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Previous research has indicated that cognitive emotion regulation strategies contribute to the development and maintenance of emotional problems in adults and adolescents. However, there is a lack of longitudinal research with adolescent samples, hence knowledge of exactly how these strategies influence the development of emotional problems in adolescence is sparse. This study investigated maladaptive cognitive emotion regulation (cognitive avoidance and repetitive negative thinking) as a potential mediator in the development of anxiety and depressed mood over time in adolescence. Self-reported depressed mood, anxiety, and cognitive emotion regulation strategies were assessed during school hours in a sample of Swedish 10th graders (N=149; 53% girls), with follow-up assessments one and two years later. Repetitive negative thinking and cognitive avoidance formed a unidimensional factor of cognitive emotion regulation. Cognitive emotion regulation was found to mediate the development of both anxiety and depressed mood over time, lending support to the previous findings that cognitive emotion regulation strategies such as cognitive avoidance and repetitive negative thinking might act as transdiagnostic mechanisms in the development of emotional symptoms in adolescence. This suggests that maladaptive forms of cognitive emotion regulation could be important targets in prevention and treatment of emotional problems in adolescence.

Introduction: Adolescence is a time of profound changes in multiple contexts, giving rise to an increased amount of potential stressors. It is also a developmental period were emotional problems tend to have their onset and are common. We know from previous research that stressors are a risk factor for internalizing problems. However, we know less about how this relationship unfolds. There has been a lack of research into potential mechanisms affecting this relationship such as moderating and mediating variables. Concerning stressors in the form of daily hassles, a potent mechanism is how well adolescents regulate their emotions. Studies have shown that especially cognitive regulatory strategies, such as worry and rumination, tend to increase in early adolescence, an increase that precedes increases in emotional problems. However, with a few exceptions, many studies have been cross-sectional and we do not know exactly how these strategies affects or are affected by stressors and emotional problems. The aim of this study is therefore to investigate how cognitive emotion regulation strategies, more specifically worry and rumination, relate to the development of emotional problems in the face of stressors.

Method: This is a prospective study following 3200 Swedish adolescents in 7th and 8th grade across one year. Participants completed questionnaires about amounts of stressors, levels och worry, rumination, anxiety and depressive symptoms during school hours in the spring of 2014 and again in 2015. Half-longitudinal mediational- and moderation analyses will be performed to investigate how worry and rumination relate to the development of emotional problems in the face of stressors.

Results: The open paper will give an overview of the above-mentioned analyses and present a discussion of the results with respect to theory and clinical implications.

Background: Stressor experience is an important topic of research concerning adolescent health and ill-health. For this, valid and reliable measures of adolescent stress are needed. The Adolescent Stress Questionnaire 2 was developed to tap into stressor domains specific for adolescence. Psychometric evaluations in Australian and European samples have indicated adequate psychometric properties. However, the ASQ-2 is quite extensive, which may render its use in large cohort studies, where several aspects of adolescent health are investigated, inconvenient and problematic.

Objective: To evaluate the psychometric properties of a short version of the ASQ-2 (ASQ-S) in terms of construct validity and factorial invariance across gender.

Method: The ASQ-2 was translated into Swedish and items were retained from nine of the ten scales based on factor loadings. One scale (stress of emerging adult responsibilities) was removed entirely due to low internal consistency and variance explained. The remaining 27 items were piloted and then included in an ongoing 5-year longitudinal study involving the participation of all students in the 7th and 8th grade in public schools from three Swedish municipalities (N = 2768, 47.5 % girls, mean age 13.64 years). For this study data from the first and second wave was used.

Results: A nine factor Confirmatory Factor Analysis (CFA) showed a good fit to the data and invariance across sexes was supported. The nine scales correlated positively with depressive symptoms, anxiety and worry and negatively with self-esteem. Girls reported higher stress levels than boys in eight of the nine scales. Stressors related to peer pressure predicted reported levels of anxiety and worry one year later, whereas stressors related to romantic relationships predicted depressive symptoms.

Conclusions: Overall this study suggests that the ASQ-S could be a valid measure of adolescent stressor experience and psychometrically equivalent to the full ASQ-2.

Objectives: Sleep has important consequences for a person's daytime functioning. Numerous studies have shown that insomnia predicts work absenteeism and work disability in adults, but only a few studies have examined this association in adolescents. This study aims to explore whether symptoms of insomnia in adolescents predict school absenteeism 1 year later, over and above known psychological risk factors for absenteeism.

Design: The study used a longitudinal design with 2 measurement points over 1 year.

Setting: The students completed questionnaires during school hours at baseline and again at follow-up.

Participants: Students in the 10th to 12th grades in a Swedish upper secondary school were followed prospectively for 1 year (age, 16-20 years; N = 353; 48.1% girls).

Measurements and results: We used logistic regression analyses, controlling for the known effects of psychological factors, and arrived at a model elucidating the role of insomnia. That is, besides symptoms of insomnia, the model included previous absenteeism, alcohol intoxication, school-related social phobia, social anxiety, depressive symptoms, somatic symptoms, and bully victimization. Symptoms of insomnia predicted school absenteeism 1 year later, over and above known risk factors for absenteeism. Adolescents reporting severe symptoms of insomnia were almost 3 times more likely than adolescents reporting no or low symptoms to report problematic absenteeism 1 year later. We did not find any gender difference.

Conclusions: Our findings underscore the importance of sleep problems on adolescents' daytime functioning as measured by school absenteeism. Therefore, sleep may be an important target for preventive interventions with adolescents.

An increase in anxiety, depressed mood and sleep problems has been observed among adolescents. These symptoms have high rates of comorbidity and shared psychological processes have been proposed as maintaining factors. This study examined the occurrence and development of individual profiles of depressive symptoms, anxiety and sleeps problems and investigated them in relation to catastrophic thinking and cognitive avoidance. We used longitudinal data from a community sample of 379 senior high school students at two time points, one year apart. Five clusters were identified: a low scores cluster, a sleep problems cluster, a comorbidity cluster (high on all variables), a low mood cluster and a cluster with elevation on anxiety and depressed mood (“distress”). In general, the clusters showed stability across time. However, for the low mood and “distress” cluster, there was also an increased odds of developing sleep problems. The comorbidity and the “distress” cluster displayed the highest levels of catastrophic thinking. In conclusion, symptom patterns differed among adolescents and were stable over time. Anxiety and/or depressive symptoms were a risk factor for the development of sleep problems. Symptom constellations were related to differences in catastrophic thinking and cognitive avoidance and this may explain maintenance and exacerbation of problems over time.

