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Introduction Cognitive behaviour therapy delivered in the format of guided self-help via the internet has been found to be effective for a range of conditions, including depression and anxiety disorders. Recent results indicate that guided self-help via the internet is a promising treatment format also for psychodynamic therapy. However, to date and to our knowledge, no study has evaluated internet-delivered psychodynamic therapy as a transdiagnostic treatment. The affect-phobia model of psychopathology by McCullough et al provides a psychodynamic conceptualisation of a range of psychiatric disorders. The aim of this study will be to test the effects of a transdiagnostic guided self-help treatment based on the affect-phobia model in a sample of clients with depression and anxiety. Methods and analysis This study will be a randomised controlled trial with a total sample size of 100 participants. The treatment group receives a 10-week, psychodynamic, guided self-help treatment based on the transdiagnostic affect-phobia model of psychopathology. The treatment consists of eight text-based treatment modules and includes therapist contact in a secure online environment. Participants in the control group receive similar online therapist support without any treatment modules. Outcome measures are the 9-item Patient Health Questionnaire Depression Scale and the 7-item Generalised Anxiety Disorder Scale (GAD-7). Process measures that concerns emotional processing and mindfulness are included. All outcome and process measures will be administered weekly via the internet and at 6-month follow-up. Discussion This trial will add to the body of knowledge on internet-delivered psychological treatments in general and to psychodynamic treatments in particular. We also hope to provide new insights in the effectiveness and working mechanisms of psychodynamic therapy based on the affect-phobia model
Cognitive behavior therapy in the treatment of irritable bowel syndrome
Background: Irritable bowel syndrome (IBS) is a disorder characterized by abdominal pain or discomfort combined with altered bowel habits and is associated with impaired quality of life. The prevalence of IBS in the general adult population is approximately 10%. Psychological factors have been implicated in IBS because of high rates of comorbidity with psychiatric diagnoses and the fact that stress can cause IBS symptoms. Several studies have been conducted on psychological treatment for IBS. Most of these have studied cognitive behavior therapy (CBT) but show inconsistent results. Although symptom-related fear and avoidance behaviors have been found to play an important role in IBS, no psychological treatment has targeted these factors primarily. The “third wave” of cognitive behavioral therapies promotes acceptance and behavioral flexibility in the presence of aversive experiences, such as IBS symptoms. Exposure treatment is a behavioral intervention aimed at decreasing fear of arbitrary stimuli. Given the high prevalence of IBS, there is need for delivery formats that allow more patients to gain access to treatment. Internet-delivered cognitive behavior therapy with online therapist support has shown effectiveness in treating both psychiatric disorders and disorders within the behavioral medicine field.
Aims: The general aim of the present thesis was to develop and evaluate an effective psychological treatment for IBS that can be made accessible to a large number of IBS patients. We developed an exposure-based CBT treatment that emphasized acceptance and behavioral flexibility in response to IBS-related experiences. Specific aims of this thesis were to: a) evaluate exposure-based CBT as a group treatment for IBS (study I), b) evaluate exposure-based CBT delivered via the internet (ICBT) for IBS (study II), c) evaluate the long-term effectiveness of ICBT for IBS (study III), d) evaluate the effectiveness and clinical utility of ICBT for IBS (study IV), and e) evaluate the specificity of ICBT for IBS (study V).
Methods: Study I included 34 referred female IBS patients who underwent exposure-based CBT in group format. Study II randomized 85 self-referred IBS patients to ICBT or waiting list. Study III was a long-term follow-up of study II, 75 of the original study’s 85 participants (88%) participated in the 15- to 18-month follow-up. Study IV randomized 62 consecutively recruited patients at a gastroenterological clinic to ICBT or waiting list. Study V randomized 195 self-referred IBS patients to ICBT or internet-delivered stress management. The stress-management condition was designed to control for effects of treatment credibility, expectancy of improvement, and attention from a caregiver. The treatment conditions in all studies lasted for 10 weeks.
Results: In all studies exposure-based CBT was associated with improvements in IBS symptoms, IBS-related fear, and quality of life. In studies II and IV, ICBT was more effective than a waiting list and in study V, ICBT was more effective than internet-delivered stress management. Study I also showed that exposure-based CBT leads to improvement in mental health.
