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  • 1.
    Andersson, Erik
    et al.
    Karolinska Institute, Sweden.
    Ljotsson, Brjann
    Karolinska Institute, Sweden.
    Hedman, Erik
    Karolinska Institute, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Enander, Jesper
    Karolinska Institute, Sweden.
    Kaldo, Viktor
    Karolinska Institute, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Lindefors, Nils
    Karolinska Institute, Sweden.
    Ruck, Christian
    Karolinska Institute, Sweden.
    Testing the Mediating Effects of Obsessive Beliefs in Internet-Based Cognitive Behaviour Therapy for Obsessive-Compulsive Disorder: Results from a Randomized Controlled Trial2015In: Clinical Psychology and Psychotherapy, ISSN 1063-3995, E-ISSN 1099-0879, Vol. 22, no 6, p. 722-732Article in journal (Refereed)
    Abstract [en]

    Although cognitive interventions for obsessive-compulsive disorder (OCD) have been tested in randomized trials, there are few trials that have tested the specific mechanisms of cognitive interventions, i.e. how they achieve their effects. In this study, we aimed to investigate the mediating effects of a short cognitive intervention in the treatment of OCD and used data from a recently conducted randomized controlled trial where 101 participants were allocated to either Internet-based CBT (ICBT) or to a control condition. Obsessive beliefs were measured at pre-treatment, at the time they had received the cognitive intervention, and also at post-treatment. Weekly OCD symptoms were measured throughout the 10 weeks of treatment. We hypothesized that (1) the ICBT group would have greater reductions in obsessive beliefs (controlling for change in OCD symptoms) after completing the cognitive intervention, and that (2) this reduction would, in turn, predict greater OCD symptom reduction throughout the rest of the treatment period. Contrary to our expectations, the longitudinal mediation analysis indicated that (1) being randomized to ICBT actually increased the degree of obsessive beliefs after receiving the cognitive intervention at weeks 1-3, and (2) increase in obsessive beliefs predicted better outcome later in treatment. However, when repeating the analysis using cross-sectional data at post-treatment, the results were in line with the initial hypotheses. Results were replicated when the control condition received ICBT. We conclude that, although obsessive beliefs were significantly reduced at post-treatment for the ICBT group, early increase rather than decrease in obsessive beliefs predicted favourable outcome. Copyright (C) 2014 John Wiley & Sons, Ltd.

  • 2.
    Andersson, Gerhard
    et al.
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Gustafsson, Tore
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Lundén, Charlotte
    Landstinget Dalarna.
    Henriksson, Oskar
    Psykologifabriken AB.
    Fattahi, Kidjan
    Psykologpartners , Linköping.
    Zetterqvist Westin, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Educational Sciences.
    Carlbring, Per
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Internet-based Acceptance and Commitment Therapy for tinnitus patients2011Conference paper (Other academic)
  • 3.
    Andersson, Gerhard
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Cima, Rilana F F.
    Maastricht University, Netherlands .
    Weise, Cornelia
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Arts and Sciences. Linköping, Disability Research.
    Autobiographical Memory Specificity in Patients with Tinnitus Versus Patients with Depression and Normal Controls2013In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 42, no 2, p. 116-126Article in journal (Refereed)
    Abstract [en]

    Several studies show that patients with depression and post-traumatic stress disorder respond with fewer specific autobiographical memories in a cued memory task (i.e. the autobiographical memory test; AMT) compared to healthy controls. One previous study found this phenomenon among tinnitus patients as well (Andersson, Ingerholt, andamp; Jansson, 2003). The aim of this study was to replicate the previous study with an additional control group of depressed patients and memory errors as measured with the AMT as an additional outcome. We included 20 normal hearing tinnitus patients, 20 healthy controls and 20 persons diagnosed with clinical depression. The AMT was administered together with self-report measures of depression, anxiety and tinnitus distress. Both the tinnitus and depression groups differed from the healthy control group in that they reported fewer specific autobiographical memories. There were, however, differences between the tinnitus and depression groups in terms of the errors made on the AMT. The depression group had more overgeneral memories than the normal control group, whereas the tinnitus group did not differ from the control group on this memory error. The tinnitus group had more semantic associations and non-memories than the other two groups, suggesting that executive functioning may play a role for the tinnitus group when completing the AMT. Clinical and theoretical implications of the findings are discussed.

  • 4.
    Andersson, Gerhard
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hummerdal, Daniel
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Bergman Nordgren, Lise
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Faculty of Arts and Sciences. Department of Psychology , Umeå University, Umeå, Sweden.
    A 3.5-year follow-up of Internet-delivered cognitive behavior therapy for major depression2013In: Journal of Mental Health, ISSN 0963-8237, E-ISSN 1360-0567, Vol. 22, no 2, p. 155-164Article in journal (Refereed)
    Abstract [en]

    BackgroundInternet-delivered cognitive behavior therapy (ICBT) for major depression has been tested in several trials, but only with follow-ups up to 1.5 years.

    AimThe aim of this study was to evaluate the outcome of ICBT 3.5 years after treatment completion.Methods

    A total of 88 people with major depression were randomized to either guided self-help or e-mail therapy in the original trial. One-third was initially on a waiting-list. Treatment was provided for eight weeks and in this report long-term follow-up data were collected. Also included were data from post-treatment and six-month follow-up. A total of 58% (51/88) completed the 3.5-year follow-up. Analyses were performed using a random effects repeated measures piecewise growth model to estimate trajectory shape over time and account for missing data.

    ResultsResults showed continued lowered scores on the Beck Depression Inventory (BDI). No differences were found between the treatment conditions. A large proportion of participants (55%) had sought and received additional treatments in the follow-up period. A majority (56.9%) of participants had a BDI score lower than 10 at the 3.5-year follow-up.

    ConclusionsPeople with mild to moderate major depression may benefit from ICBT 3.5-years after treatment completion.

  • 5.
    Andersson, Gerhard
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Veilord, Andrea
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
    Svedling, Linn
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Sleman, Owe
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Mauritzson, Lena
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Sarkohi, Ali
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Claesson, Elisabet
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Zetterqvist, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Lamminen, Mailen
    Redakliniken, Linkoping, Sweden .
    Eriksson, Thomas
    Redakliniken, Linkoping, Sweden .
    Carlbring, Per
    Stockholm University, Sweden .
    Randomised controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression2013In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 151, no 3, p. 986-994Article in journal (Refereed)
    Abstract [en]

    Background: Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in the treatment of mild to moderate depression, but there have been no direct comparisons with the more established group-based CBT with a long-term follow-up. less thanbrgreater than less thanbrgreater thanMethod: Participants with mild to moderate depression were recruited from the general population and randomized to either guided ICBT (n =33) or to live group treatment (n=36). Measures were completed before and after the intervention to assess depression, anxiety, and quality of life. Follow-ups were conducted at one-year and three-year after the treatment had ended. Results: Data were analysed on an intention-to-treat basis using linear mixed-effects regression analysis. less thanbrgreater than less thanbrgreater thanResults on the self-rated version of the Montgomery-Asberg Depression Scale showed significant improvements in both groups across time indicating non-inferiority of guided ICBT, and there was even a tendency for the guided ICBT group to be superior to group-based CBT at three year follow-up. Within-group effect sizes for the ICBT condition at post treatment showed a Cohens d=1.46, with a similar large effect at 3-year follow-up, d=1.78. For the group CBT the corresponding within group effects were d =0.99 and d=1.34, respectively. less thanbrgreater than less thanbrgreater thanLimitations: The study was small with two active treatments and there was no placebo or credible control condition. less thanbrgreater than less thanbrgreater thanConclusions: Guided ICBT is at least as effective as group based CBT and long-term effects can be sustained up to 3 years after treatment.

  • 6.
    Andersson, Gerhard
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Sarkohi, Ali
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Karlsson, Johan
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Faculty of Arts and Sciences.
    Bjärehed, Jonas
    Department of Psychology, Lund University, Lund, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Effects of Two Forms of Internet-Delivered Cognitive Behaviour Therapy for Depression on Future Thinking2013In: Cognitive Therapy and Research, ISSN 0147-5916, E-ISSN 1573-2819, Vol. 37, no 1, p. 29-34Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to investigate if future thinking would change following two forms of Internet-delivered cognitive behavior therapy (ICBT) for major depression. A second aim was to study the association between pre-post changes in future thinking and prepost changes in depressive symptoms.

    Background: Effects of psychological treatments are most often tested with self-report inventories and seldom with tests of cognitive function.

    Method: We included data from 47 persons diagnosed with major depression who received either e-mail therapy or guided self-help during 8 weeks. Participants completed the future thinking task (FTT), in which they were asked to generate positive and negative events that they thought were going to happen in the future and rated the events in terms of emotion and likelihood. The FTT was completed before and after treatment. Data on depressive symptoms were also collected.

    Results: FTT index scores for negative events were reduced after  treatment. There was no increase for the positive events. Change scores for the FTT negative events and depression symptoms were significantly correlated.

    Conclusions: We conclude that ICBT may lead to decreased negative future thinking and that changes in depression symptoms correlate to some extent with reductions in negative future thinking.

