Guts over fear : internet therapy for abdominal pain in children

Background: Pediatric functional abdominal pain disorders (FAPDs) are prevalent and associated with painful symptoms, low quality of life, and functional impairments. The origin is likely multifactorial and includes psychological factors (e.g., anxiety and coping mechanisms), biological factors (e.g., visceral sensitivity and gut microbiota), and social factors (e.g., interaction with parents or teachers). There is limited support for dietary and pharmacological treatments in FAPDs, but support for the effectiveness of cognitive behavioral therapy (CBT) is growing. Aims: The overall aim of the thesis was to develop and evaluate a therapist-supported exposure-based CBT for children 8-12 years with FAPDs, which could, if proven effective, increase accessibility of treatments for children with FAPDs. The specific aims were to: - Assess feasibility, acceptability, and potential effectiveness of the preliminary protocol of exposure-based CBT in a face-to-face setting (Study I). - Assess feasibility, acceptability, and potential effectiveness of the exposure-based CBT converted to an internet platform (Internet-CBT, Study II). - Evaluate effectiveness and cost effectiveness of the Internet-CBT compared with treatment as usual (Study III). - Investigate if gastrointestinal-specific anxiety and avoidance behaviors mediated a change in gastrointestinal symptoms in Internet-CBT compared with treatment as usual and if baseline values of the proposed mediators moderated the mediation (Study IV). Methods: All participants were children 8-12 years with FAPDs referred to the studies by their physicians. Treatment consisted of therapist-supported exposure-based CBT, delivered face-to-face (Study I) or online (studies II-IV) along with parental sessions or modules. All measures were self-assessed by children and parents. Primary outcome was pain intensity (Study I) and gastrointestinal symptoms (Study II-IV). Secondary outcomes included quality of life, school absence, anxiety, and parental responses to their children´s symptoms (Studies I-III), cost effectiveness and parental catastrophizing (Study III), gastrointestinal-specific anxiety (Study II-IV), and avoidance behavior (Study I-IV). Statistical analyses used to test within- and between-group effects were t-tests (Study I) and multi-level linear mixed models (Study II and III). Differences in costs between groups were assessed with generalized linear models (Study III). Univariate and multivariate growth models were used to assess mediation and moderated mediation (Study IV). Results: Therapist-supported exposure-based CBT, delivered face-to-face or online, rendered high adherence and treatment completion (Study I-III). Participating children and parents were satisfied with the treatment and perceived it to be helpful in dealing with abdominal symptoms (Study I-III). There were significant treatment effects in gastrointestinal symptoms, quality of life, gastrointestinal-specific anxiety, avoidance behavior, anxiety, parental catastrophizing, and parental responses to their child’s symptoms for Internet-CBT when compared with treatment as usual (Study III). Internet-CBT was found to be cost effective and even cost saving compared with treatment as usual (Study III). A reduction in gastrointestinal-specific anxiety and avoidance behavior mediated a reduction in gastrointestinal symptoms for children receiving Internet-CBT compared with children receiving treatment as usual (Study IV). Baseline values of gastrointestinal specific-anxiety and avoidance behavior moderated the mediation (Study IV). Conclusions: Internet-CBT based on exposure exercises and parental support for children with FAPDs is feasible, acceptable, clinically effective, and cost effective compared with treatment as usual. Gastrointestinal-specific anxiety and avoidance behavior are potential mechanisms of change in exposure-based Internet-CBT compared with treatment as usual. Internet-CBT seems to be particularly effective for children with high levels of gastrointestinal-specific anxiety and avoidance behaviors. The treatment has the potential to increase the availability of evidence-based treatments a large group of children with FAP

Internet-delivered cognitive behavior therapy for adolescents with irritable bowel syndrome : a randomized controlled trial

OBJECTIVES: Few treatments have been able to effectively manage pediatric irritable bowel syndrome (IBS). Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure for abdominal symptoms is effective for adult IBS. The objective of this study was to evaluate the efficacy of Internet-CBT based on behavioral exposure for adolescents with IBS. METHODS: Adolescents with IBS fulfilling the Rome III criteria were randomized to either Internet-CBT or a wait-list control. The Internet-CBT was a 10-week intervention where the main component was exposure to IBS symptoms by reduction of avoidance of abdominal symptoms and instead stepwise provocation of symptoms. The primary outcome was total score on Gastrointestinal Symptoms Rating Scale for IBS (GSRS-IBS). Secondary outcomes included adolescent- and parent-rated quality of life and parent-rated gastrointestinal symptoms. Difference between groups was assessed from pretreatment to posttreatment and the Internet-CBT group was also evaluated at 6 months after treatment completion. RESULTS: A total of 101 adolescents with IBS (13-17 years of age) were included in this study. Dropout rates were low (6%) and all randomized patients were included in intent-to-treat analyses based on mixed effects models. Analyses showed a significant larger pretreatment to posttreatment change on the primary outcome GSRS-IBS (B=-6.42, P=0.006, effect size Cohen's d=0.45, 95% confidence interval (0.12, 0.77)) and on almost all secondary outcomes for the Internet-CBT group compared with the control group. After 6 months, the results were stable or significantly improved. CONCLUSIONS: Internet-CBT based on exposure exercises for adolescents with IBS can effectively improve gastrointestinal symptoms and quality of life.Jane and Dan Olsson foundation, 4-1559/2013Kempe-Carlgrenska foundationRuth and Richard Julin foundation, 2012Juli0048Ishizu Matsumurais DonationMajblomman foundationBengt Ihre research fellowshipBengt Ihre foundation, SLS-331861The Samariten foundationThe Swedish society of medicine, SLS-331681, SLS-410501VärkstadststiftelsenGadelius foundationSwedish Research Council, 521-2013-2846Regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, 20130129Accepte

