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  • 1.
    Andersson, E.
    et al.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hedman, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Enander, J.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
    Kaldo, V.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
    Andersson, G.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Lindefors, N.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
    Rück, C.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, 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.

  • 2.
    Andersson, G.
    et al.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institute, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Cima, R. F. F.
    Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands.
    Weise, C.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany.
    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, & 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.

  • 3.
    Andersson, G.
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Hummerdal, D.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Bergman-Nordgren, L.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Carlbring, P.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; 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]

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

    Aim: The 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.

    Results: Results 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.

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

  • 4.
    Andersson, G.
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Veilord, A.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Svedling, L.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Andersson, F.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Sleman, O.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Mauritzson, L.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Sarkohi, A.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Claesson, E.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Zetterqvist, V.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Lamminen, M.
    Redakliniken, Linköping, Sweden.
    Eriksson, T.
    Redakliniken, Linköping, Sweden.
    Carlbring, P.
    Department of Psychology, Stockholm University, Stockholm, 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.

    Method: 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. Results 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 Cohen's 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.

    Limitations: The study was small with two active treatments and there was no placebo or credible control condition.

    Conclusions: Guided ICBT is at least as effective as group based CBT and long-term effects can be sustained up to 3 years after treatment.

  • 5.
    Andersson, G.
    et al.
    Department of Behavioural Sciences and Learning, SwedishInstitute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Section of Psychiatry, Karolinska Institute, Stockholm, Sweden.
    Sarkohi, A.
    Department of Behavioural Sciences and Learning, SwedishInstitute for Disability Research, Linköping University, Linköping, Sweden; Department of Psychiatry, Linköping University Hospital, Linköping, Sweden.
    Karlsson, J.
    Department of Behavioural Sciences and Learning, SwedishInstitute for Disability Research, Linköping University, Linköping, Sweden.
    Bjärehed, J.
    Department of Psychology, Lund University, Lund, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, SwedishInstitute for Disability Research, Linköping University, Linköping, Sweden.
    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]

    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 pre-post changes in depressive symptoms. Effects of psychological treatments are most often tested with self-report inventories and seldom with tests of cognitive function. 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 a 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. 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. 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.

  • 6.
    Andersson, Gerhard
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    McKenna, Laurence
    Psychological mechanisms and tinnitus2016In: Tinnitus: Clinical and research perspectives / [ed] David M Baguley, Marc Fagelson, San Diego: Plural Publishing, Inc., 2016, p. 63-73Chapter in book (Other academic)
  • 7.
    Arnison, Tor
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Schrooten, Martien G. S.
    Örebro University, School of Law, Psychology and Social Work.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Jansson-Fröjmark, Markus
    Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Persson, Jonas
    Örebro University, School of Law, Psychology and Social Work. Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
    Longitudinal, bidirectional relationships of insomnia symptoms and musculoskeletal pain across adolescence: the mediating role of mood2022In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 163, no 2, p. 287-298Article in journal (Refereed)
    Abstract [en]

    Previous studies have established a bidirectional relationship between sleep and pain, and mood has been proposed as a mediator of this relationship. There are only a limited number of longitudinal studies examining the mediational role of mood, and the directionality of effects between sleep, pain and mood is uncertain. Also, and despite the high prevalence of pain and sleep problems during adolescence, these relationships have rarely been examined in a longitudinal sample of adolescents. Here, longitudinal survey data with five yearly measurements was used to examine the bidirectional relationship between insomnia symptoms and pain across adolescence (Mbaseline age = 13.65 years, Nbaseline = 2766). We also explored if depressed mood, positive affect and anxious mood function as mediators in both directions of the sleep-pain relationship. Utilizing latent variables for insomnia, pain and mood at multiple time-points, the data was analyzed with cross-lagged panel models for longitudinal data with structural equation modeling. Current results confirmed a bidirectional relationship between insomnia symptoms and pain, where the effect of insomnia symptoms on pain was stronger than vice versa. Depressed mood and anxious mood mediated the effect of insomnia symptoms on pain, but not the reverse effect of pain on insomnia symptoms. Positive affect did not serve as a mediator in either direction. These findings add novel insights into the temporal directionality of sleep, pain and mood during adolescence, suggesting a temporal path from sleep to pain, via mood, rather than a reciprocal relationship between the constructs.