Background and aims

Chronic pain not only affects the person in pain, but can also have a negative impact on relationships with loved ones. Research shows that chronic pain is associated with difficulties in marital relationships, which in turn is related to a variety of negative outcomes such as psychological distress and conflict within the family. This suggests that couples where chronic physical pain is present also struggle with emotional pain and relationship problems, and thus targeting relationship skills and interpersonal functioning might be helpful for these couples. Although studies in this area are promising, their numbers are few. In the present study, validation as a way of communicating is suggested for handling emotional expression in interpersonal interactions. Validation communicates understanding and acceptance of the other person's experience, and it has been shown to have a down-regulating effect on negative emotions. It has previously been demonstrated to be important for these couples. However, the feasibility and effects of increasing partner validation in these couples are unknown. Therefore, the aim of the present study was to investigate if a brief training session in validation for spouses would result in more validating and fewer invalidating responses towards their partners with pain, and to investigate if changes in these behavioural responses were associated with changes in emotion and pain level in the partner with pain.

Methods

Participants were 20 couples where at least one partner reported chronic pain. The study employed a within-groups design in which spouses of people with pain received validation training (without their partner's knowledge), and their validating and invalidating responses were rated pre- and post-intervention using a reliable observational scale. Also, positive and negative affect and subjective pain level in the persons with pain were rated pre- and post-intervention.

Results

Results showed that the validation training was associated with increased validating and decreased invalidating responses in the partners. Their spouses with chronic pain reported a decrease in negative affect from pre- to post-training.

Conclusions

Our results indicate that the partner or closest family member, after brief validation training, increased validating responses and decreased invalidating responses towards the person with pain, which had an immediate positive impact on emotions in the other person.

Implications

This study suggests that using validation in interpersonal interactions is a promising tool for couples where chronic pain is present.

Background and aims: Validating and invalidating responses play an important role in communication with pain patients, for example regarding emotion regulation and adherence to treatment. However, it is unclear how patients’ perceptions of validation and invalidation relate to patient characteristics and treatment outcome. The aim of this study was to investigate the occurrence of subgroups based on pain patients’ perceptions of validation and invalidation from their physicians. The stability of these perceptions and differences between subgroups regarding pain, pain interference, negative affectivity and treatment outcome were also explored.

Methods: A total of 108 pain patients answered questionnaires regarding perceived validation and invalidation, pain severity, pain interference, and negative affectivity before and after pain rehabilitation treatment. Two cluster analyses using perceived validation and invalidation were performed, one on pre-scores and one on post-scores. The stability of patient perceptions from pre- to post-treatment was investigated, and clusters were compared on pain severity, pain interference, and negative affectivity. Finally, the connection between perceived validation and invalidation and treatment outcome was explored.

Results: Three clusters emerged both before and after treatment: (1) low validation and heightened invalidation, (2) moderate validation and invalidation, and (3) high validation and low invalidation. Perceptions of validation and invalidation were generally stable over time, although there were individuals whose perceptions changed. When compared to the other two clusters, the low validation/heightened invalidation cluster displayed significantly higher levels of pain interference and negative affectivity post-treatment but not pre-treatment. The whole sample significantly improved on pain interference and depression, but treatment outcome was independent of cluster. Unexpectedly, differences between clusters on pain interference and negative affectivity were only found post-treatment. This appeared to be due to the pre- and post-heightened invalidation clusters not containing the same individuals. Therefore, additional analyses were conducted to investigate the individuals who changed clusters. Results showed that patients scoring high on negative affectivity ended up in the heightened invalidation cluster post-treatment.

Conclusions: Taken together, most patients felt understood when communicating with their rehabilitation physician. However, a smaller group of patients experienced the opposite: low levels of validation and heightened levels of invalidation. This group stood out as more problematic, reporting greater pain interference and negative affectivity when compared to the other groups after treatment. Patient perceptions were typically stable over time, but some individuals changed cluster, and these movements seemed to be related to negative affectivity and pain interference. These results do not support a connection between perceived validation and invalidation from physicians (meeting the patients pre- and post-treatment) and treatment outcome. Overall, our results suggest that there is a connection between negative affectivity and pain interference in the patients, and perceived validation and invalidation from the physicians. Implications In clinical practice, it is important to pay attention to comorbid psychological problems and level of pain interference, since these factors may negatively influence effective communication. A focus on decreasing invalidating responses and/or increasing validating responses might be particularly important for patients with high levels of psychological problems and pain interference.

Repetitive negative thinking (RNT) has been identified as a key maintaining process of emotional difficulties. However, the consequences of repetitive thinking may depend on whether negative thoughts or feelings are processed in an abstract, evaluative mode, or in a concrete, process-focused mode. In recent years an increasing number of studies has also explored the effect of processing mode in relation to positive events, yielding inconsistent results. So far, the studies using positive material have not examined the interaction between trait rumination and processing mode. Consequently, the purpose of this study was to further explore the effects of abstract vs. concrete mode of processing on positive affect and negative affect in the context of a success task in a sample scoring high on trait rumination. 62 participants were randomly assigned to abstract vs. concrete processing training prior to a success task. The results showed that positive affect increased whereas negative affect and state RNT decreased after the success task in both groups. However, abstract vs. concrete processing did not have an effect on outcome. The findings indicate that processing mode does not influence outcome in the context of a success task.

Background Internet-delivered self-help programmes with added guidance have shown efficacy in social anxiety disorder, unguided self-help has been insufficiently studied. Aims To evaluate the efficacy of guided and unguided self-help social anxiety disorder. Method Participants followed a cognitive-behavioural self-help programme in the form of either pure bibliotherapy or an internet-based treatment with therapist guidance and online group discussions. A subsequent trial was conducted to evaluate treatment specificity. Participants (n=235) were randomised to one of three conditions in the first trial, or one of four conditions in the second. Results Pure bibliotherapy and the internet-based treatment were better than waiting list on measures of social anxiety, general anxiety, depression and quality of life. The internet-based therapy had the highest effect sizes, but directly comparable effects were noted for bibliotherapy augmented with online group discussions. Gains were well maintained a year later. Conclusions Unguided self-help through bibliotherapy can produce enduring improvement for individuals with social anxiety disorder.

