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Clinical aspects of childbirth-related anxiety
Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Norrköping.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses a risk for a negative delivery experience. This thesis focuses on the mental and health-economic effects of severe FOC, and explores new treatment options for childbirth-related anxiety.

Aims: (i) to investigate the prevalence of and variables associated with severe FOC, (ii) to estimate the cost of illness of severe FOC and (iii) to explore whether Internetbased cognitive behaviour therapy (ICBT) is feasible for treating pregnant women with severe FOC and those with childbirth-related symptoms of posttraumatic stress disorder (PTSD).

Design and Results: Study 1: In a cross-sectional study 1635 pregnant women were asked about their FOC via the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), and provided socio-demographic data and information of their preferred mode of delivery. It was found that 15.6% of the participants had a severe FOC, which also strongly correlated with the preference of a caesarean section. Study 2: In a prospective case-control cohort study we mapped all visits, in-patient care, sick leave and delivery variables from medical records and estimated the societal costs in two groups of women; one group with severe FOC and one with low FOC. The costs for the group with severe FOC were 38% higher than for the low FOC group. Study 3: Twenty-eight nulliparous women with severe FOC were self-recruited to an eight weeks ICBT program for severe FOC. Fifteen women followed the entire program. Their FOC decreased significantly after treatment (Cohen’s d=0.95, p<0.0001), which means that ICBT is feasible and an option for treating women with severe FOC. Study 4: Fifteen participants in Study 3 wrote narratives of the imminent delivery before as well as after therapy. After treatment, the women had a more realistic attitude towards childbirth, more self-confidence and more active coping strategies. Partners and staff were perceived as more helpful, and the women were more aware of the child they were bearing. Study 5: Fifty-six women with a traumatic delivery experience were included in a randomized wait-list controlled study (RCT) of the effects of an eight week long ICBT program for childbirth-related PTSD symptoms. These symptoms decreased in both groups during active therapy, while the between-group effect size varied depending on measurements. Psychiatric comorbidity decreased in both groups after active treatment.

Conclusion: Severe FOC is prevalent among Swedish pregnant women, and the cost of illness of this marker of peripartum psychological vulnerability is considerable when treated using standard care. A new treatment option for this group with ICBT seems feasible and is associated with more realistic attitudes towards the imminent delivery. An RCT with eight weeks of ICBT for parous women with PTSD symptoms also had promising results.

As severe FOC is prevalent and associated with mental and economic burdens for the individual and the society, there is an urgent need to expand the research field. It is important to find feasible and effective treatments that can be applied on a large scale.

Abstract [sv]

Denna avhandling

  • undersöker (i) hur vanligt det är att svenska gravida kvinnor lider av rädsla för förlossningen, och (ii) hur detta påverkar kvinnornas sjukvårdskonsumtion under denna period samt vilka kostnader detta innebär för samhället;
  • testar och utvärderar (iii) nya behandlingsmetoder för rädsla för förlossningen och för posttraumatiska stressymptom efter en traumatisk förlossning.

Avhandlingen består av fem delstudier:

Studie 1 var en studie bland 1635 gravida kvinnor och visade att mer än var tionde gravid kvinna har svår förlossningsrädsla. Denna hade samband med kvinnornas önskemål om planerat snitt som förlossningssätt, och hos omföderskor, med tidigare negativa upplevelser av förlossningen.

Studie 2 jämförde sjukvårdskonsumtion och sjukskrivning under graviditet och den första tiden efter förlossningen hos förstföderskor med svår respektive lindrig förlossningsrädsla, vilka omhändertagits i den ordinarie förlossningsvården. Gruppen med svår förlossningsrädsla visade sig ha avsevärt högre kostnader orsakade av att de i genomsnitt hade högre sjukskrivningstal under graviditet och fler besök på grund av psykiska besvär, samt oftare förlöstes med kejsarsnitt och hade komplicerade förlossningar.