  • 7.
    Bendelin, Nina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Internet treatment of chronic pain: Results and predictors of two RCT’s2009Conference paper (Other academic)
  • 8.
    Bendelin, Nina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Gerdle, Björn
    The role of acceptance in increased functioning in chronic pain: When, how and why does change occur?2010Conference paper (Refereed)
  • 9.
    Bendelin, Nina
    et al.
    Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Dahl, Johan
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Umea University.
    Zetterqvist Nelson, Karin
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Experiences of guided Internet-based cognitive-behavioural treatment for depression: A qualitative study2011In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 11, no 107Article in journal (Refereed)
    Abstract [en]

    ackground: Internet-based self-help treatment with minimal therapist contact has been shown to have an effect in treating various conditions. The objective of this study was to explore participants views of Internet administrated guided self-help treatment for depression. less thanbrgreater than less thanbrgreater thanMethods: In-depth interviews were conducted with 12 strategically selected participants and qualitative methods with components of both thematic analysis and grounded theory were used in the analyses. less thanbrgreater than less thanbrgreater thanResults: Three distinct change processes relating to how participants worked with the treatment material emerged which were categorized as (a) Readers, (b) Strivers, and (c) Doers. These processes dealt with attitudes towards treatment, views on motivational aspects of the treatment, and perceptions of consequences of the treatment. less thanbrgreater than less thanbrgreater thanConclusions: We conclude that the findings correspond with existing theoretical models of face-to-face psychotherapy within qualitative process research. Persons who take responsibility for the treatment and also attribute success to themselves appear to benefit more. Motivation is a crucial aspect of guided self-help in the treatment of depression.

  • 10.
    Bendelin, Nina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Öberg, Jörgen
    Linköping University, Department of Behavioural Sciences and Learning, Education, Teaching and Learning. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Gerdle, Björn
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Centre, Pain and Rehabilitation Centre.
    Internet-delivered intervention for relapse prevention after pain management program2009Conference paper (Other academic)
  • 11.
    Blom, Kerstin
    et al.
    Karolinska Institute, Sweden.
    Tarkian Tillgren, Hanna
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Wiklund, Tobias
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Danlycke, Ewa
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Forssen, Mattias
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Söderström, Alexandra
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Johansson, Robert
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Jernelov, Susanna
    Karolinska Institute, Sweden.
    Lindefors, Nils
    Karolinska Institute, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Kaldo, Viktor
    Karolinska Institute, Sweden.
    Internet-vs. group-delivered cognitive behavior therapy for insomnia: A randomized controlled non-inferiority trial2015In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 70, p. 47-55Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to compare guided Internet-delivered to group-delivered cognitive behavioral therapy (CBT) for insomnia. We conducted an 8-week randomized controlled non-inferiority trial with 6-months follow-up. Participants were forty-eight adults with insomnia, recruited via media. Interventions were guided Internet-delivered CBT (ICBT) and group-delivered CBT (GCBT) for insomnia. Primary outcome measure was the Insomnia Severity Index (ISI), secondary outcome measures were sleep diary data, depressive symptoms, response- and remission rates. Both treatment groups showed significant improvements and large effect sizes for ISI (Within Cohens d: ICBT post = 1.8, 6-months follow-up = 2.1; GCBT post = 2.1, 6-months follow-up = 2.2). Confidence interval of the difference between groups posttreatment and at FU6 indicated non-inferiority of ICBT compared to GCBT. At post-treatment, two thirds of patients in both groups were considered responders (ISI-reduction greater than 7p). Using diagnostic criteria, 63% (ICBT) and 75% (GCBT) were in remission. Sleep diary data showed moderate to large effect sizes. We conclude that both guided Internet-CBT and group-CBT in this study were efficacious with regard to insomnia severity, sleep parameters and depressive symptoms. The results are in line with previous research, and strengthen the evidence for guided Internet-CBT for insomnia. Trial registration: The study protocol was approved by, and registered with, the regional ethics review board in Linkoping, Sweden, registration number 2010/385-31.

  • 12.
    Boersma, Katja
    et al.
    Orebro Univ, Sweden.
    Södermark, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Otorhinolaryngology.
    Flink, Ida K.
    Orebro Univ, Sweden.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Linton, Steven J.
    Orebro Univ, Sweden.
    Efficacy of a transdiagnostic emotion-focused exposure treatment for chronic pain patients with comorbid anxiety and depression: a randomized controlled trial2019In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 160, no 8, p. 1708-1718Article in journal (Refereed)
    Abstract [en]

    The comorbidity between chronic pain and emotional problems has proven difficult to address with current treatment options. This study addresses the efficacy of a transdiagnostic emotion-focused exposure treatment ("hybrid") for chronic pain patients with comorbid emotional problems. Adults (n = 115) with chronic musculoskeletal pain and functional and emotional problems were included in a 2-centre, parallel randomized controlled, open-label trial comparing this treatment to an active control condition receiving a guided Internet-delivered pain management treatment based on CBT principles (iCBT). The hybrid treatment (n = 58, 10-16 sessions) integrates exposure in vivo for chronic pain based on the fear-avoidance model with an emotion-regulation approach informed by procedures in Dialectical Behavior Therapy. The iCBT (n = 57; 8 treatment modules) addresses topics such as pain education, coping strategies, relaxation, problem solving, stress, and sleep management using standard CBT techniques. Patient-reported outcomes were assessed before and after treatment as well as at a 9-month primary end point. Across conditions, 78% participants completed post-treatment and 81% follow-up assessment. Intent-to-treat analyses showed that the hybrid had a significantly better post-treatment outcome on pain catastrophizing (d = 0.39) and pain interference (d = 0.63) and significantly better follow-up outcomes on depression (d = 0.43) and pain interference (d = 0.51). There were no differences on anxiety and pain intensity. Observed proportions of clinically significant improvement favoured the hybrid on all but one comparison, but no statistically significant differences were observed. We conclude that the hybrid emotion-focused treatment may be considered an acceptable, credible, and efficacious treatment option for chronic pain patients with comorbid emotional problems.

  • 13.
    Brinkborg, Hillevi
    et al.
    Stockholm University.
    Michanek, Josefin
    Stockholm University.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Berglund, Gunilla
    Stockholm University.
    Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial2011In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 49, no 07-jun, p. 389-398Article in journal (Refereed)
    Abstract [en]

    Chronic stress increases the risk of health problems and absenteeism, with negative consequences for individuals, organizations and society. The aim of the present study was to examine the effect of a brief stress management intervention based on the principles of Acceptance and Commitment Therapy (ACT) on stress and general mental health for Swedish social workers (n = 106) in a randomized, controlled trial. Participants were stratified according to stress level at baseline in order to examine whether initial stress level moderated the effect of the intervention. Two thirds of the participants had high stress levels at baseline (Perceived Stress Scale; score of greater than= 25). The results showed that the intervention significantly decreased levels of stress and burnout, and increased general mental health compared to a waiting list control. No statistically significant effects were, however, found for those with low levels of stress at baseline. Among participants with high stress, a substantial proportion (42%) reached criteria for clinically significant change. We concluded that the intervention successfully decreased stress and symptoms of burnout, and increased general mental health. Evidence is, thus, provided supporting ACT as brief, stress management intervention for social workers.

  • 14.
    Dirkse, Dale
    et al.
    University of Regina, Canada.
    Hadjistavropoulos, Heather D.
    University of Regina, Canada.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Barak, Azy
    University of Haifa, Israel.
    Linguistic Analysis of Communication in Therapist-Assisted Internet-Delivered Cognitive Behavior Therapy for Generalized Anxiety Disorder2015In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 44, no 1, p. 21-32Article in journal (Refereed)
    Abstract [en]

    Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) involves elements of expressive writing through secure messaging with a therapist. Expressive writing has been associated with psychological and physical health benefits in past research; furthermore, certain linguistic dimensions in expressive writing have been identified as particularly beneficial to health, such as less frequent use of negative emotion words and greater use of positive emotion words. No research, to date, has analyzed linguistic dimensions in client communication over the course of therapist-assisted ICBT for individuals with symptoms of generalized anxiety. This naturalistic study examined messages sent to therapists during the course of ICBT using linguistic analysis, and explored covariation of word use with symptom improvement. Data were obtained from patients with symptoms of generalized anxiety (N=59) who completed 12 modules of therapist-assisted ICBT and rated symptoms of anxiety, depression, and panic at the beginning of each module. Linguistic analysis categorized text submitted to therapists into different word categories. Results found that patients use of negative emotion, anxiety, causation, and insight words reduced over the course of treatment, while past tense words increased. Furthermore, negative emotion words significantly covaried with symptom ratings over the course of treatment. While causal statements cannot be made, findings improve our understanding of patient communication in ICBT and suggest that the further study of linguistic dimensions as psychological indicators and the potential utility of expressive writing strategies in therapist-assisted ICBT may be worthwhile.

  • 15.
    El Alaoui, Samir
    et al.
    Karolinska Institute, Sweden.
    Hedman, Erik
    Karolinska Institute, Sweden; Karolinska Institute, Sweden.
    Kaldo, Viktor
    Karolinska Institute, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Kraepelien, Martin
    Karolinska Institute, Sweden.
    Andersson, Evelyn
    Karolinska Institute, Sweden.
    Ruck, Christian
    Karolinska Institute, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Ljotsson, Brjann
    Karolinska Institute, Sweden.
    Lindefors, Nils
    Karolinska Institute, Sweden.
    Effectiveness of Internet-Based Cognitive-Behavior Therapy for Social Anxiety Disorder in Clinical Psychiatry2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 5, p. 902-914Article in journal (Refereed)
    Abstract [en]

    Objective: Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinics years of experience in delivering ICBT. Method: A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale-Self-Rated. Results: Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinics years of experience with ICBT and treatment outcome was also observed. Conclusions: This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.