It is disputed whether anxiety disorders, like social anxiety disorder, are characterized by serotonin over- or underactivity. Here, we evaluated whether our recent finding of elevated neural serotonin synthesis rate in patients with social anxiety disorder could be reproduced in a separate cohort, and whether allelic variation in the tryptophan hydroxylase-2 (TPH2) G-703T polymorphism relates to differences in serotonin synthesis assessed with positron emission tomography. Eighteen social anxiety disorder patients and six healthy controls were scanned during 60 minutes in a resting state using positron emission tomography and 5-hydroxy-L-[β -(11)C]tryptophan, [(11)C]5-HTP, a substrate of the second enzymatic step in serotonin synthesis. Parametric images were generated, using the reference Patlak method, and analysed using Statistical Parametric Mapping (SPM8). Blood samples for genotyping of the TPH2 G-703T polymorphism were obtained from 16 social anxiety disorder patients (T carriers: n=5, GG carriers: n=11). A significantly elevated [(11)C]5-HTP accumulation rate, indicative of enhanced decarboxylase activity and thereby serotonin synthesis capacity, was detected in social anxiety disorder patients compared with controls in the hippocampus and basal ganglia nuclei and, at a more lenient (uncorrected) statistical threshold, in the amygdala and anterior cingulate cortex. In patients, the serotonin synthesis rate in the amygdala and anterior cingulate cortex was significantly elevated in TPH2 T carriers in comparison with GG homozygotes. Our results support that social anxiety disorder entails an overactive presynaptic serotonergic system that, in turn, seems functionally influenced by the TPH2 G-703T polymorphism in emotionally relevant brain regions.

BACKGROUND: Social phobia (social anxiety disorder - SAD) is a rather common but often undetected and undertreated psychiatric condition in youths. Screening of SAD in young individuals in community samples is thus important in preventing negative outcomes. The present study is the first report on the psychometric properties of the Social Phobia Screening Questionnaire for Children and adolescents (SPSQ-C).

METHODS: The SPSQ-C was administered to a community sample of high-school students. Test-retest reliability over three weeks was evaluated (n = 127) and internal consistency was calculated for items measuring level of fear in eight social situations. To measure concurrent validity, subjects who reported SAD on at least one occasion and randomly selected non-cases were blindly interviewed with the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I), as gold standard (n = 51).

RESULTS: A moderate test-retest reliability, r = .60 (P < .01), and a satisfactory alpha coefficient of .78 was found. Values of sensitivity and specificity were 71% and 86% respectively, and area under the curve (AUC) was .79. Positive likelihood ratio (LR+) showed that a positive screening result was five times more likely to be correct than to reflect a non-case. Negative likelihood ratio (LR -) was .34. In addition, positive predictive value was 45% and negative predictive value was 95%. The prevalence of self-reported SAD was found to be 7.2% at the first assessment.

CONCLUSION: The SPSQ-C is a short and psychometrically sound questionnaire for screening of SAD in adolescents, with the advantage of being based on the DSM-IV criteria.

Background  The aim of this study was to investigate the prevalence of self-reported social phobia in a community sample of Swedish adolescents in junior high school, at the risk-period for developing social phobia. Of particular interest was to investigate gender differences in prevalence across ages. Prevalence of sub-threshold social phobia was also studied. Methods  Students in grades 6–8 (aged 12–14) from seventeen schools in five Swedish municipalities were screened by means of a self-report questionnaire, the social phobia screening questionnaire-for children (SPSQ-C). Results  Data from a sample of 2,128 students were analysed and showed a point-prevalence rate of 4.4% (95%CI 3.5–5.2) and a significant gender difference (6.6% girls vs. 1.8% boys, P < 0.001). No significant differences in prevalence of probable cases emerged across the ages. At sub-threshold level, marked social fear of at least one social situation was reported by 13.8% of the total group. “Speaking in front of class” and “calling someone unfamiliar on the phone” were the most feared social situations. In the social phobia group, 91.4% reported impairment in the school-domain due to their social fear. Conclusion  Social phobia is a common psychiatric condition in Swedish adolescents, especially in girls. As impairment in the school-domain is reported to a high degree, professionals and teachers need to recognize social phobia in adolescents so that help in overcoming the difficulties can be offered.

The objective of the study was to investigate the long-term effects of internet-based relapse prevention for sufferers of partially remitted depression. Eighty-four individuals with partially remitted unipolar depression were randomized to either internet-based CBT (iCBT) or to a control group. After the ten week intervention period the participants were followed for 24 months and diagnostic interviews conducted to detect relapse. The intervention and monthly self-ratings of depressive symptoms were administered via an internet-based platform that ensured secure communication with all participants. Significantly fewer participants in the iCBT group had experienced a relapse compared with those in the control group two years after the internet-based intervention. The relapse rate in the iCBT group was 13.7% (CI 95% = 2.5-24.9) and in the control group it was 60.9% (CI 95% = 44.8-77). Furthermore, a significantly larger proportion of the iCBT group experienced remission two years after the intervention compared with the control group. Internet-based CBT seems promising for preventing relapse in sufferers of partially remitted depression. (C) 2013 Elsevier Ltd. All rights reserved.

Internet-based cognitive behaviour therapy (ICBT) is efficacious for treating depression, with therapist guidance identified as important for favourable outcomes. We have limited knowledge, however, about the fundamental components of therapist guidance in ICBT. The purpose of this study was to systematically examine therapist messages sent to patients during the course of ICBT for depressive symptoms in order to identify common "therapist behaviours" and the extent to which these behaviours correlate with completion of modules and improvements in symptoms at post-treatment, one- and two-year follow-up. A total of 664 e-mails from 5 therapists to 42 patients were analysed using qualitative content analysis. The most frequent behaviour was encouraging that accounted for 31.5% of the total number of coded behaviours. This was followed by affirming (25.1%), guiding (22.2%) and urging (9.8%). Less frequently the therapists clarified the internet treatment framework, informed about module content, emphasised the importance of patient responsibility, confronted the patient and made self-disclosures. Six of the nine identified therapist behaviours correlated with module completion. Three behaviours correlated with symptom improvement. Affirming correlated significantly (r=.42, p=.005) with improvement in depressive symptoms at post-treatment and after two years (r=.39, p=.014). Encouraging was associated with outcome directly after treatment (r=.52, p=.001). Self-disclosure was correlated with improvement in depressive symptoms at post-treatment (r=.44, p=.003). The study contributes to a better understanding of therapist behaviours in ICBT for depressive symptoms. Future directions for research are discussed.