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    Longitudinal, bidirectional relationships of insomnia symptoms and musculoskeletal pain across adolescence: the mediating role of mood
  • 8.
    Axelsson, Erland
    et al.
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, Erik
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjann
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Hedman-Lagerlöf, Erik
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Osher Center for Integrative Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Mediators of treatment effect in minimal-contact cognitive behaviour therapy for severe health anxiety: A theory-driven analysis based on a randomised controlled trial2020In: Journal of Anxiety Disorders, ISSN 0887-6185, E-ISSN 1873-7897, Vol. 69, article id 102172Article in journal (Refereed)
    Abstract [en]

    Cognitive behaviour therapy (CDT) is efficacious for severe health anxiety, but little is known about mechanisms. We analysed putative mediators of change based on 13 weekly assessments in a randomised controlled trial (N = 132) of exposure-based minimal-contact CBT (guided Internet-delivered CBT, unguided Internet-delivered CBT and bibliotherapy) vs. a waitlist control for severe health anxiety. We hypothesised that the effect of CBT on health anxiety would be mediated by non-reactivity to inner experiences, health anxiety behaviours and perceived competence. We also explored somatosensory amplification. In parallel process growth models, nonreactivity, health anxiety behaviours and perceived competence - but not somatosensory amplification - were influenced by CBT and associated with health anxiety. Random intercepts cross-lagged panel models were used to study within-individual ordering of change. None of the putative mediators systematically predicted subsequent changes in health anxiety. Rather, changes in health anxiety predicted subsequent changes in all putative mediators. In summary, CBT influenced health anxiety behaviours, non-reactivity to inner experiences and perceived competence, and these variables were associated with the outcome. However, their role as mediators was not corroborated because we found no evidence that changes in these variables predicted subsequent changes in health anxiety. We encourage further research into mediators of CBT for health anxiety.

  • 9.
    Axelsson, Erland
    et al.
    Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Liljeholmen Primary Health Care Center, Region Stockholm, Stockholm, Sweden; Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden.
    Kern, Dorian
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Hedman-Lagerlöf, Erik
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Lindfors, Perjohan
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Palmgren, Josefin
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Örebro University, School of Behavioural, Social and Legal Sciences. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, Erik
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Johansson, Robert
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Olén, Ola
    Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Department of Pediatric Gastroenterology and Nutrition, Sachs' Children's Hospital, Stockholm, Sweden.
    Bonnert, Marianne
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Lalouni, Maria
    Division of Neuro, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Psychological treatments for irritable bowel syndrome: a comprehensive systematic review and meta-analysis2023In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 52, no 6, p. 565-584Article, review/survey (Refereed)
    Abstract [en]

    A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a.

  • 10.
    Bejerot, Susanne
    et al.
    Örebro University, School of Medical Sciences. Faculty of Health and Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden.
    Eklund, Daniel
    Örebro University, School of Medical Sciences.
    Hesser, Hugo
    Örebro University, School of Behavioural, Social and Legal Sciences.
    Hietala, Max Albert
    Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.
    Kariis, Tarmo
    Karlstad Central Hospital, Region Värmland, Karlstad, Sweden.
    Lange, Niclas
    Örebro University, School of Medical Sciences.
    Lebedev, Alexander
    Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Nordenskjöld, Axel
    Örebro University, School of Medical Sciences.
    Petrovic, Predrag
    Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Söderbergh, Annika
    Department of Rheumatology, Örebro University Hospital, Örebro, Sweden.
    Thunberg, Per
    Örebro University, School of Medical Sciences. Department of Radiology and Medical Physics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Center for Experimental and Biomedical Imaging in Örebro (CEBIO), Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Wikström, Sverre
    Örebro University, School of Medical Sciences. Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden.
    Humble, Mats B.
    Örebro University, School of Medical Sciences.
    Study protocol for a randomized controlled trial with rituximab for psychotic disorder in adults (RCT-Rits)2023In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 23, no 1, article id 771Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The role of inflammation in the aetiology of schizophrenia has gained wide attention and research on the association shows an exponential growth in the last 15 years. Autoimmune diseases and severe infections are risk factors for the later development of schizophrenia, elevated inflammatory markers in childhood or adolescence are associated with a greater risk of schizophrenia in adulthood, individuals with schizophrenia have increased levels of pro-inflammatory cytokines compared to healthy controls, and autoimmune diseases are overrepresented in schizophrenia. However, treatments with anti-inflammatory agents are so far of doubtful clinical relevance. The primary objective of this study is to test whether the monoclonal antibody rituximab, directed against the B-cell antigen CD20 ameliorates psychotic symptoms in adults with schizophrenia or schizoaffective disorder and to examine potential mechanisms. A secondary objective is to examine characteristics of inflammation-associated psychosis and to identify pre-treatment biochemical characteristics of rituximab responders. A third objective is to interview a subset of patients and informants on their experiences of the trial to obtain insights that rating scales may not capture.