  • 16.
    Forsstrom, David
    et al.
    Stockholm University, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Stockholm University, Sweden.
    Usage of a Responsible Gambling Tool: A Descriptive Analysis and Latent Class Analysis of User Behavior2016In: Journal of Gambling Studies, ISSN 1050-5350, E-ISSN 1573-3602, Vol. 32, no 3, p. 889-904Article in journal (Refereed)
    Abstract [en]

    Gambling is a common pastime around the world. Most gamblers can engage in gambling activities without negative consequences, but some run the risk of developing an excessive gambling pattern. Excessive gambling has severe negative economic and psychological consequences, which makes the development of responsible gambling strategies vital to protecting individuals from these risks. One such strategy is responsible gambling (RG) tools. These tools track an individuals gambling history and supplies personalized feedback and might be one way to decrease excessive gambling behavior. However, research is lacking in this area and little is known about the usage of these tools. The aim of this article is to describe user behavior and to investigate if there are different subclasses of users by conducting a latent class analysis. The user behaviour of 9528 online gamblers who voluntarily used a RG tool was analysed. Number of visits to the site, self-tests made, and advice used were the observed variables included in the latent class analysis. Descriptive statistics show that overall the functions of the tool had a high initial usage and a low repeated usage. Latent class analysis yielded five distinct classes of users: self-testers, multi-function users, advice users, site visitors, and non-users. Multinomial regression revealed that classes were associated with different risk levels of excessive gambling. The self-testers and multi-function users used the tool to a higher extent and were found to have a greater risk of excessive gambling than the other classes.

  • 17.
    Forsström, D.
    et al.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Jansson-Fröjmark, M.
    Department of Psychology, Stockholm University, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Stockholm, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Carlbring, P.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Experiences of Playscan: Interviews with users of a responsible gambling tool2017In: Internet Interventions, ISSN 2214-7829, Vol. 8, p. 53-62Article in journal (Refereed)
    Abstract [en]

    Online gambling, encompassing a wide variety of activities and around-the-clock access, can be a potential risk factor for gamblers who tend to gamble excessively. Yet, the advent of online gambling has enabled responsible gambling (RG) features that may help individuals to limit their gambling behaviour. One of these features is RG tools that track gamblers’ behaviour, performs risk assessments and provides advice to gamblers. This study investigated users’ views and experiences of the RG tool Playscan from a qualitative perspective using a semi-structured interview. The tool performs a risk assessment on a three-step scale (low, medium and high risk). Users from every risk category were included. Twenty interviews were carried out and analysed using thematic analysis. Two main themes with associated sub-themes were identified: “Usage of Playscan and the gambling site” and “Experiences of Playscan”. Important experiences in the sub-themes were lack of feedback from the tool and confusion when signing up to use Playscan. These experiences counteracted positive attitudes that should have promoted usage of the tool. Providing more feedback directly to users is a suggested solution to increase usage of the RG tool. © 2017 The Authors

  • 18.
    Green-Landell, Malin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Persson, Stefan
    3Örebro University, School of Law, Psychology and Social work, Örebro, Sweden.
    Furmark, Tomas
    Uppsala University, Department of Psychology, Uppsala, Sweden.
    Bohlin, Gunilla
    Uppsala University, Department of Psychology, Uppsala, Sweden.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social work, Örebro, Sweden.
    Longitudinal associations between social anxiety, depressive symptoms and peer victimization in adolescence: A prospective community studyManuscript (preprint) (Other academic)
    Abstract [en]

    Self-reported social anxiety, depressive symptoms and peer victimization was investigated in 350 students in grade 7 and then in grade 8, 9 and 11. Using latent growth modeling, social anxiety was found to be stable over time and to have a time-invariant association with depressive symptoms. Further, social anxiety predicted subsequent depressive symptoms but not vice versa. Support was found for a meditational model. That is, peer victimization in grade 7 was related to higher level of social anxiety, which in turn was associated with more depressive symptoms in grade 8, 9 and 11. The development of social anxiety and depression symptomatology among adolescents can thus be described as one sequential longitudinal process initiated by peer victimization.

  • 19.
    Hadjistavropoulos, H. D.
    et al.
    University of Regina, Canada.
    Pugh, N. E.
    University of Regina, Canada.
    Nugent, M. M.
    University of Regina, Canada.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Ivanov, M.
    University of Regina, Canada.
    Butz, C. G.
    University of Regina, Canada.
    Marchildon, G.
    University of Regina, Canada.
    Asmundson, G. J. G.
    University of Regina, Canada.
    Klein, B.
    Federat University of Australia, Australia; Federat University of Australia, Australia; Australian National University, Australia; Swinburne University of Technology, Australia.
    Austin, D. W.
    Deakin University, Australia.
    Therapist-assisted Internet-delivered cognitive behavior therapy for depression and anxiety: Translating evidence into clinical practice2014In: Journal of Anxiety Disorders, ISSN 0887-6185, E-ISSN 1873-7897, Vol. 28, no 8, p. 884-893Article in journal (Refereed)
    Abstract [en]

    This dissemination study examined the effectiveness of therapist-assisted Internet-delivered Cognitive Behavior Therapy (ICBT) when offered in clinical practice. A centralized unit screened and coordinated ICBT delivered by newly trained therapists working in six geographically dispersed clinical settings. Using an open trial design, 221 patients were offered 12 modules of ICBT for symptoms of generalized anxiety (n=112), depression (n=83), or panic (n=26). At baseline, midpoint and post-treatment, kpatients completed self-report measures. On average, patients completed 8 of 12 modules. Latent growth curve modeling identified significant reductions in depression, anxiety, stress and impairment (d=.65-.78), and improvements in quality of life (d=.48-.66). Improvements in primary symptoms were large (d=.91-1.25). Overall, therapist-assisted ICBT was effective when coordinated across settings in clinical practice, but further attention should be given to strategies to improve completion of treatment modules.

  • 20.
    Hadjistavropoulos, Heather D.
    et al.
    University of Regina, Canada.
    Pugh, Nicole E.
    University of Regina, Canada.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Predicting Response to Therapist-Assisted Internet-Delivered Cognitive Behavior Therapy for Depression or Anxiety Within an Open Dissemination Trial2016In: Behavior Therapy, ISSN 0005-7894, E-ISSN 1878-1888, Vol. 47, no 2, p. 155-165Article in journal (Refereed)
    Abstract [en]

    Therapist-assisted Internet-delivered cognitive behavior therapy (ICBT) is efficacious for treating anxiety and depression, but predictors of response to treatment when delivered in clinical practice are not well understood. In this study, we explored demographic, clinical, and program variables that predicted modules started and symptom improvement (i.e., Generalized Anxiety Disorder-7 or Patient Health Questionnaire-9 total scores over pre-, mid-, and posttreatment) within a previously published open dissemination trial (Hadjistavropoulos et al., 2014). The sample consisted of 195 patients offered 12 modules of therapist-assisted ICBT for depression or generalized anxiety; ICBT was delivered by therapists working in six geographically dispersed clinics. Consistent across ICBT for depression or generalized anxiety, starting fewer modules was associated with more phone calls from therapists reflecting that therapists tended to call patients who did not start modules as scheduled. Also consistent for both ICBT programs, greater pretreatment condition severity and completion of more modules was associated with superior ICBT-derived benefit. Other predictors of response to treatment varied across the two programs. Younger age, lower education, taking psychotropic medication, being in receipt of psychiatric care and lower comfort with written communication were associated with either fewer program starts or lower symptom improvement in one of the two programs. It is concluded that monitoring response to ICBT may be particularly important in patients with these characteristics. Research directions for identifying patients who are less likely to benefit from ICBT are discussed.

  • 21.
    Hadjistavropoulos, Heather D.
    et al.
    University of Regina, Canada.
    Pugh, Nicole E.
    University of Regina, Canada; 715 East 12th Ave, Canada.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Department Clin Neurosci, Stockholm, Sweden.
    Therapeutic Alliance in Internet-Delivered Cognitive Behaviour Therapy for Depression or Generalized Anxiety2017In: Clinical Psychology and Psychotherapy, ISSN 1063-3995, E-ISSN 1099-0879, Vol. 24, no 2, p. 451-461Article in journal (Refereed)
    Abstract [en]

    There has been limited research on therapeutic alliance in the context of therapist-assisted Internet-delivered cognitive behaviour therapy (ICBT) when delivered in clinical practice. The present study investigated therapeutic alliance in ICBT delivered to patients seeking treatment for symptoms of depression (n=83) or generalized anxiety (n=112) as part of an open dissemination trial. ICBT was provided by 27 registered therapists or 28 graduate students working in six geographically dispersed clinics; therapist-assistance was delivered primarily through secure messages and occasionally telephone calls. The Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were collected pre-, mid- and post-treatment, and the Therapeutic Alliance Questionnaire was assessed mid- and post-treatment. Therapeutic alliance ratings were high both at mid-treatment and post-treatment (above 80%). There was no relationship between therapeutic alliance ratings and improvement on primary outcomes. Among patients treated for depression, lower ratings of mid-treatment alliance were associated with concurrent treatment by a psychiatrist and fewer phone calls and emails from their therapist. Among patients treated for generalized anxiety, ratings of mid-treatment alliance were higher among registered providers as compared to graduate students. Multiple directions for future research on therapeutic alliance in ICBT are offered, including suggestions for developing a new measure of therapeutic alliance specific to ICBT and measuring therapeutic alliance throughout the treatment process. Copyright (c) 2016 John Wiley amp; Sons, Ltd.