Objective:

To investigate whether Internet-based cognitive behaviour therapy (CBT) can prevent relapse in persons with partially remitted major depression after previous treatment.

Method:

Seventy-one women and 13 men (N= 84) with partially remitted major depression after treatment were randomly assigned to either 10 weeks of Internet-based CBT or to a control group. Self-help material was used in combination with e-mail contact with a personal therapist. Monthly self-ratings of depressive symptoms were made, and diagnostic interviews were conducted before and after the treatment period, as well as 6 months later.

Results:

Significantly fewer participants in the CBT group experienced relapse (4⁄38 or 10.5%) compared with those in the control group (14⁄37 or 37.8%). The difference in relapse rates between groups occurred early in the study period and was still apparent after 6 months. A trend towards a larger reduction in depressive symptoms was observed at post-treatment in the participants who received CBT compared with controls. Reduction in depressive symptoms reduced the risk of relapse. A trend towards a higher remission rate was found in the CBT group at the 6 month follow-up.

Conclusion:

Internet-based CBT seems promising in preventing relapse in persons with partially remitted major depression after previous treatment.

The study objective was to assess if a 3-week intervention with the Somnox sleep robot had effects on symptoms of insomnia, somatic arousal, and/or concurrent symptoms of depression and anxiety in adults with insomnia, compared with a waitlist-control group. The participants (n = 44) were randomized to a 3-week intervention with the sleep robot (n = 22), or to a waitlist-control group (n = 22). The primary outcome measure was the Insomnia Severity Index administered at baseline, mid-intervention, post-intervention and at 1-month follow-up. Secondary outcome measures were the Pre-Sleep Arousal Scale, and the Hospital Anxiety and Depression Scale. Additionally, sleep-onset latency, wake time after sleep onset, total sleep time and sleep efficiency were measured the week prior to and the last week of the intervention, both subjectively with the Consensus Sleep Diary and objectively with wrist actigraphy. Mixed-effects models were used to analyse data. The effect of the sleep robot on the participants' insomnia severity was not statistically significant. The differences between the intervention group and the control group on the measures of arousal, anxiety and depression were also not statistically significant, and neither were the sleep diary and actigraphy variables. In conclusion, a 3-week intervention with daily at-home use of the robot was not found to be an effective method to relieve the symptom burden in adults with insomnia.

Culturally validated rating scales for social anxiety disorder (SAD) are of significant importance when screening for the disorder, as well as for evaluating treatment efficacy. This study examined construct validity and additional psychometric properties of two commonly used scales, the Social Phobia Scale and the Social Interaction Anxiety Scale, in a clinical SAD population (n = 180) and in a normal population (n = 614) in Sweden. Confirmatory factor analyses of previously reported factor solutions were tested but did not reveal acceptable fit. Exploratory factor analyses (EFA) of the joint structure of the scales in the total population yielded a two-factor model (performance anxiety and social interaction anxiety), whereas EFA in the clinical sample revealed a three-factor solution, a social interaction anxiety factor and two performance anxiety factors. The SPS and SIAS showed good to excellent internal consistency, and discriminated well between patients with SAD and a normal population sample. Both scales showed good convergent validity with an established measure of SAD, whereas the discriminant validity of symptoms of social anxiety and depression could not be confirmed. The optimal cut-off score for SPS and SIAS were 18 and 22 points, respectively. It is concluded that the factor structure and the additional psychometric properties of SPS and SIAS support the use of the scales for assessment in a Swedish population.

An atypical subgroup of Social Anxiety Disorder (SAD) with impulsive rather than inhibited traits has recently been reported. The current study examined whether such an atypical subgroup could be identified in a clinical population of 84 adults with SAD. The temperament dimensions harm avoidance and novelty seeking of the Temperament and Character Inventory, and the Liebowitz Social Anxiety Scale were used in cluster analyses. The identified clusters were compared on depressive symptoms, the character dimension self-directedness, and treatment outcome. Among the six identified clusters, 24% of the sample had atypical characteristics, demonstrating mainly generalized SAD in combination with coexisting traits of inhibition and impulsivity. As additional signs of severity, this group showed low self-directedness and high levels of depressive symptoms. We also identified a typically inhibited subgroup comprising generalized SAD with high levels of harm avoidance and low levels of novelty seeking, with a similar clinical severity as the atypical subgroup. Thus, higher levels of harm avoidance and social anxiety in combination with higher or lower levels of novelty seeking and low self-directedness seem to contribute to a more severe clinical picture. Post hoc examination of the treatment outcome in these subgroups showed that only 20 to 30% achieved clinically significant change.

Introduction: Insomnia and depression is a common comorbidity and several pilot studies have demonstrated promising results on both conditions by targeting insomnia only. The aim was to investigate the effects of CBT for insomnia (CBT-I) on both sleep and depressive symptoms in a sample with insomnia comorbid with major depression, minor depression or depressive symptoms, using a randomized controlled study.

Materials and methods: 64 participants were recruited through advertisements and randomised to receive either CBT-I or an active control (relaxation training: RT) in groups during four sessions over seven weeks. Insomnia and depressive severity was measured before, during and after treatment, using Insomnia Severity Index (ISI) and Beck Depression Inventory (BDI- II).