    METHODS: A proof-of-concept study employing a randomised, parallel-group, double-blind, placebo-controlled design testing the effect of B-cell depletion in patients with psychosis. 120 participants with a diagnosis of schizophrenia spectrum disorders (SSD) (ICD-10 codes F20, F25) will receive either one intravenous infusion of rituximab (1000 mg) or saline. Psychiatric measures and blood samples will be collected at baseline, week 12, and week 24 post-infusion. Brief assessments will also be made in weeks 2 and 7. Neuroimaging and lumbar puncture, both optional, will be performed at baseline and endpoints. Approximately 40 of the patients and their informants will be interviewed for qualitative analyses on the perceived changes in well-being and emotional qualities, in addition to their views on the research.

    DISCUSSION: This is the first RCT investigating add-on treatment with rituximab in unselected SSD patients. If the treatment is helpful, it may transform the treatment of patients with psychotic disorders. It may also heighten the awareness of immune-psychiatric disorders and reduce stigma.

    TRIAL REGISTRATION: NCT05622201, EudraCT-nr 2022-000220-37 version 2.1. registered 14th of October 2022.

  • 11.
    Bendelin, N.
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Dahl, J.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Carlbring, P.
    Department of Psychology, Umeå University, Umeå, Sweden.
    Nelson, K. Z.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of ClinicalNeuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    Experiences of guided Internet-based cognitive-behavioural treatment for depression: A qualitative study2011In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 11, article id 107Article in journal (Refereed)
    Abstract [en]

    Background: 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.

    Methods: 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.

    Results: 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.

    Conclusions: 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.

  • 12.
    Bjureberg, Johan
    et al.
    Stanford Univ, Dept Psychol, Stanford CA, USA; Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Solna, Sweden; Reg Stockholm, Stockholm Hlth Care Serv, Stockholm, Sweden.
    Ojala, Olivia
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Solna, Sweden; Reg Stockholm, Stockholm Hlth Care Serv, Stockholm, Sweden.
    Berg, Anton
    Linköping Univ, Dept Behav Sci & Learning, Linköping, Sweden.
    Edvardsson, Elin
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Solna, Sweden..
    Kolbeinsson, Orn
    Linköping Univ, Dept Behav Sci & Learning, Linköping, Sweden.
    Molander, Olof
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Solna, Sweden.;Reg Stockholm, Stockholm Hlth Care Serv, Stockholm, Sweden.
    Morin, Evelina
    Linköping Univ, Dept Behav Sci & Learning, Linköping, Sweden.
    Nordgren, Line
    Linköping Univ, Dept Behav Sci & Learning, Linkoping, Sweden.;Reg Ostergotland, Dept Child & Adolescent Psychiat, Linköping, Sweden.
    Palme, Kristin
    Linköping Univ, Dept Behav Sci & Learning, Linköping, Sweden.
    Särnholm, Josefin
    Karolinska Inst, Dept Clin Neurosci, Div Psychol, Solna, Sweden.
    Wedin, Leif
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Solna, Sweden.
    Rück, Christian
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Solna, Sweden.;Reg Stockholm, Stockholm Hlth Care Serv, Stockholm, Sweden.
    Gross, James J. J.
    Stanford Univ, Dept Psychol, Stanford CA, USA.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Linköping Univ, Dept Behav Sci & Learning, Linköping, Sweden.
    Targeting Maladaptive Anger With Brief Therapist-Supported Internet-Delivered Emotion Regulation Treatments: A Randomized Controlled Trial2023In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 91, no 5, p. 254-266Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate the relative impact of three brief therapist-supported internet-delivered emotion regulation treatments for maladaptive anger (mindful emotion awareness [MEA], cognitive reappraisal [CR], and mindful emotion awareness + cognitive reappraisal [MEA + CR]) and to test whether baseline levels of anger pathology moderate treatment outcome.