Conclusions: Exposure-based CBT is effective both in group format and when delivered via internet. Both self-referred and clinical samples of IBS patients improve from the treatment. The effects of exposure-based CBT cannot be explained by non-specific factors such as treatment credibility, expectancy of improvement, and attention from a caregiver. ICBT is a promising new treatment modality that can be made accessible to a large number of IBS patients
Internet-Based Cognitive Behavior Therapy vs. Cognitive Behavioral Group Therapy for Social Anxiety Disorder: A Randomized Controlled Non-inferiority Trial
Background and Aims: Cognitive behavioral group therapy (CBGT) is an effective, well-established, but not widely available treatment for social anxiety disorder (SAD). Internet-based cognitive behavior therapy (ICBT) has the potential to increase availability and facilitate dissemination of therapeutic services for SAD. However, ICBT for SAD has not been directly compared with in-person treatments such as CBGT and few studies investigating ICBT have been conducted in clinical settings. Our aim was to investigate if ICBT is at least as effective as CBGT for SAD when treatments are delivered in a psychiatric setting. Methods: We conducted a randomized controlled non-inferiority trial with allocation to ICBT (n = 64) or CBGT (n = 62) with blinded assessment immediately following treatment and six months post-treatment. Participants were 126 individuals with SAD who received CBGT or ICBT for a duration of 15 weeks. The Liebowitz Social Anxiety Scale (LSAS) was the main outcome measure. The following non-inferiority margin was set: following treatment, the lower bound of the 95 % confidence interval (CI) of the mean difference between groups should be less than 10 LSAS-points. Results: Both groups made large improvements. At follow-up, 41 (64%) participants in the ICBT group were classified as responders (95% CI, 52%-76%). In the CBGT group, 28 participants (45%) responded to the treatment (95% CI, 33%-58%). At post-treatment and follow-up respectively, the 95 % CI of the LSAS mean difference was 0.68-17.66 (Cohens d between group = 0.41) and -22.51-15.69 (Cohens d between group = 0.36) favoring ICBT, which was well within the non-inferiority margin. Mixed effects models analyses showed no significant interaction effect for LSAS, indicating similar improvement across treatments (F = 1.58; df = 2, 219; p = .21). Conclusions: ICBT delivered in a psychiatric setting can be as effective as CBGT in the treatment of SAD and could be used to increase availability to CBT.Original Publication:Erik Hedman, Gerhard Andersson, Brjann Ljotsson, Erik Andersson, Christian Ruck, Ewa Mortberg and Nils Lindefors, Internet-Based Cognitive Behavior Therapy vs. Cognitive Behavioral Group Therapy for Social Anxiety Disorder: A Randomized Controlled Non-inferiority Trial, 2011, PLOS ONE, (6), 3, .http://dx.doi.org/10.1371/journal.pone.0018001Licensee: Public Library of Science (PLoS)http://www.plos.org
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
Foreword: The Vanishing Constitution
Increasing survival rates in childhood cancer have yielded a growing population of parents of childhood cancer survivors (CCSs). This systematic review compiles the literature on positive and negative long-term psychological late effects for parents of CCSs, reported at least five years after the child’s diagnosis and/or two years after the end of the child’s treatment. Systematic searches were made in the databases CINAHL, EMBASE, PsycINFO, and PubMed. Fifteen studies, published between 1988 and 2010, from 12 projects were included. Thirteen studies used quantitative methodology, one quantitative and qualitative methodology, and one qualitative methodology. A total of 1045 parents participated in the reviewed studies. Mean scores were within normal ranges for general psychological distress, coping, and family functioning. However, a substantial subgroup reported a clinical level of general psychological distress, and 21–44% reported a severe level of posttraumatic stress symptoms. Worry, disease-related thoughts and feelings, marital strains, as well as posttraumatic growth was reported. Several factors were associated with the long-term late effects, such as parents’ maladaptive coping during earlier stages of the childs disease trajectory and children’s current poor adjustment. Quality assessments of reviewed studies and clinical implications of findings are discussed and recommendations for future research are presented
Face-to-Face Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: The Effects on Gastrointestinal and Psychiatric Symptoms
Face-to-Face Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: The Effects on Gastrointestinal and Psychiatric Symptoms
Irritable bowel syndrome (IBS) is a gastrointestinal disorder linked to disturbances in the gut-brain axis. Visceral hypersensitivity and pain are hallmarks of IBS and linked to the physiological and psychological burden and to the nonadaptive coping with stress. Cognitive-behavioral therapy (CBT) for IBS has proven effective in reducing gastrointestinal and psychiatric symptoms in IBS by means of coping with stress. The present pilot study evaluated for the first time whether CBT for IBS affected visceral sensitivity and pain. Individual CBT was performed for 12 weeks in 18 subjects with IBS and evaluated in terms of visceral sensitivity and pain during rectal distensions using the barostat method and self-rated visceral sensitivity and gastrointestinal and psychiatric symptoms. Visceral discomfort, urge, and pain induced by the barostat were not affected by CBT but were stable across the study. However, the level of self-rated visceral sensitivity and gastrointestinal and psychiatric symptoms decreased after the intervention. Central working mechanisms and increased ability to cope with IBS-symptoms are suggested to play a key role in the alleviation of IBS symptoms produced by CBT. Background Irritable bowel syndrome (IBS) is a common multifactorial functional gastrointestinal disorder with a point prevalence of 11% in the adult western population Visceral sensitivity is a robust hallmark of IBS. Previous studies, selecting the visceral stimuli of a barostat as a stressful trigger to assess visceral hypersensitivity in IBS