Results: We used independent t-tests to investigate if groups were different on symptom severity prior to treatment. There was no difference between CBT-I and RT regarding insomnia severity (t (55) = 1.30, p = 0.20) or depression severity (t (53) = −0.77, p = 0.44). Looking at development over time, mixed between-within subjects ANOVAs demonstrated a significant interaction between treatment type and time for both insomnia and depression (ISI: F (2, 54) = 4.96, p = 0.01; BDI: F (2, 58) = 2.80, p = 0.07) meaning that CBT-I meant a larger decrease of both insomnia and depressive severity compared to control treatment. There was also a significant main effect for time with decreasing scores for both groups over time on ISI (F (2, 52) = 28.86, p = 0.0005) and BDI-II (F (2, 58) = 7.11, p = 0.002) and a main effect for group on ISI (F (1, 53) = 9.25, p = 0.01) but not on BDI-II (F (1, 59) = 0.27, p = 0.60). A six months follow-up assessment is currently conducted and those results will also be presented during the conference.

Conclusion: CBT-I was associated with a greater reduction in insomnia and depression severity compared to control treatment. These results show that it is possible to have an effect on both insomnia and depression during a relatively short and cost effective group treatment, targeting insomnia only.

Aim: Insomnia is a common health problem that affects about 10% of the population. The purpose of this investigation was to examine the association between cognitive processes and the persistence and remission from insomnia in the general population.

Methods: In a longitudinal design, 2333 participants completed a survey on night time and daytime symptoms, and cognitive processes. Follow-up surveys were sent out six months and 18 months after the first assessment. Participants were categorised as having persistent insomnia, being in remission from insomnia or being a normal sleeper.

Results: Cognitive processes distinguished between people with persistent insomnia and normal sleepers. Specifically, worry, dysfunctional beliefs, somatic arousal, selective attention and monitoring, and safety behaviours increased the likelihood of reporting persistent insomnia rather than normal sleep. For people with insomnia, more worry about sleep at baseline predicted persistent insomnia but not remission later on. Lower selective attention and monitoring, and use of safety behaviours over time increased the likelihood of remission from insomnia. In general, these results remained, when psychiatric symptoms and medical complaints were added to the models.

Conclusions: The findings support that certain cognitive processes may be associated with persistence and remission of insomnia. Clinical implications are discussed.

Introduction: The purpose was to explore the development and remission of insomnia in the general population. Models of chronic insomnia suggest that cognitive and behavioural factors may maintain and worsen sleep problems. This had not been investigated prospectively before.

Method: A survey with sleep related questionnaires was sent out to 5000 in the general public three times over 1, 5 years. Respondents were classified as normal sleepers, poor sleepers, and insomniacs.

Results: Statistical software EXACON was used to examine expected and unexpected movement between sleep classifications over time. It was typical to remain in the same sleep category (p<.0001), and typical to move from insomnia to poor sleep (p<.0001). It was atypical to move from normal sleep to poor sleep or insomnia (p<.0001), and atypical to move from poor sleep or insomnia to normal sleep (p<.0001). Poor sleepers showed most classification movements. A multinomial logistic regression explored if worry (APSQ), somatic arousal (PSAS), monitoring (SAMI), dysfunctional beliefs (DBAS) and safety behaviours (SRBQ) could predict development to insomnia and normal sleep respectively for people with poor sleep at baseline. The model was significant (p<.01) with increased safety behaviours as a unique predictor of movement to insomnia (p<.01) Decreased safety behaviours showed a tendency towards significance for development to normal sleep (p>.01).

Conclusion: Complete remission was unusual once sleep problems had developed, although the severity varied over time. Safety behaviours seem to influence the development of insomnia for people with poor sleep. The role of psychological processes for insomnia needs to be explored further.

Introduction: Models of chronic insomnia suggest that cognitive and behavioural processes may maintain and worsen sleep problems. Our aim was to investigate if the degree of psychological processes at baseline would differ between three groups of stable sleep categories over 1.5 years, defined as having “insomnia disorder”, “poor sleep” or “normal sleep” at both times. Another aim was to investigate if groups with trajectories to worsened sleep (e.g. poor sleep to insomnia) would differ from groups with stable or improved sleep regarding the psychological processes.

Method: A survey with sleep-related questionnaires was sent to the general population. A multivariate analysis of variance was performed to investigate differences in psychological processes between sleep category groups. The dependent variables were safety behaviours, sleep related worry, selective attention, somatic arousal, and dysfunctional beliefs about sleep. The independent variable (1-9) consisted of nine possible combinations of development between the categories insomnia disorder, poor sleep, and normal sleep from time one until time two, 1.5 years later.

Results: There was a difference between the groups on the combined psychological processes F (5, 1238) = 19.36, p = .0001, with the groups explaining between 16-38 % of the variance of the five processes. Further analyses revealed that there were significant differences between the stable sleep groups on all psychological processes, where “stable insomnia” reported higher scores than “stable poor sleep” which in turn reported higher scores than “stable normal sleep” (p = .0001). “Poor sleep to insomnia” had significantly higher means on safety behaviours and worry compared with “stable poor sleep” and “poor sleep to normal sleep” (p = .0001).

Conclusion: The results suggest that the psychological processes are associated with different sleep trajectories over time, with worry and safety behaviours as possible risk factors for insomnia for people with poor sleep.

Aim: To investigate the effects of group CBT for insomnia (CBT-I) on insomnia and depressive symptomatology in a comorbid sample through a randomised controlled trial with a 6 month follow-up.

Methods: 64 participants were recruited through advertisements and randomised to receive CBT-I or an active control (relaxation training: RT) during four group sessions. Insomnia Severity Index and BDI-II were the primary outcome measures, assessed pre-treatment, post-treatment and at 6 month follow-up. Insomnia and depressive diagnoses, and functional impairment were assessed before and after treatment, whereas sleep diary data was gathered continuously from one week before treatment until after treatment.

Results: CBT-I was more efficient than RT in reducing insomnia severity and equally effective in reducing depressive symptoms, although CBT-I was associated with a higher proportion of remitted persons than RT, regarding both insomnia and depression diagnoses. Also, CBT-I was associated with less functional impairment, shorter sleep onset latency and wake after sleep onset but both treatments had equal improvements of sleep quality, early morning awakenings and total sleep time.

Conclusion: Group CBT-I is an efficient form of insomnia-treatment for people with insomnia comorbid with depressive symptomatology. The mixed results regarding depression outcomes warrants replication and further studies into treatment mechanisms. (C) 2015 Elsevier Ltd. All rights reserved.