  • 22.
    Hedman, Erik
    et al.
    Karolinska Institute, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Erik
    Karolinska Institute, Sweden.
    Axelsson, Erland
    Karolinska Institute, Sweden.
    Ljotsson, Brjann
    Karolinska Institute, Sweden.
    The mediating effect of mindful non-reactivity in exposure-based cognitive behavior therapy for severe health anxiety2017In: Journal of Anxiety Disorders, ISSN 0887-6185, E-ISSN 1873-7897, Vol. 50, p. 15-22Article in journal (Refereed)
    Abstract [en]

    Exposure-based cognitive behavior therapy (CBT) has been shown to be effective in the treatment of severe health anxiety, but little is known about mediators of treatment effect. The aim of the present study was to investigate mindful non-reactivity as a putative mediator of health anxiety outcome using data from a large scale randomized controlled trial. We assessed mindful non-reactivity using the Five Facets Mindfulness Questionnaire-Non-Reactivity scale (FFMQ-NR) and health anxiety with the Short Health Anxiety Inventory (SHAI). Participants with severe health anxiety (N = 158) were randomized to internet-delivered exposure based CBT or behavioral stress management (BSM) and throughout the treatment, both the mediator and outcome were measured weekly. As previously reported, exposure-based CBT was more effective than BSM in reducing health anxiety. In the present study, latent process growth modeling showed that treatment condition had a significant effect on the FFMQ-NR growth trajectory (alpha-path), estimate = 0.18, 95% CI [0.04, 0.32], p = .015, indicating a larger increase in mindful non-reactivity among participants receiving exposure-based CBT compared to the BSM group. The FFMQ-NR growth trajectory was significantly correlated with the SHAI trajectory (13 -path estimate = -1.82, 95% CI [-2.15, -1.48], p amp;lt;.001. Test of the indirect effect, i.e. the estimated mediation effect (an) revealed a significant cross product of 0.32, which was statistically significant different from zero based on the asymmetric confidence interval method, 95% CI [0.59, -0.06]. We conclude that increasing mindful non-reactivity may be of importance for achieving successful treatment outcomes in exposure-based CBT for severe health anxiety.

  • 23.
    Hedman, Erik
    et al.
    Karolinska Institute, Sweden Karolinska Institute, Sweden Karolinska Institute, Sweden .
    Ljotsson, Brjann
    Karolinska Institute, Sweden Karolinska Institute, Sweden .
    Kaldo, Viktor
    Karolinska Institute, Sweden .
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    El Alaoui, Samir
    Karolinska Institute, Sweden .
    Kraepelien, Martin
    Karolinska Institute, Sweden .
    Andersson, Evelyn
    Karolinska Institute, Sweden .
    Ruck, Christian
    Karolinska Institute, Sweden .
    Svanborg, Cecilia
    Karolinska Institute, Sweden .
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Lindefors, Nils
    Karolinska Institute, Sweden .
    Effectiveness of Internet-based cognitive behaviour therapy for depression in routine psychiatric care2014In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 155, p. 49-58Article in journal (Refereed)
    Abstract [en]

    Background: Efficacy of guided Internet-based cognitive behaviour therapy (ICBT) for depression has been demonstrated in several randomised controlled trials. Knowledge on the effectiveness of the treatment, i.e. how it works when delivered within routine care, is however scarce. The aim of this study was to investigate the effectiveness of ICBT for depression. Methods: We conducted a cohort study investigating all patients (N =1203) who had received guided ICBT for depression between 2007 and 2013 in a routine care setting at an outpatient psychiatric clinic providing Internet-based treatment The primary outcome measure was the Montgomery Asberg Depression Rating Scale-Self rated (MADRS-S). Results: Patients made large improvements from pre-treatment assessments to post-treatment on the primary outcome (effect size d on the MADRS-S = 1.27, 99% CI, 1.14-1.39). Participants were significantly improved in terms of suicidal ideation and sleep difficulties improvements were sustained at 6-month follow-up. Limitations: Attrition was rather large at 6-month follow-up. However, additional data was collected through telephone interviews with dropouts and advanced statistical models indicated that missing data did not bias the findings. Conclusions: ICBT for depression can be highly effective when delivered within the context of routine psychiatric care. This study suggests that the effect sizes are at least as high when the treatment is delivered in routine psychiatric care by qualified staff as when delivered in a controlled trial setting.

  • 24.
    Hedman, Erik
    et al.
    Karolinska Institute, Sweden .
    Mortberg, Ewa
    Stockholm University, Sweden .
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Clark, David M.
    University of Oxford, England .
    Lekander, Mats
    Karolinska Institute, Sweden .
    Andersson, Erik
    Karolinska Institute, Sweden .
    Ljotsson, Brjann
    Karolinska Institute, Sweden .
    Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy2013In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 51, no 10, p. 696-705Article in journal (Refereed)
    Abstract [en]

    According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in la and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.

  • 25.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Comment: Methodological considerations in treatment evaluations of tinnitus distress:: a call for guidelines2010In: Journal of Psychosomatic Research, ISSN 0022-3999, E-ISSN 1879-1360, Vol. 69, no 3, p. 305-307Article in journal (Refereed)
    Abstract [en]

    n/a

  • 26.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Tinnitus in Context: A Contemporary Contextual Behavioral Approach2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Tinnitus is the experience of sounds in the ears without any external auditory source and is a common, debilitating, chronic symptom for which we have yet to develop sufficiently efficacious interventions. Cognitive behavioral therapy (CBT) has evolved over the last 20 years to become the most empirically supported treatment for treating the adverse effects of tinnitus. Nevertheless, a significant proportion of individuals do not benefit from CBT-based treatments. In addition, the theoretical underpinnings of the CBT-model are poorly developed, the relative efficacy of isolated procedures has not yet been demonstrated, and the mechanisms of therapeutic change are largely unknown. These significant limitations preclude scientific progression and, as a consequence, leave many individuals with tinnitus suffering.

    To address some of these issues, a contextual multi-method, principle-focused inductive scientific strategy, based on pragmatic philosophy, was employed in the present thesis project. The overarching aim of the thesis was to explore the utility of a functional dimensional process in tinnitus: Experiential avoidance—experiential openness/acceptance (EA). EA is defined as the inclination to avoid or alter the frequency, duration, or intensity of unwanted internal sensations, including thoughts, feelings or physical sensations. The thesis is based on experimental work (Study II, VI), process and mediation studies (Study I, III, V), and on randomized controlled trials (Study III, IV).

    Three main sets of findings supported the utility of EA in tinnitus. First, an acceptance-based treatment (i.e.,Acceptance and Commitment Therapy, ACT) was found to be effective in controlled trials. Study III demonstrated that face-to-face ACT was more effective than a wait-list control and a habituation-based sound therapy. Study IV showed that internet-delivered ACT was more effective than an active control condition (internet-discussion forum) and equally effective as an established internet-delivered CBT treatment. Second, processes research (Study I, III, V) showed that key postulated processes of change were linked to the specific technology of ACT and that these changes in processes were associated with therapeutic outcomes. Specifically, Study V found evidence to that decreases in suppression of thoughts and feelings over the course of treatment were uniquely associated with therapeutic gains in ACT as compared with CBT. Third, experimental manipulations of experiential avoidance and acceptance processes provided support to the underlying dimension (Study II, VI). That is, Study II, employing an experimental manipulation, found that controlling background sounds were associated with reduced cognitive efficiency and increased tinnitus interference over repeated experimental trials. In addition, in normal hearing participants, experimentally induced mindfulness counteracted reduced persistence in a mentally challenging task in the presence of a tinnitus-like sound stemming from initial effortful suppression of the same sound (Study VI). It is concluded that a principle-, contextual-focused approach to treatment development may represent an efficient strategy for scientific progression in the field of psychological treatments of tinnitus severity.

    List of papers
    1. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.
    Open this publication in new window or tab >>Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.
    2009 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 47, no 6, p. 523-8Article in journal (Refereed) Published
    Abstract [en]

    Cognitive-behavioral treatment (CBT) is considered to be an effective treatment of distress associated with tinnitus (perception of internal noises without any outer auditory stimulation), but the processes by which the therapy works remain unclear. Mindfulness and acceptance is receiving increased attention in the treatment literature for chronic medical conditions. However, few studies have examined these and related processes with behavioral or observer measures. In the present study 57 videotapes (a total of 1710min) from 19 clients who participated in a controlled trial of an acceptance-based treatment for tinnitus distress, were coded for frequency and peak level of verbal behaviors expressing either acceptance or cognitive defusion. Frequency of cognitive defusion behaviors and peak level of cognitive defusion as well as peak level of acceptance rated in Session 2, predicted symptom reduction 6 month following treatment. These relationships were not accounted for by the improvement that had occurred prior to the measurement point of the process variables. Moreover, prior symptom changes could not predict process variables rated later in therapy (after most of the improvement in therapy had occurred). Thus, clients' in-session acceptance and cognitive defusion behaviors appear to play an important role in the reduction of negative impact of tinnitus.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-18989 (URN)10.1016/j.brat.2009.02.002 (DOI)19268281 (PubMedID)
    Available from: 2009-06-07 Created: 2009-06-07 Last updated: 2018-12-12Bibliographically approved
    2. Consequences of Controlling Background Sounds: The Effect of Experiential Avoidance on Tinnitus Interference
    Open this publication in new window or tab >>Consequences of Controlling Background Sounds: The Effect of Experiential Avoidance on Tinnitus Interference
    2009 (English)In: REHABILITATION PSYCHOLOGY, ISSN 0090-5550, Vol. 54, no 4, p. 381-389Article in journal (Refereed) Published
    Abstract [en]

    Objective: Masking by the use of sounds has been one of the most commonly applied means of coping with tinnitus. The ability to control auditory stimulation represents a potentially important process involved in tinnitus masking strategies. Little is, however, known about the consequences of control on tinnitus experience. The present study investigated the effects of control of background sounds (type and loudness) on perceived intrusiveness of tinnitus and cognitive performance. Design: Using an experimental design with a series of trials, participants with clinically significant tinnitus (N = 35) were randomly assigned to I of 2 experimental manipulation conditions (control of sounds vs. no control of sounds). Measures: Self-reported tinnitus interference and the Digit-Symbol subtest served as dependent measures. Results: Latent growth curve modeling showed that individuals assigned to the condition with control exhibited faster growth rates on tinnitus interference (increased interference) and demonstrated slower rates of improvement on cognitive performance measures over trials compared to individuals assigned to the condition with no control. Conclusion: These results suggest that efforts to control tinnitus through sounds can be associated with increased disability in individuals with tinnitus.