    Method: Treatments were evaluated in a randomized controlled trial. In total, 234 participants (59% female; mean age = 41.1, SD = 11.6) with maladaptive anger were randomized to MEA (n = 78), CR (n = 77), or MEA + CR (n = 79). Self-reported primary and secondary outcomes were followed up at primary endpoint, 3 months after treatment termination (88% retention). Primary outcomes were also assessed weekly during a prolonged baseline phase (4 weeks) and an active treatment phase (4 weeks).

    Results: At the primary endpoint, the MEA + CR was superior in terms of anger expression (d = 0.27 95% confidence interval, CI [0.03, 0.51]), aggression (d = 0.43 [0.18, 0.68]), and anger rumination (d = 0.41 [0.18, 0.63]). MEA + CR was particularly effective in reducing anger expression (d = 0.66 [0.21, 1.11]), aggression (d = 0.90 [0.42, 1.39]), and anger rumination (d = 0.80 [0.40, 1.20]) for individuals who reported high values (+1SD) of the outcomes at baseline.

    Conclusions: Brief therapist-supported internet-delivered MEA and CR treatments are effective interventions for maladaptive anger. Combining MEA and CR is especially effective in reducing anger expression and aggression, particularly, in individuals who report higher levels of initial anger pathology. The present study highlights the importance of emotion regulation as an important treatment target for reducing maladaptive anger.

  • 13.
    Bjureberg, Johan
    et al.
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Ojala, Olivia
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Hesser, Hugo
    Örebro University, School of Behavioural, Social and Legal Sciences.
    Häbel, Henrike
    Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Sahlin, Hanna
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Gratz, Kim L.
    Department of Psychology, University of Toledo, Toledo, Ohio, USA; Lyra Health, Burlingame, California, USA.
    Tull, Matthew T.
    Department of Psychology, University of Toledo, Toledo, Ohio, USA.
    Claesdotter Knutsson, Emma
    Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hellner, Clara
    Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Effect of Internet-Delivered Emotion Regulation Individual Therapy for Adolescents With Nonsuicidal Self-Injury Disorder: A Randomized Clinical Trial2023In: JAMA Network Open, E-ISSN 2574-3805, Vol. 6, no 7, article id e2322069Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Nonsuicidal self-injury is prevalent in adolescence and associated with adverse clinical outcomes. Effective interventions that are brief, transportable, and scalable are lacking.

    OBJECTIVE: To test the hypotheses that an internet-delivered emotion regulation individual therapy for adolescents delivered adjunctive to treatment as usual is superior to treatment as usual only in reducing nonsuicidal self-injury and that improvements in emotion regulation mediate these treatment effects.

    DESIGN, SETTING, AND PARTICIPANTS: This 3-site, single-masked, randomized superiority trial enrolled participants from November 20, 2017, to April 9, 2020. Eligible participants were aged between 13 and 17 years and met diagnostic criteria for nonsuicidal self-injury disorder; they were enrolled as a mixed cohort of consecutive patients and volunteers. Parents participated in parallel to their children. The primary end point was at 1 month after treatment. Participants were followed up at 3 months posttreatment. Data collection ended in January 2021.

    INTERVENTIONS: Twelve weeks of therapist-guided, internet-delivered emotion regulation individual therapy delivered adjunctive to treatment as usual vs treatment as usual only.

    MAIN OUTCOMES AND MEASURES: Primary outcome was the youth version of the Deliberate Self-harm Inventory, both self-reported by participants prior to treatment, once every week during treatment, and for 4 weeks posttreatment, and clinician-rated by masked assessors prior to treatment and at 1 and 3 months posttreatment.

    RESULTS: A total of 166 adolescents (mean [SD] age, 15.0 [1.2] years; 154 [92.8%] female) were randomized to internet-delivered emotion regulation therapy plus treatment as usual (84 participants) or treatment as usual only (82 participants). The experimental intervention was superior to the control condition in reducing clinician-rated nonsuicidal self-injury (82% vs 47% reduction; incidence rate ratio, 0.34; 95% CI, 0.20-0.57) from pretreatment to 1-month posttreatment. These results were maintained at 3-month posttreatment. Improvements in emotion dysregulation mediated improvements in self-injury during treatment.

    CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a 12-week, therapist-guided, internet-delivered emotion regulation therapy delivered adjunctive to treatment as usual was efficacious in reducing self-injury, and mediation analysis supported the theorized role of emotion regulation as the mechanism of change in this treatment. This treatment may increase availability of evidence-based psychological treatments for adolescents with nonsuicidal self-injury.

    TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03353961.

  • 14.
    Blom, K.
    et al.
    Karolinska Institutet, Department of Clinical Neuroscience, Division of Psychiatry, Stockholm, Sweden.
    Tarkian Tillgren, H.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Wiklund, T.
    Department of Pain and Rehabilitation Center, Linköping, Sweden; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Danlycke, E.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Forssén, M.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Söderström, A.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Johansson, R.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Jernelöv, S.
    Karolinska Institutet, Department of Clinical Neuroscience, Section of Psychology, Stockholm, Sweden.
    Lindefors, N.
    Karolinska Institutet, Department of Clinical Neuroscience, Division of Psychiatry, Stockholm, Sweden.
    Andersson, G.
    Karolinska Institutet, Department of Clinical Neuroscience, Division of Psychiatry, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Kaldo, V.
    Karolinska Institutet, Department of Clinical Neuroscience, Division of Psychiatry, Stockholm, 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 Cohen's 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 > 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.

  • 15.
    Boersma, Katja
    et al.
    Örebro University, School of Law, Psychology and Social Work. Center for Health and Medical Psychology.
    Södermark, Martin
    Department of Medical and Health Sciences, Pain and Rehabilitation Centre, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Division of Psychology, Linköping University, Linköping, Sweden.
    Flink, Ida
    Örebro University, School of Law, Psychology and Social Work.
    Gerdle, Björn
    Department of Medical and Health Sciences, Pain and Rehabilitation Centre, Linköping University, Linköping, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work. Center for Health and Medical Psychology.
    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.

  • 16.
    Brinkborg, H.
    et al.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Michanek, J.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Berglund, G.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    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 6-7, 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 >= 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.

  • 17.
    Dirkse, D.
    et al.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Hadjistavropoulos, H. D.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Hesser, Hugo
    Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden.
    Barak, A.
    Department of Counseling Psychology, University of Haifa, 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.

  • 18.
    El Alaoui, S.
    et al.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Hedman, E.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden.
    Kaldo, V.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden.
    Kraepelien, M.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Rück, C.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Andersson, G.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Lindefors, N.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, 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 clinic's 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 clinic's 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.

  • 19.
    Fors, Maria
    et al.
    Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Activity and Health in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Öberg, Birgitta
    Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Enthoven, Paul
    Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Schröder, Karin
    Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Hesser, Hugo
    Örebro University, School of Behavioural, Social and Legal Sciences. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hedevik, Henrik
    Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
    Abbott, Allan
    Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Orthopaedics, Linköping University Hospital, Linköping, Sweden.
    Are illness perceptions and patient self-care enablement mediators of treatment effect in best practice physiotherapy low back pain care? Secondary mediation analyses in the BetterBack trial2023In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, p. 1-14Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: A best practice physiotherapy model of care (BetterBack MoC) for low back pain (LBP) aimed to improve patients' illness perceptions and self-care enablement, according to the Common-Sense Model of Self-Regulation (CSM).

    OBJECTIVE: To confirm if illness perceptions and patient self-care enablement, in line with the CSM, are mediators of treatment effects on disability and pain of the BetterBack MoC for patients with LBP compared to routine primary care. A secondary aim was to explore if illness perceptions and patient self-care enablement are mediators of guideline adherent care.

    METHODS: Pre-planned single mediation analyses tested whether hypothesized mediators at 3 months mediated the treatment effect of the MoC (n = 264) compared to routine care (n = 203) on disability and pain at 6 months. Secondary mediation analyses compared guideline adherent care with non-adherent care.

    RESULTS: No indirect effects were identified. The BetterBack intervention did not have superior effects over routine care on the hypothesized mediators. Illness perceptions and self-care enablement were significantly associated with disability and pain at 6 months. Secondary analyses showed significant indirect effects of guideline adherent care through tested mediators.