Aim: To investigate the effects of group CBT for insomnia (CBT-I) on insomnia and depressive symptomatology in a comorbid sample through a randomised controlled trial with a 6 month follow-up.

Methods: 64 participants were recruited through advertisements and randomised to receive CBT-I or an active control (relaxation training: RT) during four group sessions. Insomnia Severity Index and BDI-II were the primary outcome measures, assessed pre-treatment, post-treatment and at 6 month follow-up. Insomnia and depressive diagnoses, and functional impairment were assessed before and after treatment, whereas sleep diary data was gathered continuously from one week before treatment until after treatment.

Results: CBT-I was more efficient than RT in reducing insomnia severity and equally effective in reducing depressive symptoms, although CBT-I was associated with a higher proportion of remitted persons than RT, regarding both insomnia and depression diagnoses. Also, CBT-I was associated with less functional impairment, shorter sleep onset latency and wake after sleep onset but both treatments had equal improvements of sleep quality, early morning awakenings and total sleep time.

Conclusion: Group CBT-I is an efficient form of insomnia-treatment for people with insomnia comorbid with depressive symptomatology. The mixed results regarding depression outcomes warrants replication and further studies into treatment mechanisms.

Aim: CBT for insomnia (CBT-I) seems to affect both insomnia and depression in comorbid samples but there is a gap in the knowledge about how the treatment works. The aim was to gain a greater understanding of the relationship between insomnia-specific cognitive processes, insomnia, depressive symptoms and CBT-I in sample with insomnia comorbid with depressive problems.

Methods: 64 participants were recruited through advertisements and randomised to receive either CBT-I or an active control (relaxation training: RT) in groups during four sessions over seven weeks. Insomnia, depressive severity, and cognitive processes were measured pre-, mid- and post-treatment.

Results: All cognitive processes: sleep-related worry, dysfunctional beliefs, somatic arousal, selective attention and monitoring, and safety behaviours, lowered over the course of treatment. CBT-I was associated with greater reductions of safety behaviours and dysfunctional beliefs about sleep compared to RT. Mid-treatment dysfunctional beliefs aboutsleep mediated between CBT-I and outcomes on insomnia and depression severity.

Conclusion: Dysfunctional beliefs may be a transdiagnostic process of both insomnia and depression. Clinical implications and further directions are discussed.

Background: Recent treatment studies with cognitive behavioural therapy for insomnia (CBT-I) have demonstrated effects on both sleep problems and depression. Two previous studies have indicated that the beneficial effect from CBT-I on depression may come through improved sleep, although insomnia severity during treatment had not previously been investigated as a mediator.

Aims: Our aim was to investigate if insomnia severity during treatment mediated between CBT-I and depression severity after treatment, in a sample with co-morbid insomnia and depressive symptomology. We also examined whether depressive severity during treatment mediated between CBT-I and insomnia after treatment.

Method: The participants were recruited from advertisements and fulfilled criteria for insomnia diagnosis, and had depressive symptomatology (Beck Depression Inventory-second edition: BDI-II > 13). Two-thirds of the participants were diagnosed with major depressive disorder. The participants received four biweekly group sessions of CBT-I or relaxation training (active control). Insomnia severity (Insomnia Severity Index) and depressive severity (BDI-II) were measured at baseline, mid-treatment, post-treatment and 6-month follow-up. The mid-treatment measures were used as mediators.

Results: Mediational analyses demonstrated a significant reciprocal relationship between insomnia severity and depressive severity throughout CBT-I, although mid-treatment insomnia had a stronger effect on depression than mid-treatment depression had on insomnia. The results were similar for both post-treatment and follow-up.

Discussion: Some improvement in depressive severity after CBT-I is explained by improved sleep. The findings emphasize the importance of making comorbid insomnia a treatment focus in its own right.

Clinical trials have shown that cognitive behavioural therapy for insomnia (CBT-I) may have an effect on both insomnia and depression in comorbid samples, but there is a gap in the knowledge on why CBT-I has an impact on depression. Neuropsychological theories suggest that disturbed sleep may work as a transdiagnostic process that maintains psychopathology. The aim was to test whether CBT-I impacts depressive symptoms through improved sleep, in a sample with insomnia comorbid with major depression and subthreshold depressive symptoms. 64 participants were recruited through advertisements and randomised to receive either CBT-I or an active control (relaxation training: RT) in groups during four bi-weekly sessions. Insomnia (ISI) and depressive severity (BDI-II) were measured pre-, mid- and post-treatment. Mediational analyses were conducted. Insomnia and depressive severity lowered over the course of treatments. CBT-I was superior in reducing insomnia. The main treatment outcomes have been published elsewhere (Norell-Clarke et al, 2015). The relationship between CBT-I and post-treatment depressive severity was mediated by mid-treatment insomnia severity, which indicates that the effect of CBT-I on depression goes through improved sleep (b = -4.87, BCa CI = -9.21, -1.97). The results were maintained when pre-treatment insomnia and depressive severity were controlled for (b = -3.36, BCa CI = -8.86, -0.45). Testing for reciprocity, we found that mid-treatment depressive severity did not mediate between CBT-I and post-treatment insomnia severity. The results support the perpetuating role of insomnia in depression. This may have implications for other psychiatric patient groups with comorbid insomnia. Also, the results indicate that CBT for comorbid patient groups may need to target sleep specifically.

Group based preventive parenting programs are efficacious, but seem hard to implement sustainably within regular service. This review aimed to investigate specific challenges related to their implementation. Through a systematic search in several databases, we retrieved 1356 articles for title, abstract, and full-text screening. After screening, we selected 35 articles for quality rating. An established narrative approach allowed us to include 24 studies. We used an ecological approach and a recently suggested implementation construct terminology to report our findings. To date, there are no evaluations of the implementation of group based programs where implementation aspects and effectiveness are compared with other kinds of programs or formats. Hence, important research knowledge is lacking concerning implementation of group based parenting programs. Our finding indicate that certain format specific implementation aspects of group based parenting programs are perceived by practitioners as particularly challenging. For instance, scheduling of group leader workload, provision of additional services (e.g., meals and childcare), and recruitment of participants. Further, practitioners and group leaders influence implementation success and program sustainability as well as parental attitudes and reasons for participation. To highlight the importance of practitioners and parents we suggest adaptations to the ecological model approach. Overall, the theoretical foundation of current implementation research is weak and future implementation research need to be theoretically driven. It is important to fill the existing lack of implementation knowledge because it might be one of the reasons why group based parenting programs have limited impact as preventive interventions on children's mental well-being.