    Keywords
    tinnitus, control, tinnitus interference, cognitive functioning, experiential avoidance
    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-52818 (URN)10.1037/a0017565 (DOI)
    Available from: 2010-01-12 Created: 2010-01-12 Last updated: 2018-12-12
    3. Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus: A randomised controlled trial
    Open this publication in new window or tab >>Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus: A randomised controlled trial
    Show others...
    2011 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 49, no 11, p. 737-747Article in journal (Refereed) Published
    Abstract [en]

    The study compared the effects of Acceptance and Commitment Therapy (ACT) with Tinnitus Retraining Therapy (TRT) on tinnitus impact in a randomised controlled trial. Sixty-four normal hearing subjects with tinnitus were randomised to one of the active treatments or a wait-list control (WLC). The ACT treatment consisted of 10 weekly 60min sessions. The TRT treatment consisted of one 150min session, one 30min follow-up and continued daily use of wearable sound generators for a recommended period of at least 8h/day for 18 months. Assessments were made at baseline, 10 weeks, 6 months and 18 months. At 10 weeks, results showed a superior effect of ACT in comparison with the WLC regarding tinnitus impact (Cohen's d=1.04), problems with sleep and anxiety. The results were mediated by tinnitus acceptance. A comparison between the active treatments, including all assessment points, revealed significant differences in favour of ACT regarding tinnitus impact (Cohen's d=0.75) and problems with sleep. At 6 months, reliable improvement on the main outcome measure was found for 54.5% in the ACT condition and 20% in the TRT condition. The results suggest that ACT can reduce tinnitus distress and impact in a group of normal hearing tinnitus patients.

    Place, publisher, year, edition, pages
    Elsevier, 2011
    Keywords
    Acceptance and commitment therapy; Stress; Social workers; Burnout; Randomized controlled trial; Stress management
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-71844 (URN)10.1016/j.brat.2011.08.001 (DOI)000296941700003 ()21864830 (PubMedID)
    Available from: 2011-11-07 Created: 2011-11-07 Last updated: 2018-12-12
    4. A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus
    Open this publication in new window or tab >>A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus
    Show others...
    2012 (English)In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 80, no 4, p. 649-661Article in journal (Refereed) Published
    Abstract [en]

    Objective: Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format. Method: Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up. Results: Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16). Conclusions: Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

    Place, publisher, year, edition, pages
    Washington, DC, USA: American Psychological Association (APA), 2012
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:liu:diva-76865 (URN)10.1037/a0027021 (DOI)000306861800011 ()22250855 (PubMedID)
    Available from: 2012-04-20 Created: 2012-04-20 Last updated: 2018-12-12Bibliographically approved
    5. Acceptance as a Mediator in Internet-delivered Acceptance and Commitment Therapy and Cognitive Behavior Therapy for Tinnitus
    Open this publication in new window or tab >>Acceptance as a Mediator in Internet-delivered Acceptance and Commitment Therapy and Cognitive Behavior Therapy for Tinnitus
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Despite demonstrated efficacy of behavioral and cognitive techniques in treating the impact of tinnitus (constant ringing in the ears), little is known about the mechanisms by which these techniques achieve their effect. The present study examined acceptance of tinnitus as a potential mediator of treatment changes on global tinnitus severity in internet-delivered acceptance and commitment therapy (iACT) and internet-delivered cognitive behavior therapy (iCBT). Data from 67 participants who were distressed by tinnitus and who were randomly assigned to 1 of the 2 treatments were analyzed using a multilevel moderated mediation model. We predicted that acceptance as measured with the two subscales of the tinnitus acceptance questionnaire (i.e., activity engagement and tinnitus suppression) would mediate the outcome in iACT, but not in iCBT. Results provided partial support to the notion that mediation was moderated by treatment: tinnitus suppression mediated changes in tinnitus severity in iACT, but not in iCBT. However, inconsistent with the view that the treatments worked through different processes of change, activity engagement mediated treatment changes across both iACT and iCBT. Acceptance is identified as a key source of therapeutic change in behavioral-based treatments for tinnitus.

    Keywords
    Tinnitus, acceptance, mechanisms of change, internet-delivered selfhelp, cognitive behavior therapy
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:liu:diva-88336 (URN)
    Available from: 2013-02-03 Created: 2013-02-03 Last updated: 2014-11-28Bibliographically approved
    6. Costs of Suppressing Emotional Sound and Countereffects of a Mindfulness Induction: An Experimental Analog of Tinnitus Impact
    Open this publication in new window or tab >>Costs of Suppressing Emotional Sound and Countereffects of a Mindfulness Induction: An Experimental Analog of Tinnitus Impact
    2013 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 5, p. e64540-Article in journal (Other academic) Published
    Abstract [en]

    Tinnitus is the experience of sounds without an appropriate external auditory source. These auditory sensations are intertwined with emotional and attentional processing. Drawing on theories of mental control, we predicted that suppressing an affectively negative sound mimicking the psychoacoustic features of tinnitus would result in decreased persistence in a mentally challenging task (mental arithmetic) that required participants to ignore the same sound, but that receiving a mindfulness exercise would reduce this effect. Normal hearing participants (N = 119) were instructed to suppress an affectively negative sound under cognitive load or were given no such instructions. Next, participants received either a mindfulness induction or an attention control task. Finally, all participants worked with mental arithmetic while exposed to the same sound. The length of time participants could persist in the second task served as the dependent variable. As hypothesized, results indicated that an auditory suppression rationale reduced time of persistence relative to no such rationale, and that a mindfulness induction counteracted this detrimental effect. The study may offer new insights into the mechanisms involved in the development of tinnitus interference. Implications are also discussed in the broader context of attention control strategies and the effects of emotional sound on task performance. The ironic processes of mental control may have an analog in the experience of sounds.

    Keywords
    Mental control, tinnitus, emotional sound, mindfulness, suppression
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:liu:diva-88337 (URN)10.1371/journal.pone.0064540 (DOI)000318852400071 ()
    Note

    On the day of the defence date the status of this article was Manuscript.

    Available from: 2013-02-03 Created: 2013-02-03 Last updated: 2018-12-12Bibliographically approved
  • 27.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Dimensional or Categorical Approach to Tinnitus Severity: an Item Response Mixture Modeling Analysis of Tinnitus Handicap2014In: International Journal of Behavioral Medicine, ISSN 1070-5503, E-ISSN 1532-7558, Vol. 21, no 6, p. 982-988Article in journal (Refereed)
    Abstract [en]

    Background Whether handicap due to tinnitus-sound(s) in the ears and/or in the head in the absence of an external auditory source-is best conceived as dimensional or categorical remains an unanswered empirical question. Purpose The objective was to investigate whether tinnitus severity was best conceptualized as qualitatively distinct subtypes, quantitative differences varying along a single continuum, or as severity differences within subtypes. Methods Various forms of item response mixture models (latent class models, factor analysis models, and hybrid models) that corresponded to the competing hypotheses were fitted to item responses on the Tinnitus Handicap Inventory in a Swedish sample of individuals with tinnitus (N = 362). Results A latent class model could be fitted to the data with a high probability of correctly classifying individuals into three different classes: high-, moderate-, and low-severity classes. However, a comparison of models showed that a unidimensional factor analysis model with a single class provided the best fit to the data. Conclusions The analysis provided evidence that tinnitus severity varies along a single severity continuum from mild to moderate to severe tinnitus-related handicap. The result that tinnitus severity exists on a continuum rather than as discrete categories has important implications for clinical research.

  • 28.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    The role of anxiety sensitivity and behavioral avoidance in tinnitus disability2009In: INTERNATIONAL JOURNAL OF AUDIOLOGY, ISSN 1499-2027, Vol. 48, no 5, p. 295-299Article in journal (Refereed)
    Abstract [en]

    The purpose of this study was to investigate the role of anxiety sensitivity and behavioral avoidance in tinnitus distress and functioning. A cross-sectional sample of 283 individuals experiencing tinnitus was obtained from an epidemiological national survey study on hearing loss, dizziness, and tinnitus. The subjects completed a series of questionnaires measuring anxiety sensitivity, anxiety, and depression. They also answered questions regarding tinnitus distress, functioning, and avoidance. Results revealed a positive significant correlation between anxiety sensitivity and tinnitus distress. This relationship was not better explained by anxiety and depression symptoms. In addition, the findings provided support for a model where behavioral avoidance fully mediated the relationship between anxiety sensitivity and tinnitus functioning, and partially mediated the relationship between anxiety sensitivity and tinnitus distress. Implications for the role of anxiety sensitivity and behavioral avoidance in tinnitus research are discussed

  • 29.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Axelsson, Sandra
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Backe, Victoria
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Engstrand, Jonna
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Gustafsson, Tina
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmgren, Elin
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Jeppsson, Ulrika
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Pollack, Maria
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Norden, Kjell
    Alternat Violence, Sweden.
    Rosenqvist, Dan
    Alternat Violence, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Preventing intimate partner violence via the Internet: A randomized controlled trial of emotion-regulation and conflict-management training for individuals with aggression problems2017In: Clinical Psychology and Psychotherapy, ISSN 1063-3995, E-ISSN 1099-0879, Vol. 24, no 5, p. 1163-1177Article in journal (Refereed)
    Abstract [en]

    Objective

    The aim of this randomized controlled trial was to investigate the effect of an Internet-delivered cognitive behaviour therapy (iCBT), which incorporated emotion-regulation and conflict-resolution techniques, on intimate partner violence (IPV). Another aim was to test the theoretical underpinnings of the treatment model using mediation analysis.