I Studie 3 testade 28 förstföderskor med svår förlossningsrädsla en ny behandlingsmetod med kognitiv beteendeterapi (KBT) via internet. Behandlingen medförde att kvinnornas rädsla kraftigt minskade från företill efter behandling.

I Studie 4 skickade 15 av kvinnorna i Studie 3 in berättelser via nätet om hur de föreställde sig att deras förlossning skulle bli, såväl innan terapin startade som när den var avslutad. Efter genomförd terapi hade kvinnorna en mer realistisk attityd till förlossningen än före terapin och visade tecken på att ha ett bättre självförtroende och mer aktiva strategier att hantera den kommande förlossningen.

Studie 5 utforskade om kvinnor, som upplevt en traumatisk förlossning, kan bli hjälpta av behandling med KBT via internet. Traumatiserade kvinnor slumpades till att antingen få behandling direkt eller få behandlingen efter en väntetid (kontrollgruppen). I båda grupperna minskade kvinnornas posttraumatiska stressymtom, liksom förekomsten av depression och andra ångestproblem.

Sammanfattning: Avhandlingen visar att svår förlossningsrädsla är vanligt förekommande och medför lidande för kvinnor och ökade kostnader för samhället i samband med graviditet och förlossning, när detta problem hanteras i den vanliga vården. Två internetbaserade studier testar kognitiv beteendeterapi som behandling för svår förlossningsrädsla och för problem efter en traumatisk förlossning och visar att dessa behandlingsformer tycks fungera väl och i framtiden skulle kunna utgöra ett alternativ som medför att vård görs tillgänglig också för kvinnor som inte har tillgång till kvalificerade hjälpinsatser på andra sätt. Svår förlossningsrädsla och ångestproblem efter en traumatisk förlossning föreligger ofta tillsammans med annan psykisk sjuklighet varför diagnostik och behandling behöver utföras av personer med tillräcklig kompetens för dessa uppgifter. Otillräckligt behandlad/icke behandlad svår förlossningsrädsla ökar riskerna för att kvinnan upplever en kommande förlossning som traumatisk.

Avhandlingens slutsatser behöver undersökas i fler och större studier, och, avseende behandlingsstudierna, i undersökningar som har tillräckligt stora kontrollgrupper. Om sådana studier bekräftar dessa preliminära fynd, blir frågan om screening för svår förlossningsrädsla aktuell eftersom det då finns såväl bra screeninginstrument som behandling som skulle kunna göras tillgänglig för stora grupper. Kommer samhället i denna situation att ha råd att inte försöka förebygga individuellt lidande och stora merkostnader för kvinnor med svår förlossningsrädsla?

Abstract [fi]

Tämän tutkimuksen tavoitteena on

  • tutkia (i) kuinka yleinen synnytyspelko on ruotsalaisten raskaana olevien naisten keskuudessa ja (ii) kuinka se vaikuttaa heidän terveyden‐ ja sairaanhoitopalveluiden kulutukseen raskauden aikana ja sen jälkeen, sekä selvittää miten synnytyspelko vaikuttaa yhteiskunnan kustannuksiin;
  • kehittää, testata ja arvioida (iii) uusia hoitomuotoja synnytyspelon sekä synnytyksestä johtuvien psykologisen trau man (posttraumaattinen stressi, PTSD) hoitoon.'

Tämä väitöskirja koostuu viidestä osatyöstä:

1. Ensimmäinen osatyö tutki synnystyspelon yleisyyttä 1635 raskaana olevan naisen keskuudessa. Tutkimus osoitti että joka seitsemäs raskaana oleva nainen Ruotsissa kärsii vakavasta synnytyspelosta. Keisarinleikkaus toiveen takana on usein vakava synnystyspelko. Uudelleen synnyttäjillä synnytyspelkoon vaikuttaa myös aiempi traumaattinen synnytyskokemus.