Development and cross‑national investigation of a model explaining participation in WHO‑recommended and placebo behaviours to prevent COVID‑19 infection

To protect themselves from COVID-19, people follow the recommendations of the authorities, but they also resort to placebos. To stop the virus, it is important to understand the factors underlying both types of preventive behaviour. This study examined whether our model (developed based on the Health Belief Model and the Transactional Model of Stress) can explain participation in WHO-recommended and placebo actions during the pandemic. Model was tested on a sample of 3346 participants from Italy, Japan, Poland, Korea, Sweden, and the US. It was broadly supported: objective risk and cues to action showed both direct and indirect (through perceived threat) associations with preventive behaviours. Moreover, locus of control, decision balance, health anxiety and preventive coping moderated these relationships. Numerous differences were also found between countries. We conclude that beliefs about control over health and perceived benefits of actions are critical to the development of interventions to improve adherence to recommendations

Upplevelser av hjälpande och försvårande faktorer i KBT gruppbehandling för insomni.

Sömnstörningar är vanliga bland människor och kan påverka både livskvalitet och hälsa. Insomni är en sömnstörning med nattliga uppvaknanden, svårigheter att somna in och trötthet under dagen. Sömnmottagningen och Stressmottagningen tar emot människor som lider av insomni och behandlar dem med KBT för insomni i grupp. Syftet med föreliggande uppsats var att undersöka och beskriva åtta gruppdeltagares upplevelser av hjälpande respektive försvårande faktorer i behandlingen. Deltagarna intervjuades om sina upplevelser. Terapeuternas beteende, psykoedukation, avdramatisering av sömnen och sömnstörningen samt registreringar i sömndagboken är några av de faktorer som har upplevts som hjälpande. Att grupperna upplevts som för stora, heterogena samt att det varit tidsbrist under sessionerna är faktorer som har upplevts som försvårande

Breaking the vicious circle of fear and avoidance in children with abdominal pain: A mediation analysis

Objectives: Exposure-based cognitive behavioral therapy via internet (Internet-CBT) has been shown to reduce symptoms and increase quality of life for children with functional abdominal pain disorders (FAPDs), but the mechanisms of change are unknown. The objective was to examine whether a change in symptom-specific fear and avoidance, i.e., gastrointestinal-specific anxiety (GI-anxiety) and gastrointestinal-specific avoidance (GI avoidance), mediated changes in parent-reported abdominal symptoms for children receiving Internet-CBT compared with children receiving treatment as usual. A further aim was to assess if baseline levels of the proposed mediators moderated the mediation. Methods: Weekly assessments of child-reported mediators and parent-reported outcome from 90 children aged 8-12 who were included in a randomized controlled trial were used in univariate and multivariate growth models to test the direct effect of treatment on outcome and the indirect effects via mediators and moderated mediation. Results: Treatment condition significantly predicted the slope of the mediators (a-path), in favor of Internet-CBT, and mediators were correlated with the outcome (b-path). The indirect effects of the mediators on the outcome (cross-product of the a and b-paths) were significantly different from zero for both GI-avoidance, ab = 1.43, 95% CI [0.42, 3.23]; and GI-anxiety ab = 1.58, 95%CI [0.43, 3.62]. Baseline levels of the proposed mediators moderated the size of the mediation. Conclusions: GI-anxiety and GI-avoidance were mediators of change in Internet-CBT and high levels of the mediators at baseline were associated with larger mediated effects. Healthcare professionals should be aware of, and inform families about, the potential benefits of reducing symptom-specific fear and avoidance.Funding Agencies|Jane and Dan Olsson Foundation [4-1559/2013]; Swedish Research CouncilSwedish Research Council [521-2013-2846]; Kempe-Carlgrenska Foundation; Ruth and Richard Julin Foundation [2012Juli0048]; Majblomman Foundation; Ishizu Matsumurais Donation; Bengt Ihre Foundation [SLS-331861]; Bengt Ihre research fellowship in Gastroenterology; Swedish Society of Medicine [SLS331681, SLS-410501]; Swedish Research Council for Health, Working life, and WelfareSwedish Research CouncilSwedish Research Council for Health Working Life &amp; Welfare (Forte) [2014-4052]; Centre for Psychiatry Research; Stockholm County CouncilStockholm County Council [20130129, 20150414)]; Karolinska InstitutetKarolinska Institutet [20130129, 20150414]</p

Targeting excessive avoidance behavior to reduce anxiety related to asthma: A feasibility study of an exposure-based treatment delivered online

There is an established relationship between anxiety and asthma, which is associated with poor health outcomes. Most previous cognitive behavior therapies (CBT) have focused on comorbid panic disorder whereas anxiety related to asthma may rather be illness-specific. The feasibility of an online CBT targeting avoidance behavior in anxiety related to asthma was evaluated, using a pretest-posttest design. Thirty participants with self-reported anxiety related to asthma were offered an eight-week treatment with therapist support. Mean adherence was good (80% of content), and most participants (89%) reported adequate relief after treatment. Catastrophizing about asthma (CAS), assessed at 2 months after treatment, improved significantly with a large effect size (Cohen's d = 1.52). All secondary outcomes, including asthma control, avoidance behavior, fear of asthma symptoms and quality of life, improved significantly with moderate to large effect sizes (d: 0.40–1.44). All improvements were stable at 4 months follow up. Weekly ratings showed that a decrease in avoidance behavior predicted a decrease in CAS the following week throughout the treatment period. We conclude that CBT targeting avoidance behavior is a feasible treatment for anxiety related to asthma. The results justify investigation of efficacy and mechanisms of change in a randomized controlled trial.ClinicalTrials.gov, ID: NCT03486756