    Method

    Sixty-five participants with aggression problems in intimate adult relationships were recruited from the community and were randomly assigned to iCBT or to a monitored waitlist control. Participants were assessed with standardized self-report measures of IPV or aggression (Multidimensional Measure of Emotional Abuse, Revised Conflict Tactics Scale, and Aggression Questionnaire), relationship quality (Dyadic Adjustment Scale), anxiety or depression symptomatology (Patient Health Questionnaire; Generalized Anxiety Disorder Screener), at pretreatment, posttreatment (8 weeks), and 1-year follow-up. Process variables (subscales of Dysfunctional and Emotional Regulation Scale and Anger Rumination Scale) were assessed weekly over the active treatment phase.

    Results

    Robust linear regression analysis of all randomized participants showed significant treatment effects on emotional abuse relative to control at postassessment. Mediation analysis using growth curve modeling revealed that the treatment effect was partially mediated by changes in emotion-regulation ability. Controlled effects on secondary outcomes were also observed. Analyses of uncontrolled effects indicted that gains on IPV were maintained at 1-year follow-up.

    Conclusions

    iCBT focusing on enhancing conflict-resolution skills and emotion-regulation ability has the potential to reduce IPV among self-recruited individuals with mild forms of abusive behaviour in intimate relationships. Emotion-regulation ability is potentially a key therapeutic process of change.

    Key Practitioner Message

    • Internet-delivered clinician-guided cognitive behaviour therapy is a viable treatment option for reducing intimate partner violence among self-recruited individuals with mild forms of abusive behaviour.
    • For persons who display patterns of frequent and severe violence, other treatments are most likely needed.
    • Emotion-regulation training is potentially a key therapeutic component that ought to be incorporated in interventions targeting IPV.
  • 30.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Bånkestad, Ellinor
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Acceptance of Tinnitus As an Independent Correlate of Tinnitus Severity2015In: Ear and Hearing, ISSN 0196-0202, E-ISSN 1538-4667, Vol. 36, no 4, p. e176-e182Article in journal (Refereed)
    Abstract [en]

    Objectives: Tinnitus is the experience of sounds without an identified external source, and for some the experience is associated with significant severity (i.e., perceived negative affect, activity limitation, and participation restriction due to tinnitus). Acceptance of tinnitus has recently been proposed to play an important role in explaining heterogeneity in tinnitus severity. The purpose of the present study was to extend previous investigations of acceptance in relation to tinnitus by examining the unique contribution of acceptance in accounting for tinnitus severity, beyond anxiety and depression symptoms. Design: In a cross-sectional study, 362 participants with tinnitus attending an ENT clinic in Sweden completed a standard set of psychometrically examined measures of acceptance of tinnitus, tinnitus severity, and anxiety and depression symptoms. Participants also completed a background form on which they provided information about the experience of tinnitus (loudness, localization, sound characteristics), other auditory-related problems (hearing problems and sound sensitivity), and personal characteristics. Results: Correlational analyses showed that acceptance was strongly and inversely related to tinnitus severity and anxiety and depression symptoms. Multivariate regression analysis, in which relevant patient characteristics were controlled, revealed that acceptance accounted for unique variance beyond anxiety and depression symptoms. Acceptance accounted for more of the variance than anxiety and depression symptoms combined. In addition, mediation analysis revealed that acceptance of tinnitus mediated the direct association between self-rated loudness and tinnitus severity, even after anxiety and depression symptoms were taken into account. Conclusions: Findings add to the growing body of work, supporting the unique and important role of acceptance in tinnitus severity. The utility of the concept is discussed in relation to the development of new psychological models and interventions for tinnitus severity.

  • 31.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Engstrand, Jonna
    Jeppsson, Ulrika
    Gustafsson, Tina
    Axelsson, Sandra
    Pollack, Maria
    Bäcke, Viktoria
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Internet-delivered acceptance-based skills training for the prevention of interpersonal violence2014Conference paper (Refereed)
  • 32.
    Hesser, Hugo
    et al.
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Gustafsson, Tore
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Lundén, Charlotte
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Henrikson, Oskar
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Fattahi, Kidjan
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Johnsson, Erik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Westin Zetterqvist, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Educational Sciences.
    Carlbring, Per
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Mäki-Torkko, Elina
    Linköping University, Department of Clinical and Experimental Medicine, Technical Audiology. Linköping University, Faculty of Health Sciences.
    Kaldo, Viktor
    Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus2012In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 80, no 4, p. 649-661Article in journal (Refereed)
    Abstract [en]

    Objective: Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format. Method: Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up. Results: Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16). Conclusions: Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

  • 33.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hedman, E.
    Karolinska Institute, Sweden.
    Lindfors, P.
    University of Gothenburg, Sweden; Karolinska Institute, Sweden.
    Andersson, E.
    Karolinska Institute, Sweden.
    Ljotsson, B.
    Karolinska Institute, Sweden.
    The specific effect of systematic exposure in irritable bowel syndrome: complier average causal effect analysis using growth mixture modeling2017In: Psychological Medicine, ISSN 0033-2917, E-ISSN 1469-8978, Vol. 47, no 15, p. 2653-2662Article in journal (Refereed)
    Abstract [en]

    Background. We reanalyzed data from a previously published randomized component study that aimed to test the incremental effect of systematic exposure in an internet-delivered cognitive behavioral treatment (ICBT) for irritable bowel syndrome (IBS). Methods. Three hundred and nine individuals with IBS were randomly assigned to either the full treatment protocol (experimental condition) or the same treatment protocol without systematic exposure (control). Participants were assessed weekly for IBS symptoms over the active treatment phase. We used a complier average causal effect (CACE) analysis, in the growth mixture modeling framework, to (1) examine the specific effect of exposure among those who received the intervention (i.e. compliers), and (2) explore the associations of pre-treatment patient characteristics with compliance status and outcome changes. Results. Fifty-five per cent of those assigned to the experimental condition were classified as compliers. The CACE analysis that took into account compliance status demonstrated that the magnitude of the incremental effect of systematic exposure on IBS symptoms was larger than the effect observed in an intention-to-treat analysis that ignored compliance status (d = 0.81 v. d = 0.44). Patients with university education showed more improvement during the exposure phase of the treatment. Pre-treatment patient characteristics did not predict compliance status. Conclusions. The effect of systematic exposure on IBS symptoms is of substantial magnitude among those individuals who actually receive the intervention (CACE). Studying the subsample of individuals who discontinue treatment prematurely and tailoring interventions to improve compliance may increase overall improvement rates in ICBT for IBS.

  • 34.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hedman-Lagerlöf, Erik
    Karolinska Inst, Sweden.
    Andersson, Erik
    Karolinska Inst, Sweden.
    Lindfors, Perjohan
    Karolinska Inst, Sweden; Univ Gothenburg, Sweden.
    Ljotsson, Brjann
    Karolinska Inst, Sweden.
    How Does Exposure Therapy Work? A Comparison Between Generic and Gastrointestinal Anxiety-Specific Mediators in a Dismantling Study of Exposure Therapy for Irritable Bowel Syndrome2018In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 86, no 3, p. 254-267Article in journal (Refereed)
    Abstract [en]

    Objective: Systematic exposure is potentially an effective treatment procedure for treating irritable bowel syndrome (IBS), but little is known about the processes by which it achieves its effect on outcome. The aim of this study was to identify mediators in a previously published randomized dismantling trial in which participants with IBS were randomized to Internet-delivered cognitive-behavioral treatment (ICBT) that incorporated systematic exposure or to the same treatment protocol without exposure (ICBT-WE). Method: Weekly measurements of gastrointestinal anxiety-specific process variables (behavioral avoidance, gastrointestinal-specific anxiety) based on the gastrointestinal symptom-specific anxiety model, generic process variables (self-efficacy and mindful nonreactivity), and treatment outcome (IBS symptoms) were obtained from 309 participants with IBS. Growth models and cross-lagged panel models, estimated within structural equation modeling, were employed to evaluate mediators of outcome. Results: Parallel process growth modeling showed that behavioral avoidance, gastrointestinal-specific anxiety, self-efficacy mediated the incremental effect of ICBT compared to ICBT-WE. The mediated effect of avoidance was stronger for individuals scoring high on the avoidance variable at 1st measurement point. Cross-lagged regression analyses with random effects revealed that behavioral avoidance and gastrointestinal-specific anxiety had a stronger effect on subsequent symptom change rather than vice versa, whereas mindful nonreactivity and self-efficacy displayed the opposite pattern. Conclusions: The evidence collectively provided support for the hypothesis that exposure for IBS achieves its positive results by virtue of changing gastrointestinal anxiety-specific processes rather than generic processes. IBS-specific behavioral avoidance emerged as the most clear-cut mediator of the specific effect of exposure on outcome.

  • 35.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, The Swedish Institute for Disability Research. Linköping University, Faculty of Arts and Sciences.
    Molander, Peter
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Jungermann, Mikael
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, The Swedish Institute for Disability Research. Linköping University, Faculty of Arts and Sciences.
    Costs of Suppressing Emotional Sound and Countereffects of a Mindfulness Induction: An Experimental Analog of Tinnitus Impact2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 5, p. e64540-Article in journal (Other academic)
    Abstract [en]

    Tinnitus is the experience of sounds without an appropriate external auditory source. These auditory sensations are intertwined with emotional and attentional processing. Drawing on theories of mental control, we predicted that suppressing an affectively negative sound mimicking the psychoacoustic features of tinnitus would result in decreased persistence in a mentally challenging task (mental arithmetic) that required participants to ignore the same sound, but that receiving a mindfulness exercise would reduce this effect. Normal hearing participants (N = 119) were instructed to suppress an affectively negative sound under cognitive load or were given no such instructions. Next, participants received either a mindfulness induction or an attention control task. Finally, all participants worked with mental arithmetic while exposed to the same sound. The length of time participants could persist in the second task served as the dependent variable. As hypothesized, results indicated that an auditory suppression rationale reduced time of persistence relative to no such rationale, and that a mindfulness induction counteracted this detrimental effect. The study may offer new insights into the mechanisms involved in the development of tinnitus interference. Implications are also discussed in the broader context of attention control strategies and the effects of emotional sound on task performance. The ironic processes of mental control may have an analog in the experience of sounds.