2. Toisessa osatyössa verrattiin ensisynnyttäjien terveyden- ja sairaanhoitokustannuksia sekä sairaslomapäiviä raskauden aikana, synnyksen yhteydessä sekä sitä seuraavan kolmen ensimmäisen kuukauden aikana. Vertailuryhmät seurasivat tavallista äitiysneuvolaohjelmaa, ryhmistä toisella oli vakava ja toisella lievä synnytyspelko. Vakavasta synnytyspelosta kärsivien naisten terveyden ja sairaanhoitopalvelujen käyttö osoittautui huomattavasti korkeammaksi kuin vertailuryhmässä.

3. Kolmannessa osatyössa 28 vakavasta synnytyspelosta kärsivää ensisynnyttäjää, testasi uutta ratkaisukeskeiseen terapiaan (KBT) pohjautuvaa Internetin kautta ohjattua psykologista hoito-ohjelmaa. Hoito lievensi huomattavasti osallistujien synnytyspelkoa.

4. Neljännessä osatyössä 15 naista (edellisestä osatyöstä 3) kirjoittivat osana terapiaansa kertomuksen tulevan synnytyksensä odotuksista. Sama tehtävä kertautui ennen terapian alkua sekä sen jälkeen. Kertomusten yhtäläiset teemat tunnistettiin minkä jälkeen ennen ja jälkeen hoitoohjelmaa kirjoitettujen kertomusten teemoja vertailtiin. Hoidon jälkeen naisten odotukset pohjautuivat suuremmassa määrin tietoon, he kuvailivat itsensä varmemmiksi sekä paremmin  valmistautuneiksi tulevaa synnytystä ajatellen.

5. Viides osatyö tutki Internetin kautta ohjatun ratkaisukeskeisen terapian (KBT) vaikutusta naisiin jotka kärsivät synnytyksen jälkeisestä henkisestä traumasta. Naiset satunnaistettiin tutkimuksessa joko välittömän hoidon ryhmään tai odotuslista ryhmään, joka sai saman hoidon myöhemmin. Hoidon jälkeen PTSD oireet vähenivät sekä hoitoettä kontrolliryhmässä. Myös masentuneisuus ja ahdistusoireet väheniväthoidon myötä.

Yhteenvetona voidaan oheisista tutkimuksista todeta että synnytyspelko on yleinen ruotsalaisten raskaana olevien naisten keskuudessa. Synnytyspelko aiheuttaa kärsimystä sekä raskaana olevalle naiselle mutta myös lisäkustannuksia yhteiskunnalle. Kahdessa Internetin kautta ohjatussa ratkaisukeskeisessä hoito-ohjelmassa testattiin uusia hoitomuotoja raskaana oleville ensisynnyttäjille sekä synnytyksen jälkeisistä traumaoireista kärsiville naisille. Tulokset osoittavat, että Internetin kautta ohjattu hoito toimii näissä ryhmissä hyvin ja saattaisi tulevaisuudessa olla vaihtoehto kohderyhmille, joille sopivaa terapeuttista hoitoa nykytilanteessa ei voida tarjota. Koska vaikea synnytyspelko ja synnytystä seuraavat PTSD oireet esiintyvät usein muiden mielialahäiriöiden rinnalla, on tärkeää, että näitä naisia hoitavalla henkilökunnalla on tarpeellinen pätevyys hoitaa myös mielenterveysongelmia. Hoitamatta jätetty tai puutteelisesti hoidettu synnytyspelko lisää raskaana olevan naisen riskiä kokea synnytyksensä traumaattisena.

Tulevissa tutkimuksissa tämän tutkimusprojektin tulokset ja johtopäätökset on syytä toistaa useammissa ja ennen kaikkea suuremmissa ryhmissä. Jos tutkimustemme alustaville tuloksille löytyy tukea, nousee kysymys synnystyspelon seulonnasta äitiysneuvoloissa ajankohtaiseksi; sekä seulontamenetelmä että tehokas hoitotapa ovat olemassa ja voitaisiin tarjota suuremmille kohderyhmille. Onko yhteiskunnalla sellaisessa tilanteessa varaa olla ennaltaehkäisemättä synnystyspelkoisten naisten kärsimystä?