    CONCLUSION: Despite no indirect effects, patients' illness perceptions and self-care enablement were associated with disability and back pain intensity outcomes and are potentially relevant treatment targets.

  • 20.
    Forsström, D.
    et al.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Carlbring, P.
    Department of Psychology, Stockholm University, Stockholm, 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 individual's 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.

  • 21.
    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
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    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.

  • 22.
    Forsström, David
    et al.
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Department of Psychology, Stockholm University, Stockholm, Sweden.
    Lindner, Philip
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Centre for Dependency Disorders, Stockholm County Council, Stockholm, Sweden.
    Jansson-Fröjmark, Markus
    v.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Carlbring, Per
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    GamTest: Psychometric Evaluation in a Low-Gambling General Population2020In: Journal of Gambling Issues, E-ISSN 1910-7595, no 44, p. 77-102Article in journal (Refereed)
    Abstract [en]

    Instruments that investigate different aspects of gambling activities are needed to distinguish negative consequences. Because gambling is a complex activity that occurs both offline and online, different questionnaires are necessary for screening and risk classification. GamTest, an instrument used by several gambling companies, was designed to cover different aspects of gambling: money and time spent, as well as social, financial, and emotional consequences. This study explores GamTest's psychometric properties in a general population. A total of 2,234 Swedish respondents completed an online survey containing demographic questions, the questionnaire (GamTest), and the Problem Gambling Severity Index (PGSI). A confirmatory factor analysis was performed and GamTest's reliability and validity tested. The confirmatory factor analysis yielded an inclusive fit. The internal consistency (omega) for the five factors was high (.79-.91), indicating good reliability, and a high positive correlation with the PGSI supported the validity of the GamTest. The inclusive fit of the confirmatory factor analysis can be explained by the low endorsement of negative consequences of gambling in the sample. However, GamTest seems to have good reliability and validity. The utility of GamTest is discussed in relation to its psychometric properties and its use in the responsible gambling tool Playscan.

  • 23.
    Forsström, David
    et al.
    Department of Psychology, Stockholm University, Stockholm, Sweden; Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Rozental, Alexander
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; UCL, Great Ormond Street, Institute of Child Health, London, UK.
    Kottorp, Anders
    Faculty of Health and Society, Malmö University, Malmö, Sweden.
    Lindner, Philip
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Centre for Dependency Disorders, Stockholm Health Care Services, Stockholm, Sweden.
    Jansson-Fröjmark, Markus
    Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden..
    Further Exploration of the Psychometric Properties of GamTest: A Rasch Analysis2021In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 18, no 9, article id 4824Article in journal (Refereed)
    Abstract [en]

    GamTest is a self-rating scale of negative consequences of gambling, included in the popular responsible gambling tool Playscan as part of an overall risk assessment and feedback feature. Two previous psychometric evaluations of this instrument yielded contradictory results: in an online high-gambling population, a five-factor model was supported and the instrument had overall good psychometric properties, but in a low-gambling population, the same factor structure was not supported. Because GamTest is used with both low- and high-gambling populations, more psychometric research is needed to fully understand how the instrument works. The current study examined, for the first time, psychometric performance among a sample of low-gambling respondents using a Rasch analysis. Results indicated that the instrument could be improved by decreasing the scale-steps and removing several problematic items demonstrating misfit. Furthermore, the findings indicated that some items functioned differently depending on gender, and that a shortened, improved nine-item version could not differentiate between different levels of risk. Our findings suggest that the instrument would arguably benefit from being adapted for use in a low-gambling population.

  • 24.
    Frick, Matilda A.
    et al.
    Department of Psychology, Stockholm University, Albanovägen 12, 106 91, Stockholm, Sweden; Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
    Hesser, Hugo
    Örebro University, School of Behavioural, Social and Legal Sciences. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Sonuga-Barke, Edmund
    Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
    Pervasive versus situational childhood ADHD: latent classes and their clinical characteristics, based on parent and teacher ratings in a large longitudinal population sample2023In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165XArticle in journal (Refereed)
    Abstract [en]