  • 36.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Pereswetoff-Morath, Carl Emil
    Uppsala University, Department Psychol, Uppsala, Sweden .
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Consequences of Controlling Background Sounds: The Effect of Experiential Avoidance on Tinnitus Interference2009In: REHABILITATION PSYCHOLOGY, ISSN 0090-5550, Vol. 54, no 4, p. 381-389Article in journal (Refereed)
    Abstract [en]

    Objective: Masking by the use of sounds has been one of the most commonly applied means of coping with tinnitus. The ability to control auditory stimulation represents a potentially important process involved in tinnitus masking strategies. Little is, however, known about the consequences of control on tinnitus experience. The present study investigated the effects of control of background sounds (type and loudness) on perceived intrusiveness of tinnitus and cognitive performance. Design: Using an experimental design with a series of trials, participants with clinically significant tinnitus (N = 35) were randomly assigned to I of 2 experimental manipulation conditions (control of sounds vs. no control of sounds). Measures: Self-reported tinnitus interference and the Digit-Symbol subtest served as dependent measures. Results: Latent growth curve modeling showed that individuals assigned to the condition with control exhibited faster growth rates on tinnitus interference (increased interference) and demonstrated slower rates of improvement on cognitive performance measures over trials compared to individuals assigned to the condition with no control. Conclusion: These results suggest that efforts to control tinnitus through sounds can be associated with increased disability in individuals with tinnitus.

  • 37.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Weise, Cornelia
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Rief, Winfried
    University of Marburg.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    The effect of waiting: A meta-analysis of wait-list control groups in trials for tinnitus distress2011In: JOURNAL OF PSYCHOSOMATIC RESEARCH, ISSN 0022-3999, Vol. 70, no 4, p. 378-384Article, review/survey (Refereed)
    Abstract [en]

    Objective: The response rates and effects of being placed on a wait-list control condition are well documented in psychiatric populations. Despite the usefulness of such estimates and the frequent use of no-treatment controls in clinical trials for tinnitus, the effect of waiting in a tinnitus trial has not been investigated systematically. The aim of the present study was to quantify the overall effect of wait-list control groups on tinnitus distress. Methods: Studies were retrieved via a systematic review of randomised controlled trials of cognitive behaviour therapy for tinnitus distress. Outcomes of psychometrically robust tinnitus-specific measures (Tinnitus Handicap Inventory, Tinnitus Questionnaire, Tinnitus Reaction Questionnaire) from wait-list control groups were quantified using meta-analytic techniques. Percentage of change and standard mean difference effect sizes were calculated using the pre and post wait period. Results: Eleven studies involving 314 wait-list subjects with tinnitus were located. The analysis for a waiting period of 6 to 12 weeks revealed a mean decrease in scores on tinnitus-specific measures of 3% to 8%. Across studies, a statically significant small mean within-group effect size was obtained (Hedges g=.17). The effects were moderated by methodological quality of the trial, sample characteristics (i.e., age, tinnitus duration), time of the wait-list and how diagnosis was established. Conclusion: Subjects in a tinnitus trial improve in tinnitus distress over a short waiting phase. The effects of waiting are highly variable and depend on the characteristics of the sample and of the trial.

  • 38.
    Hesser, Hugo
    et al.
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Weise, Cornelia
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Zetterqvist Westin, Vendela
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Educational Sciences.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    A Systematic Review and Meta-Analysis of Cognitive-Behavioral Therapy for Tinnitus Distress2010Conference paper (Other academic)
  • 39.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Weise, Cornelia
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Zetterqvist Westin, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Educational Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress2011In: CLINICAL PSYCHOLOGY REVIEW, ISSN 0272-7358, Vol. 31, no 4, p. 545-553Article, review/survey (Refereed)
    Abstract [en]

    Tinnitus is defined as a sound in the ear(s) and/or head without external origin and is a serious health concern for millions worldwide. The aim of the present study was to determine whether Cognitive Behavior Therapy (CBT) is effective in reducing distress associated with tinnitus. Randomized, controlled trials that assessed the efficacy of CBT for tinnitus-related distress in adults were identified by searching electronic databases (PsychINFO, PubMed, the Cochrane Library), and by manual searches. Fifteen studies (total of 1091 participants) were included in the meta-analysis. CBT compared with a passive and active control at post-assessment yielded statistically significant mean effect sizes for tinnitus-specific measures (Hedgess g = 0.70. and Hedgess g = 0.44, respectively). The average weighted pre-to-follow-up effect size for the CBT group suggested that these effects were maintained over time. Smaller but yet statistically significant effects of CBT were found for mood outcome measures. Characteristics of the studies were unrelated to effect sizes. Methodological rigor, publication bias, and a series of sensitivity analyses did not influence the findings. The results suggest that CBT is an effective treatment of tinnitus distress. However, caution is warranted given that few large-scale, well-controlled trials were identified.

  • 40.
    Hesser, Hugo
    et al.
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Weise, Cornelia
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Zetterqvist Westin, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Educational Sciences.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Is CBT effective in the treatment of distress associated with tinnitus?: A systematic review and meta-analysis2011Conference paper (Other academic)
  • 41.
    Hesser, Hugo
    et al.
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Westin, Vendela
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Educational Sciences.
    Hayes, Steven
    University of Nevada, Reno, NV, USA.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Clients’ in-session acceptance and cognitive defusion behaviors in ACT treatment of tinnitus distress2009Conference paper (Other academic)
  • 42.
    Hesser, Hugo
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research.
    Westin, Vendela
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Hayes, Steven C
    University of Nevada.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress.2009In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 47, no 6, p. 523-8Article in journal (Refereed)
    Abstract [en]

    Cognitive-behavioral treatment (CBT) is considered to be an effective treatment of distress associated with tinnitus (perception of internal noises without any outer auditory stimulation), but the processes by which the therapy works remain unclear. Mindfulness and acceptance is receiving increased attention in the treatment literature for chronic medical conditions. However, few studies have examined these and related processes with behavioral or observer measures. In the present study 57 videotapes (a total of 1710min) from 19 clients who participated in a controlled trial of an acceptance-based treatment for tinnitus distress, were coded for frequency and peak level of verbal behaviors expressing either acceptance or cognitive defusion. Frequency of cognitive defusion behaviors and peak level of cognitive defusion as well as peak level of acceptance rated in Session 2, predicted symptom reduction 6 month following treatment. These relationships were not accounted for by the improvement that had occurred prior to the measurement point of the process variables. Moreover, prior symptom changes could not predict process variables rated later in therapy (after most of the improvement in therapy had occurred). Thus, clients' in-session acceptance and cognitive defusion behaviors appear to play an important role in the reduction of negative impact of tinnitus.

  • 43.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Zetterqvist Westin, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Educational Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institutet, Stockholm, Sweden .
    Acceptance as a mediator in internet-delivered acceptance and commitment therapy and cognitive behavior therapy for tinnitus2014In: Journal of behavioral medicine, ISSN 0160-7715, E-ISSN 1573-3521, Vol. 37, no 4, p. 756-767Article in journal (Refereed)
    Abstract [en]

    Despite demonstrated efficacy of behavioral and cognitive techniques in treating the impact of tinnitus (constant ringing in the ears), little is known about the mechanisms by which these techniques achieve their effect. The present study examined acceptance of tinnitus as a potential mediator of treatment changes on global tinnitus severity in internet-delivered acceptance and commitment therapy (iACT) and internet-delivered cognitive behavior therapy (iCBT). Data from 67 participants who were distressed by tinnitus and who were randomly assigned to 1 of the 2 treatments were analyzed using a multilevel moderated mediation model. We predicted that acceptance as measured with the two subscales of the tinnitus acceptance questionnaire (i.e., activity engagement and tinnitus suppression) would mediate the outcome in iACT, but not in iCBT. Results provided partial support to the notion that mediation was moderated by treatment: tinnitus suppression mediated changes in tinnitus severity in iACT, but not in iCBT. However, inconsistent with the view that the treatments worked through different processes of change, activity engagement mediated treatment changes across both iACT and iCBT. Acceptance is identified as a key source of therapeutic change in behavioral-based treatments for tinnitus.

  • 44.
    Ivarsson, David
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Blom, Marie
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Linköping University, Faculty of Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Rehabilitation Medicine.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Enderby, Pia
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Nordberg, Rebecca
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Guided internet-delivered cognitive behavior therapy for post-traumatic stress disorder: A randomized controlled trial2014In: Internet Interventions, ISSN 2214-7829, Vol. 1, no 1, p. 33-40Article in journal (Refereed)
    Abstract [en]

    The aim of this randomized controlled trial was to investigate the effects of guided internet-based cognitive behavior therapy (ICBT) for posttraumatic stress disorder (PTSD). Sixty-two participants with chronic PTSD, as assessed by the Clinician-administered PTSD Scale, were recruited via nationwide advertising and randomized to either treatment (n= 31) or delayed treatment attention control (n= 31). The ICBT treatment consisted of 8 weekly text-based modules containing psychoeducation, breathing retraining, imaginal and in vivo exposure, cognitive restructuring, and relapse prevention. Therapist support and feedback on homework assignment were given weekly via an online contact handling system. Assessments were made at baseline, post-treatment, and at 1-year follow-up. Main outcome measures were the Impact of Events Scale - Revised (IES-R) and the Posttraumatic Stress Diagnostic Scale (PDS). Results showed significant reductions of PTSD symptoms (between group effect on the IES-R Cohens d= 1.25, and d= 1.24 for the PDS) compared to the control group. There were also effects on depression symptoms, anxiety symptoms, and quality of life. The results at one-year follow-up showed that treatment gains were maintained. In sum, these results suggest that ICBT with therapist support can reduce PTSD symptoms significantly. © 2014 The Authors.