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016. , 106 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1513
Keyword [en]
Fear of childbirth, Childbirth-related PTSD, prevalence, societal costs, Internet-based Cognitive Behaviour Therapy
National Category
Obstetrics, Gynecology and Reproductive Medicine Clinical Medicine
Identifiers
URN: urn:nbn:se:liu:diva-126494DOI: 10.3384/diss.diva-126494ISBN: 978-91-7685-816-5 (print)OAI: oai:DiVA.org:liu-126494DiVA: diva2:915208
Public defence
2016-04-29, K4-salen, Kåkenhus, Campus Norrköping, Norrköping, 09:00 (Swedish)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and WelfareMedical Research Council of Southeast Sweden (FORSS)Region ÖstergötlandLinköpings universitet
Available from: 2016-03-29 Created: 2016-03-29 Last updated: 2017-06-26Bibliographically approved
List of papers
1. Women’s fear of childbirth and preference for cesarean section – a cross-sectional study at various stages of pregnancy in Sweden
Open this publication in new window or tab >>Women’s fear of childbirth and preference for cesarean section – a cross-sectional study at various stages of pregnancy in Sweden
2009 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 88, no 7, 807-813 p.Article in journal (Refereed) Published
Abstract [en]

Objective. To investigate Swedish women’s level of antenatal fear of childbirth at various gestational ages, and factors associated with intense fear and with preference for cesarean section.

Design. A cross-sectional study. Setting. All antenatal clinics in four geographical areas. Sample. Thousand six hundred and thirty-five pregnant women at various gestational ages recruited during September–October 2006.

Method. A questionnaire completed at the antenatal clinic. The women reported their appraisal of the approaching delivery according to the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ).

Main outcome measures. The level of fear of childbirth and preferred mode of delivery. Results. Mean W-DEQ score was 62.8. The prevalence of intense fear of childbirth (W-DEQ score ≥85) was 15.8% and very intense fear (tocophobia) (W-DEQ score ≥100) 5.7%. Nulliparous women had a higher mean score than parous women, but more parous women reported an intense fear. Preference for cesarean section was associated with fear of childbirth (OR 11.79, 6.1–22.59 for nulliparous and OR 8.32, 4.36–15.85 for parous women) and for parous women also with a previous cesarean section (OR 18.54, 9.55–35.97), or an instrumental vaginal delivery (OR 2.34, 1.02–5.34). The level of fear of childbirth was not associated with the gestational age.

Conclusions. When a woman requests a cesarean section, both primary fear of birth and traumatic childbirth experiences need to be considered and dealt with. The W-DEQ can be used at any time during pregnancy in order to identify pregnant women who suffer from intense fear of childbirth.

Place, publisher, year, edition, pages
John Wiley & Sons, 2009
Keyword
Fear of childbirth, tocophobia, cesarean section, W-DEQ
National Category
Obstetrics, Gynecology and Reproductive Medicine Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-126490 (URN)10.1080/00016340902998436 (DOI)19488882 (PubMedID)
Available from: 2016-03-29 Created: 2016-03-29 Last updated: 2017-11-30Bibliographically approved
2. Severe fear of childbirth indicates high perinatal costs for Swedish women giving birth to their first child.
Open this publication in new window or tab >>Severe fear of childbirth indicates high perinatal costs for Swedish women giving birth to their first child.
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2017 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 96, no 4, 438-446 p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: The objective of this study was to calculate costs associated with severe fear of childbirth (FOC) during pregnancy and peripartum by comparing two groups of women expecting their first child and attending an ordinary antenatal program; one with low FOC and one with severe FOC.

MATERIAL AND METHODS: In a prospective case-control cohort study one group with low FOC [Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) sum score ≤60, n = 107] and one with severe FOC (W-DEQ ≥85, n = 43) were followed up till 3 months postpartum and included in the analysis. Medical records were assessed and medical parameters were mapped. Mean costs for healthcare consumption and sick leave during pregnancy were calculated and compared.