Background and aims: Returning to work after periods of sick-leave due to chronic pain problems, involve a number of situations of interpersonal nature (e.g. meeting supervisors/insurance companies to adapt work setting to present functional level, receive help from colleagues, express pain, etc.). Since chronic pain has shown co-morbidity with social anxiety, it is of interest to investigate restraining factors in return to work among chronic pain sufferers from a social perspective. Catastrophizing is identified in both pain and social anxiety as a mechanism that might fuel a continuous bias in how situations are perceived (threat) and by hindering the development of functional behavior strategies. The presence of social anxiety in chronic pain patients might be seen as a stressor that limits the individuals' ability to effectively communicate pain-related needs to colleagues, and/or employers and therefore act as a hindering factor in return-to-work. Hence, the overall aim of this study was to examine the relationship between social anxiety, pain catastrophizing, and perceived ability to communicate pain-related needs to the work environment in a clinical pain population.

Methods: The study employed a cross-sectional design and involved 247 individuals with chronic pain (82.3% women; M-age = 44 years). Measures included the Pain catastrophizing Scale, the Social Phobia Screening Questionnaire and the communication of pain-related needs-subscale of the Return-To-Work Self-efficacy Questionnaire. Analyzes were run to examine whether social anxiety moderated the relation between pain catastrophizing, and perceived ability to communicate pain-related needs while controlling for pain severity/interference and sick leave.

Results: Social anxiety and pain catastrophizing correlated positively with each other and negatively with perceived ability to communicate pain-related needs. No support was obtained for a moderating effect of social anxiety. However, social anxiety and pain interference were each significant predictors of the individual's confidence in being able to communicate pain-related needs to the work environment.

Conclusions: In the context of pain and work-related communication, symptoms of social anxiety was identified as being of similar importance to the outcome as pain interference, while pain severity was not associated with the individual's confidence in communicating one's pain-related needs.

Implications: The results implicate that fears relating to pain-related social situations at work might be central in the process of return-to-work and rehabilitation in chronic pain.

Internet-based cognitive behavior therapy (CBT) has proven to be effective for university students with social anxiety disorder (SAD) and public speaking fears. The aim of this study was to investigate if the promising results can be transferred to high school students suffering from this condition. A total of 19 speech-anxious high school students with SAD were randomized either into nine weeks of Internet-delivered CBT or to a waitlist control group. Significant improvements were found on measures of social anxiety, general anxiety, and depression. Effects were maintained at a 1-year follow-up. The average within and between-group effect sizes for the primary social anxiety scales at post-test were Cohen’s d = 0.98 and 1.38 respectively. However, the average number of completed modules in the CBT program was low. Although compliance can be improved, the results suggest that Internet-based guided self-help is effective in the treatment of high school students with SAD.

BACKGROUND: This study investigated the efficacy of an Internet-based self-help program with minimal therapist contact via e-mail for Swedish university students with social phobia and public speaking fears. The main objective was to test if the Internet-based self-help program would be more effective if five live group exposure sessions were added.

METHODS: Thirty-eight students meeting the diagnostic and statistical manual of mental disorders, 4th edition criteria for social phobia were randomized into two different treatment groups: Internet delivered cognitive behavior therapy combined with five group exposure sessions (ICBT+ exp) or the Internet program alone (ICBT).

RESULTS: Results were analyzed on an intention-to-treat basis. Both treatment groups showed significant improvement from pre- to post-test, and from pre-test to 1-year follow-up, on all measured dimensions (social anxiety, general anxiety, depression levels, and quality of life). For both the groups, the average within-group effect sizes for the primary social anxiety scales, expressed as Cohen's d, were comparable to those seen in traditionally administered cognitive behavioral therapy both at post-test and at 1- year follow-up.

CONCLUSIONS: The results suggest that the Internet-based self-help program on its own is efficient in the treatment of university students with social phobia. Adding group exposure sessions did not improve the outcome significantly.

A high degree of co-morbidity has been observed in general between chronic pain and various anxiety disorders and specifically between chronic pain and social anxiety disorder (or social phobia) both in clinical pain populations and in general populations. What is the etiology behind this co-morbidity? One clue may come from the concept of self-focused attention. A personality trait that refers to people’s individual differences in the degree of self-focused attention is self-consciousness, which has been observed to consist of two separate aspects. One is a private aspect addressing a person’s inner experiences as thoughts, feelings and somatic symptoms. The other aspect is a public aspect addressing a person’s attention to the self as a social object. Social anxiety disorder is characterized by a marked fear of scrutiny in a variety of social situations which implies a high degree of public self-consciousness. High degree of public self- consciousness has been associated both with higher degree of sensitivity to being socially rejected, and with physical (sexual) pain. However, research related to public self-consciousness and pain is very limited. Interesting to note is that from a neurobiological perspective the same area in the brain is activated both in physical pain and in social exclusion. In line with this, it has also been observed that sensitivity to physical pain and sensitivity to social rejection are mutually reinforcing. In Western societies we build much of our identity from what we achieve. For people who develop chronic pain and the often accompanying labor reduction should the social environment be experienced more invalidating if the person at the same time worries a lot for how others will perceive him/her (i.e., being high on public self-consciousness). This in turn may reinforce the impulse to avoid not only situations involving activities of a physical nature but also social activities. Overall, it should be of interest to examine public self-consciousness in relation to both pain and social anxiety. It has to our knowledge not been done before.

Aim: The aim of the present study was to examine and identify possible patterns (by cluster analysis) of self-consciousness (public and private), social anxiety and pain in a non-clinical population. These profiles were examined in relation to disabling social anxiety respectively disabling pain.

Methods: In this study, cluster analysis was used to identify subgroups of people characterized by different profiles of social anxiety, self-consciousness (public and private) and pain. University students (19-46 years old; N = 302) participated in a cross-sectional study.

Results: We identified six clusters, including one group scoring high on all variables (the co-morbidity cluster). Further, we found a significant relation between the cluster solution and both disabling pain and disabling social anxiety where people belonging to the co-morbidity cluster were overrepresented.