  • 45.
    Johansson, Robert
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Björklund, Martin
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hornborg, Christoffer
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Karlsson, Stina
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Ljótsson, Brjánn
    Karolinska Institutet, Sweden.
    Rousseau, Andréas
    Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Psychiatry. Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Health Sciences.
    Frederick, Ronald J.
    Center for Courageous Living, California, USA.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Affect-focused psychodynamic psychotherapy for depression and anxiety through the Internet: a randomized controlled trial2013In: PeerJ, ISSN 2167-8359, Vol. 1, p. e102-Article in journal (Refereed)
    Abstract [en]

    Background. Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders.

    Methods. One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up.

    Results. Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen’s d = 0.77 (95% CI: 0.37–1.18) was found on the PHQ-9 and a moderately large between-group effect size d = 0.48 (95% CI: 0.08–0.87) was found on the GAD-7. The number of patients who recovered (had no diagnoses of depression and anxiety, and had less than 10 on both the PHQ-9 and the GAD-7) were at post-treatment 52% in the treatment group and 24% in the control group. This difference was significant, χ2(N = 100, df = 1) = 8.3, p < .01. From post-treatment to follow-up, treatment gains were maintained on the PHQ-9, and significant improvements were seen on the GAD-7.

    Conclusion. This study provides initial support for the efficacy of Internet-delivered psychodynamic therapy based on the affect-phobia model in the treatment of depression and anxiety disorders. The results support the conclusion that psychodynamic treatment approaches may be transferred to the guided self-help format and delivered via the Internet.

  • 46.
    Johansson, Robert
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Ljótsson, Brjánn
    Karolinska Institutet, Stockholm, Sweden .
    Frederick, Ronald J
    Center for Courageous Living, Beverly Hills, California, USA .
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Transdiagnostic, affect-focused, psychodynamic, guided self-help for depression and anxiety through the internet: study protocol for a randomised controlled trial2012In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, no 6Article in journal (Refereed)
    Abstract [en]

    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.

  • 47.
    Johansson, Robert
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Stockholm University, Sweden.
    Hesslow, Thomas
    Stockholm University, Sweden.
    Ljotsson, Brjann
    Karolinska Institute, Sweden; Karolinska Institute, Sweden.
    Jansson, Angelica
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Jonsson, Lina
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Färdig, Smilla
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Karlsson, Josefine
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Frederick, Ronald J.
    Centre Courageous Living, CA USA.
    Lilliengren, Peter
    Stockholm University, Sweden.
    Carlbring, Per
    Stockholm University, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Internet-based Affect-focused Psychodynamic Therapy for Social Anxiety Disorder: A Randomized Controlled Trial With 2-Year Follow-Up2017In: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 54, no 4, p. 351-360Article in journal (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) is associated with considerable individual suffering and societal costs. Although there is ample evidence for the efficacy of cognitive behavior therapy, recent studies suggest psychodynamic therapy may also be effective in treating SAD. Furthermore, Internet-based psychodynamic therapy (IPDT) has shown promising results for addressing mixed depression and anxiety disorders. However, no study has yet investigated the effects of IPDT specifically for SAD. This paper describes a randomized controlled trial testing the efficacy of a 10-week, affect-focused IPDT protocol for SAD, compared with a wait-list control group. Long-term effects were also estimated by collecting follow-up data, 6, 12, and 24 months after the end of therapy. A total of 72 individuals meeting diagnostic criteria for DSM-IV social anxiety disorder were included. The primary outcome was the self-report version of Liebowitz Social Anxiety Scale. Mixed model analyses using the full intention-to-treat sample revealed a significant interaction effect of group and time, suggesting a larger effect in the treatment group than in the wait-list control. A between-group effect size Cohens d = 1.05 (95% [CI]: [0.62, 1.53]) was observed at termination. Treatment gains were maintained at the 2-year follow-up, as symptom levels in the treated group continued to decrease significantly. The findings suggest that Internet-based affect-focused psychodynamic therapy is a promising treatment for social anxiety disorder.

  • 48.
    Jungert, Tomas
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Träff, Ulf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Contrasting two models of academic self-efficacy - domain-specific versus cross-domain - in children receiving and not receiving special instruction in mathematics2014In: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 55, no 5, p. 440-447Article in journal (Refereed)
    Abstract [en]

    In social cognitive theory, self-efficacy is domain-specific. An alternative model, the cross-domain influence model, would predict that self-efficacy beliefs in one domain might influence performance in other domains. Research has also found that children who receive special instruction are not good at estimating their performance. The aim was to test two models of how self-efficacy beliefs influence achievement, and to contrast children receiving special instruction in mathematics with normally-achieving children. The participants were 73 fifth-grade children who receive special instruction and 70 children who do not receive any special instruction. In year four and five, the childrens skills in mathematics and reading were assessed by national curriculum tests, and in their fifth year, self-efficacy in mathematics and reading were measured. Structural equation modeling showed that in domains where children do not receive special instruction in mathematics, self-efficacy is a mediating variable between earlier and later achievement in the same domain. Achievement in mathematics was not mediated by self-efficacy in mathematics for children who receive special instruction. For normal achieving children, earlier achievement in the language domain had an influence on later self-efficacy in the mathematics domain, and self-efficacy beliefs in different domains were correlated. Self-efficacy is mostly domain specific, but may play a different role in academic performance depending on whether children receive special instruction. The results of the present study provided some support of the Cross-Domain Influence Model for normal achieving children.

  • 49.
    Kemani, Mike
    et al.
    Karolinska University Hospital,Karolinska Institutet Stockholm, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Olsson, Gunnar
    Karolinska University Hospital,Karolinska Institutet Stockholm, Sweden.
    Lekander, Mats
    Karolinska University Hospital,Stockholm University, Stockholm, Sweden.
    Wicksell, Rikard
    Karolinska University Hospital,Karolinska Institutet, Stockholm, Sweden.
    Processes of change in Acceptance and Commitment Therapy and Applied Relaxation for longstanding pain2016In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 20, no 4, p. 521-531Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The utility of cognitive behavioural (CB) interventions for chronic pain has been supported in numerous studies. This includes Acceptance and Commitment Therapy (ACT), which has gained increased empirical support. Previous research suggests that improvements in pain catastrophizing and psychological inflexibility are related to improvements in treatment outcome in this type of treatment. Although a few studies have evaluated processes of change in CB-interventions, there is a particular need for mediation analyses that use multiple assessments to model change in mediators and outcome over time, and that incorporate the specified timeline between mediator and outcome in the data analytic model.

    METHODS:

    This study used session-to-session assessments to evaluate if psychological inflexibility, catastrophizing, and pain intensity mediated the effects of treatment on pain interference. Analyses were based on data from a previously conducted randomized controlled trial (n = 60) evaluating the efficacy of ACT and Applied Relaxation (AR). A moderated mediation model based on linear mixed models was used to analyse the data.

    RESULTS:

    Neither catastrophizing nor pain intensity mediated changes in pain interference for any of the treatments. In contrast, psychological inflexibility mediated effects on outcome in ACT but not in AR.

  • 50.
    Kemani, Mike K.
    et al.
    Karolinska University Hospital, Sweden; Karolinska Institute, Sweden.
    Olsson, Gunnar L.
    Karolinska University Hospital, Sweden; Karolinska Institute, Sweden.
    Lekander, Mats
    Karolinska Institute, Sweden; Stockholm University, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Erik
    Karolinska Institute, Sweden.
    Wicksell, Rikard K.
    Karolinska University Hospital, Sweden; Karolinska Institute, Sweden.
    Efficacy and Cost-effectiveness of Acceptance and Commitment Therapy and Applied Relaxation for Longstanding Pain A Randomized Controlled Trial2015In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 31, no 11, p. 1004-1016Article in journal (Refereed)
    Abstract [en]

    Background and Objectives:To date, few studies have compared Acceptance and Commitment Therapy (ACT) for longstanding pain with established treatments. Only 1 study has evaluated the cost-effectiveness of ACT. The aim of the current study was to evaluate the efficacy and cost-effectiveness of ACT and applied relaxation (AR) for adults with unspecific, longstanding pain.Materials and Methods:On the basis of the inclusion criteria 60 consecutive patients received 12 weekly group sessions of ACT or AR. Data were collected pretreatment, midtreatment, and posttreatment, as well as at 3- and 6-month follow-up. Growth curve modeling was used to analyze treatment effects on pain disability, pain intensity, health-related quality of life (physical domain), anxiety, depression, and acceptance.Results:Significant improvements were seen across conditions (pretreatment to follow-up assessment) on all outcome measures. Pain disability decreased significantly in ACT relative to AR from preassessment to postassessment. A corresponding decrease in pain disability was seen in AR between postassessment and 6-month follow-up. Pain acceptance increased only in ACT, and this effect was maintained at 6-month follow-up. Approximately 20% of the participants achieved clinically significant change after treatment. Health economic analyses showed that ACT was more cost-effective than AR at post and 3-month follow-up assessment, but not at 6-month follow-up.Discussion:More studies investigating moderators and mediators of change are needed. The present study is one of few that have evaluated the cost-effectiveness of ACT and AR and compared ACT with an established behavioral intervention, and the results provide additional support for behavioral interventions for longstanding pain.

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