RESULTS: When means were compared between the groups, the group with severe FOC had more visits for psychosocial reasons (p = 0.001) and more hours on sick leave (p = 0.03) during pregnancy, and stayed longer at the maternity ward (p = 0.04). They also more seldom had normal spontaneous deliveries (p = 0.03), and more often had an elective cesarean section on maternal request (p = 0.02). Postpartum, they more often than the group with low FOC paid visits to the maternity clinic because of complications (p = 0.001) and to the antenatal unit because of adverse childbirth experiences (p = 0.001). The costs for handling women with severe FOC was 38% higher than those for women with low FOC.

CONCLUSION: Women with severe FOC generate considerably higher perinatal costs than women with low FOC when handled in care as usual.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keyword
Costs, W-DEQ, severe fear of childbirth
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-136484 (URN)10.1111/aogs.13091 (DOI)000397384800007 ()28052318 (PubMedID)
Note

Funding agencies: Swedish Research Council for Health, Working Life and Welfare (FORTE); Medical Research Council of Southeast Sweden (FORSS); Regional Council in Ostergotland (RO); Linkoping University (LIU)

Available from: 2017-04-14 Created: 2017-04-14 Last updated: 2017-06-26
3. Treatment of nulliparous women with severe fear of childbirth via the Internet: a feasibility study
Open this publication in new window or tab >>Treatment of nulliparous women with severe fear of childbirth via the Internet: a feasibility study
Show others...
2016 (English)In: Journal of Psychosomatic Obstetrics and Gynaecology, ISSN 0167-482X, E-ISSN 1743-8942, Vol. 37, no 2, 37-43 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of the present study was to test the feasibility of Internet interventions among nulliparous women suffering from severe fear of childbirth (FOC) by means of an Internet-delivered therapist-supported self-help program based on cognitive behavioral therapy (ICBT).

Design: Prospective, longitudinal cohort study.Setting: A feasibility study of an ICBT program for the treatment of severe FOC in pregnant women.Sample: Twenty-eight Swedish-speaking nulliparous women with severe FOC recruited via a project home page from January 2012 to December 2013.

Methods: The main components of the ICBT program for the treatment of severe FOC comprised psycho-education, breathing retraining, cognitive restructuring, imaginary exposure, in vivo exposure and relapse prevention. The study participants were anonymously self-recruited over the Internet, interviewed by telephone and then enrolled. All participants were offered 8 weeks of treatment via the Internet. Participants reported their homework weekly, submitted measurements of their fear and received feedback from a therapist via a secure online contact management system.

Main outcome measures: Level of FOC measured with the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A) during screening at enrollment and weekly during the treatment (W-DEQ version A), and after the delivery (W-DEQ version B).

Results: A statistically significant (p < 0.0005) decrease of FOC [W-DEQ sum score decreased pre to post-therapy, with a large effect size (Cohen’s d = 0.95)].Conclusions: The results of this feasibility study suggest that ICBT has potential in the treatment of severe FOC during pregnancy in motivated nulliparous women. The results need to be confirmed by randomized controlled studies.

Place, publisher, year, edition, pages
Taylor & Francis, 2016
National Category
Clinical Medicine Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-126491 (URN)10.3109/0167482X.2016.1140143 (DOI)000372410100001 ()26918752 (PubMedID)
Note

Funding agencies: Swedish Research Council for Health, Working Life and Welfare (FORTE); Medical Research Council of Southeast Sweden (FORSS); County Council in Ostergotland (LIO)

Available from: 2016-03-29 Created: 2016-03-29 Last updated: 2017-11-30Bibliographically approved
4. Nulliparous pregnant womens narratives of imminent childbirth before and after internet-based cognitive behavioural therapy for severe fear of childbirth: a qualitative study
Open this publication in new window or tab >>Nulliparous pregnant womens narratives of imminent childbirth before and after internet-based cognitive behavioural therapy for severe fear of childbirth: a qualitative study
Show others...
2015 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 122, no 9, 1259-1265 p.Article in journal (Refereed) Published
Abstract [en]

