed sleep and emotion : a developmental perspective
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Sleep disturbances are not only defining features, but also diagnostic criteria for most psychiatric disorders. Recently, researchers have proposed a theoretic role for sleep disturbances in emotion dysregulation, subsequently linking neurobiological processes and psychopathology. Most prior research examining the potential role for sleep disturbance in emotion dysregulation is from a neurophysiological or clinical perspective, or primarily focused on maintaining processes. Less well understood are how sleep disturbances may be involved at the levels of predisposition, precipitation, and perpetuation of emotion dysregulation concurrently and over time.This dissertation presents findings from three studies that were designed to expand on what is known about sleep disturbance in the predisposition, precipitation, and perpetuation of emotion dysregulation. Study 1 examined the long-term relation between sleep-onset problems and neuroticism over twenty-years. Adolescent sleep-onset posed risk (predisposition) for neuroticism in midlife, not vice versa. Study 2 investigated the effects of 3-nights partial sleep deprivation (5-hours total time in bed) on the positive and negative affect and emotions of otherwise healthy adults. Following partial sleep deprivation, people reported significant reductions in positive affect and emotions compared to rested people (precipitation). The only impact on negative emotions was on the discrete level. Sleep deprived peo-ple reported significantly more irritability, loathing, hostility, and shakiness compared to controls. Study 3 measured adolescent sleep disturbances, depressive symptoms, and catastrophic worry. In addition to direct risk, sleep disturbances posed a non-gender specific risk for depressive symptoms one-year later through catastrophic worry (perpetuation). Overall, the results provide support for the role of sleep disturbances in the predis-position, precipitation, and perpetuation of emotion dysregulation. An implication is that sleep disturbances and catastrophic worry are two po-tentially modifiable markers of risk for emotion dysregulation.
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| 3. |
- Alfonsson, Sven
(författare)
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Treatment Adherence in Internet-Based CBT : The Effects of Presentation, Support and Motivation
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Homework assignments that patient work with between sessions is a key component in both face-to-face and Internet-based Cognitive Behavior Therapy (CBT). However, adherence to assignments is often low and it is largely unclear what factors predict or affect treatment adherence, and in the end, treatment outcomes. The overall aim of this thesis was to investigate if treatment presentation and therapist support can affect adherence and treatment outcome in internet-based CBT, whether adherence can be predicted by motivation variables and to compare differences in face-to-face and online conditions in this regard.A randomized controlled trial with a brief online relaxation program for people with stress and anxiety symptoms was conducted (n = 162). Participants in the enhanced support conditions completed a larger proportion of the online treatment but adherence was not affected by enhanced treatment presentation (Study I). Participants reported reduced symptoms of stress and anxiety after the relaxation program but there were no significant additional effects of enhanced presentation or support (Study II). Participants who adhered to the prescribed assignments reported lower symptom levels at study end, regardless of treatment conditions. Adherence to the online treatment was predicted by subject factors such as treatment credibility prior to the treatment and intrinsic motivation during the treatment (Study III). To further elucidate how motivation may affect adherence, an experiment with a one-session psychotherapy model was subsequently conducted (n = 100). Participants who were randomized to the face-to-face condition reported higher motivation for the assignment and completed significantly more of the homework compared to participants in the online condition (Study IV). Self-reported intrinsic motivation could predict adherence in both conditions while new motivational variables were identified specifically for the online condition.The results from these studies confirm that adherence to assignments in Internet-based CBT is difficult to affect with treatment features but can be predicted early in treatment by subject factors such as treatment credibility and motivation. How such motivational variables can be affected to improve treatments is still unclear.
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