The promise and pitfalls of the internet for cognitive behavioral therapy
Internet-administered cognitive behavior therapy is a promising new way to deliver psychological treatment. There are an increasing number of controlled trials in various fields such as anxiety disorders, mood disorders and health conditions such as headache and insomnia. Among the advantages for the field of cognitive behavior therapy is the dissemination of the treatment, being able to access treatment from a distance, and possibilities to tailor the interventions. To date, studies in which large effects have been obtained have included patient support from a clinician. Recent trials suggest that this support may come from non-clinicians and that therapist effects are minimal. Since studies also suggest that internet-delivered cognitive behavior therapy can be equally effective as face-to-face cognitive behavior therapy, this is a finding that may have implications for CBT practitioners. However, there are other aspects to consider for implementation, as while clinicians may hold positive attitudes towards internet-delivered CBT a recent study suggested that patients are more skeptical and may prefer face-to-face treatment. In the present work, I argue that internet-delivered CBT may help to increase adherence to treatment protocols, that training can be facilitated by means of internet support, and that research on internet interventions can lead to new insights regarding what happens in regular CBT. Moreover, I conclude that internet-delivered CBT works best when support is provided, leaving an important role for clinicians who can incorporate internet treatment in their services. However, I also warn against disseminating internet-delivered CBT to patients for whom it is not suitable, and that clinical skills may suffer if clinicians are trained and practice mainly using the internet
Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders : a single-centre, single-blind, randomised controlled trial
Background: Paediatric anxiety disorders are prevalent and associated with substantial disability and long-term adverse consequences. Only a minority of affected children have access to evidence-based treatment; internet-delivered cognitive behaviour therapy (ICBT) could help increase accessibility but needs further rigorous evaluation. The objective of this trial was to evaluate the clinical efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders.
Methods: In this single-blind randomised controlled trial, children 8-12 years with a principal anxiety disorder diagnosis were randomly allocated (1:1) to ICBT or internet-delivered child-directed play (ICDP), an active comparator aimed to improve parent-child relationships and increase child self-esteem without directly targeting anxiety. The study was conducted at a single site within the Stockholm specialist child and adolescent mental health services (CAMHS). Primary endpoint was clinician-rated symptom severity (CSR) of the principal anxiety disorder at post-treatment. All participants were included in the primary analysis (intent-to-treat). Trial registration number: NCT02350257.
Findings: Participants (N=131) were recruited between March 2015 and October 2016, mainly via advertisement and referrals from CAMHS, and allocated to ICBT (n=66) or ICDP (n=65). Analyses revealed greater reduction of symptom severity in favour of ICBT (mean difference 0·79, 95% CI 0·42 to 1·16, p=0·002; Cohen’s d=0·77, 95% CI 0·40 to 1·15) and at post-treatment, 48% (n=29) of participants randomised to ICBT no longer fulfilled their principal diagnosis, compared to 15% (n=9) in ICDP (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001). Numbers needed to treat were 3 (95% CI 2·85 to 3·15). Treatment gains were maintained at 3-month follow-up, at which point 70% (n=40) of participants randomised to ICBT no longer met the criteria for their principal anxiety disorder. ICBT resulted in an average societal cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported.
Interpretation: ICBT is a cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care.The Swedish Research Council for Health, Working Life and WelfareStockholm County CouncilAccepte
A mixed methods feasibility study to evaluate the use of a low-intensity, nurse-delivered cognitive behavioural therapy for the treatment of irritable bowel syndrome
Introduction: Irritable bowel syndrome (IBS) is characterised by symptoms such as abdominal pain, constipation, diarrhoea and bloating. These symptoms impact on health-related quality of life, result in excess service utilisation and are a significant burden to healthcare systems. Certain mechanisms which underpin IBS can be explained by a biopsychosocial model which is amenable to psychological treatment using techniques such as cognitive behavioural therapy (CBT). While current evidence supports CBT interventions for this group of patients, access to these treatments within the UK healthcare system remains problematic. Methods and analysis: A mixed methods feasibility randomised controlled trial will be used to assess the feasibility of a low-intensity, nurse-delivered guided self-help intervention within secondary care gastrointestinal clinics. A total of 60 participants will be allocated across four treatment conditions consisting of: high-intensity CBT delivered by a fully qualified cognitive behavioural therapist, low-intensity guided self-help delivered by a registered nurse, self-help only without therapist support and a treatment as usual control condition. Participants from each of the intervention arms of the study will be interviewed in order to identify potential barriers and facilitators to the implementation of CBT interventions within clinical practice settings. Quantitative data will be analysed using descriptive statistics only. Qualitative data will be analysed using a group thematic analysis.N/
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