ObjectiveTo describe the expectations concerning imminent childbirth before and after 8weeks of internet-based cognitive behavioural therapy (ICBT) among nulliparous pregnant women with severe fear of childbirth. DesignQualitative study of nulliparous pregnant womens narratives before and after CBT. SettingThe first ICBT programme for treating severe fear of childbirth. SampleFifteen nulliparous pregnant Swedish women with severe fear of childbirth participating in an ICBT self-help programme. MethodsSemi-structured open-ended questions over the internet before and after 8weeks of ICBT. The data were analysed using thematic analysis. Main outcome measuresThe participants narratives pertaining to five different situations during labour and delivery before and after ICBT. ResultsAfter therapy, participants described a more realistic attitude towards imminent childbirth, more self-confidence and more active coping strategies. They perceived their partners and the staff as more supportive. They were more aware of the approaching meeting with their baby when giving birth. ConclusionsFollowing the ICBT programme, participants changed their attitude towards imminent childbirth from negative to more positive. This was manifested in positive and more realistic expectations regarding themselves, their partner and the staff that would look after them.

Place, publisher, year, edition, pages
Wiley: 12 months, 2015
Keyword
Active coping; appraisal; delivery; fear of childbirth; internet cognitive behavioural therapy; self-confidence
National Category
Clinical Medicine Basic Medicine
Identifiers
urn:nbn:se:liu:diva-120728 (URN)10.1111/1471-0528.13358 (DOI)000358619900020 ()25817045 (PubMedID)
Note

Funding Agencies|Swedish Research Council for Health, Working Life and Welfare (FORTE); Medical Research Council of Southeast Sweden (FORSS); County Council in Ostergotland (LIO)

Available from: 2015-08-24 Created: 2015-08-24 Last updated: 2017-12-04
5. Internet-provided cognitive behaviour therapy of posttraumatic stress symptoms following childbirth—a randomized controlled trial
Open this publication in new window or tab >>Internet-provided cognitive behaviour therapy of posttraumatic stress symptoms following childbirth—a randomized controlled trial
Show others...
2016 (English)In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 45, no 4, 287-306 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to analyse the effects of trauma-focused guided Internet-based cognitive behaviour therapy for relieving posttraumatic stress disorder (PTSD) symptoms following childbirth, a problem that about 3% women encounter postpartum. Following inclusion, 56 traumatized women were randomized to either treatment or to a waiting list control group. Primary outcome measures were the Traumatic Event Scale (TES) and Impact of Event Scale—Reversed (IES-R). Secondary measures were Beck depression inventory II, Patient Health Questionnaire (PHQ-9), Beck Anxiety Inventory, Quality Of Life Inventory and the EuroQol 5 Dimensions. The treatment was guided by a clinician and lasted eight weeks and comprised eight modules of written text. The between-group effect size (ES) was d = .82 (p < .0001) for the IES-R. The ES for the TES was small (d = .36) and not statistically significant (p = .09). A small between-group ES (d = .20; p = .02) was found for the PHQ-9. The results from pre- to post-treatment showed large within-group ESs for PTSD symptoms in the treatment group both on the TES (d = 1.42) and the IES-R (d = 1.30), but smaller ESs in the control group from inclusion to after deferred treatment (TES, d = .80; IES-R d = .45). In both groups, the treatment had positive effects on comorbid depression and anxiety, and in the treatment group also on quality of life. The results need to be verified in larger trials. Further studies are also needed to examine long-term effects.

Place, publisher, year, edition, pages
Routledge, 2016
Keyword
Childbirth; Internet-based cognitive behaviour therapy (ICBT); posttraumatic stress disorder (PTSD); trauma-focused psychotherapy
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-127695 (URN)10.1080/16506073.2016.1169626 (DOI)000379764500003 ()27152849 (PubMedID)
Note

Funding agencies: Linkoping University (LiU) Department of Behavioral Sciences and Learning; Region Council in Ostergotland (RO)

Available from: 2016-05-09 Created: 2016-05-09 Last updated: 2017-11-30Bibliographically approved

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