Conclusions: This suggests that public self-consciousness may be important to consider in terms of co-morbidity between pain and social anxiety. A next step is to try to replicate this result and thereby increase the external validity. Finally, if a person has a pattern in which he/she scores high on pain, social anxiety and public and private self-consciousness this may point to an enhanced risk for that person to developing both social anxiety disorder and chronic pain.

The Axis I disorder social phobia and the Axis II disorder avoidant personality disorder were first introduced in the DSM nomenclature in 1980. Since then a major nosological theme in research has concerned whether or not social phobia and avoidant personality disorder represent distinct clinical categories. Our main aim was to summarize both the current situation regarding this conceptual debate, as well as what we still do not know. In the present review we describe the evolution of these disorders as they have been addressed over time, from their introduction in the DSM-III system to their current descriptions in the DSM-IV. Thereafter, earlier empirical literature concerning this conceptual debate is evaluated, with the main focus on comorbidity between social phobia and avoidant personality disorder. The PsycINFO and PubMed electronic databases were searched for studies, and complementary searches of references in articles and books were conducted. To conclude, the studies summarized provide support for the view that social phobia and avoidant personality disorder are more than arbitrary cutoffs along a continuum of social anxiety.

Little is understood about generalized and non-generalized social anxiety disorder (SAD) and their associations with co-occurring internalizing and externalizing problems in adolescence. In the present study, we investigated adolescent boys with SAD symptoms and considered depressive symptoms as well as antisocial behaviors when looking for patterns during two developmental time periods; junior high and high school. Participants in the analyses were part of a longitudinal study. No patterns were found linking antisocial problems and non-generalized SAD in either junior high or high school. Furthermore, it was uncommon for youths in the non-generalized SAD subgroup to develop comorbidity over time. The generalized SAD subgroup of boys, however, was likely to develop comorbidity either with depressive symptoms only or with depressive symptoms and antisocial tendencies. Our findings suggest that developmental pathways for SAD subgroups may differ.

Det är inte antalet stressorer i sig som gör att ungdomar utvecklar ohälsa. Nyckeln är hur dessa hanteras, emotionsreglering. Utifrån den hypotesen studerar Maria tillfors, professor i psykologi, ida Flink, lektor och forskare i psykologi, samt Malin Anniko, doktorand i psykologi, samtliga tillhörande forskargruppen CHAMP vid Örebro universitet, utvecklingen av hälso-psykologiska problem bland tonåringar. 

BACKGROUND: Public speaking is a common situation that university students have to endure. This situation is feared or avoided by most individuals with social phobia, which has been associated with low levels of educational attainment. However, epidemiological data on social phobia in university students are scarce. The present study examined the prevalence of social phobia and its subgroups in a university student population. Demographic characteristics and avoidant behavior in educational settings were also examined.

METHODS: The Social Phobia Screening Questionnaire (SPSQ)--a validated and DSM-IV compatible instrument, was distributed as a postal survey to 753 randomly selected university students in Sweden. Interpretable questionnaires were obtained from 523 students (69.5%). To investigate subgroups, students who met the SPSQ diagnostic criteria of social phobia were analyzed by hierarchical cluster analysis.

RESULTS: The point prevalence of social phobia among the Swedish university students was 16.1%, comparable with 15.6% previously reported for the general population. Two clusters were distinguished consisting of students scoring either low (discrete subgroup) or high (generalized subgroup) on all cluster variables. The discrete subgroup was more common representing 83% of the cases. Social phobia was associated with use of dysfunctional avoidant strategies in educational situations and in anticipation of public speaking. The disorder was less common among students following a pedagogic university program.

CONCLUSIONS: Social phobia was highly prevalent among Swedish university students, most cases pertaining to a mild or discrete form of the disorder. The commonness and severity of social phobia in students did not deviate significantly from the general population suggesting that socially anxious individuals do apply for higher education. However, since avoidance and low educational attainment are commonly reported features, future studies should investigate whether sufferers of social phobia underachieve or abolish their studies prematurely.

In social anxiety disorder (SAD) co-morbid depressive symptoms as well as avoidance behaviors have been shown to predict insufficient treatment response. It is likely that subgroups of individuals with different profiles of risk factors for poor treatment response exist. This study aimed to identify subgroups of social avoidance and depressive symptoms in a clinical sample (N=167) with SAD before and after guided internet-delivered CBT, and to compare these groups on diagnostic status and social anxiety. We further examined individual movement between subgroups over time. Using cluster analysis we identified four subgroups, including a high-problem cluster at both time-points. Individuals in this cluster showed less remission after treatment, exhibited higher levels of social anxiety at both assessments, and typically remained in the high-problem cluster after treatment. Thus, in individuals with SAD, high levels of social avoidance and depressive symptoms constitute a risk profile for poor treatment response.

Purpose: Socially anxious people are typically thought of as being behaviorally inhibited; however, an atypical subgroup, which is impulsive rather than inhibited, has recently been identified [1]. Theoretically, inhibition and impulsivity could be viewed as different strategies for coping with anxiety that have the same goal—escape from negative emotions—but they seem to have different implications. Previous studies have found that the socially anxious-impulsive subgroup was higher on risk-prone behavior, as for example drug use, compared with a socially anxious-inhibited subgroup [1]. In this study, we aimed to identify these subgroups in a general population, and asked whether they also experience various levels of depressive symptoms and life satisfaction, as well as moderating effects of gender.

Methods: Cluster analysis was used to identify subgroups of young adults (20 - 24 years old; N = 772) characterized by different profiles of social anxiety and impulsivity. These subgroups were compared on levels of internal adjustment, and the moderating effects of gender were also tested.

Results: We identified five clusters, including an Anxious-Inhibited and an Anxious-Impulsive cluster. In the interaction between gender and cluster membership, gender showed evidence of moderation regarding both depressive symptoms and life satisfaction, with the young women in the Anxious-Inhibited and the Anxious-Impulsive clusters faring worst.

Conclusions: We replicated previous findings demonstrating the existence of a socially anxious-impulsive subgroup, thus solidifying current knowledge that may be important when it comes to diagnostics and treatment. This may prove particularly important for young women regarding internalizing symptoms.