    Attention-deficit/hyperactivity disorder (ADHD) diagnoses require symptoms to be present in two settings. Low levels of concordance between symptoms rated at home and school raise questions regarding this approach. The aim was to examine whether there are sub-groups with context-specific expressions of ADHD symptoms (i.e., at home or school only) with clinically significant problems sufficient to support a new diagnostic formulation. We applied latent class transition analysis to parent and teacher data (N = 10,476) from the Avon Longitudinal Study of Parents and Children (ALSPAC), collected at ages 8, 10, and 20 years. We examined the short-term stability of emergent classes and their childhood and adult-associated risk profiles. In addition to an Unaffected class (~ 45%), there was a Pervasive Combined class with elevated inattentive and hyperactive/impulsive symptoms at both home and school (~ 11%) and three classes with situational expressions; School Combined (~ 9%), Home Combined (~ 18%), and School Inattentive (~ 16%). Stability ranged from 0.27 to 0.78. The Pervasive Combined class was most symptomatic and impaired. School inattentive also displayed clinical symptom levels, whereas the School and Home Combined classes displayed subclinical levels. Different profiles regarding sex, cognition, conduct problems, and substance use emerged for the three situational classes. Distinct groupings of pervasive and situational ADHD expressions are identifiable in the general population. The isolation of a stable and burdensome Pervasive Combined class lends support to the current diagnostic approach. However, there are indications of situational expressions of ADHD with clinical symptom levels and associated difficulties.

  • 25.
    Hadjistavropoulos, H. D.
    et al.
    Department of Psychology, University of Regina, Regina, Canada.
    Pugh, N. E.
    Department of Psychology, University of Regina, Regina, Canada.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    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.

  • 26.
    Hadjistavropoulos, H. D.
    et al.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Pugh, N. E.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Karolinska Institute, 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.

  • 27.
    Hadjistavropoulos, H. D.
    et al.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Pugh, N. E.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Nugent, M. M.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Ivanov, M.
    Department of Computer Science, University of Regina, Regina SK, Canada.
    Butz, C. G.
    Department of Computer Science, University of Regina, Regina SK, Canada.
    Marchildon, G.
    Johnson-Shoyama Graduate School of Public Policy, Department of Psychology, University of Regina, Regina SK, Canada.
    Asmundson, G. J. G.
    Department of Psychology, University of Regina, Regina SK, Canada.
    Klein, B.
    School of Health Sciences and DVC-Research Portfolio, Federation University Australia, Victoria, Australia; Centre of Mental Health Research, The Australian National University, Canberra, Australia; The Nationale Therapy Centre, Swinburne University of Technology, Ballarat, Australia.
    Austin, D. W.
    Centre for Mental Health and Wellbeing Research, School of Psychology, Deakin University, Burwood, 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.

  • 28.
    Hedman, E.
    et al.
    Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Axelsson, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, 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 <.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.

  • 29.
    Hedman, E.
    et al.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Kaldo, V.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    El Alaoui, S.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden.
    Kraepelien, M.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden.
    Rück, C.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden.
    Svanborg, C.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden.
    Andersson, G.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Lindefors, N.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, 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, no 1, 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.

  • 30.
    Hedman, E.
    et al.
    Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Mörtberg, E.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioral Science and Learning, Linköping University, Linköping, Sweden.
    Clark, D. M.
    Department of Experimental Psychology, University of Oxford, Oxford, UK.
    Lekander, M.
    Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Stress Research Institute, Stockholm University, Stockholm, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, 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.

  • 31.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Estimating causal effects of internet interventions in the context of nonadherence2020In: Internet Interventions, ISSN 2214-7829, Vol. 21, article id 100346Article in journal (Refereed)
    Abstract [en]

    A substantial proportion of participants who are offered internet-based psychological treatments in randomized trials do not adhere and may therefore not receive treatment. Despite the availability of justified statistical methods for causal inference in such situations, researchers often rely on analytical strategies that either ignore adherence altogether or fail to provide causal estimands. The objective of this paper is to provide a gentle nontechnical introduction to complier average causal effect (CACE) analysis, which, under clear assumptions, can provide a causal estimate of the effect of treatment for a subsample of compliers. The article begins with a brief review of the potential outcome model for causal inference. After clarifying assumptions and model specifications for CACE in the latent variable framework, data from a previously published trial of an internet-based psychological treatment for irritable bowel syndrome are used to demonstrate CACE-analysis. Several model extensions are then briefly reviewed. The paper offers practical recommendations on how to analyze randomized trials of internet interventions in the context of nonadherence. It is argued that CACE-analysis, whenever it is considered appropriate, should be carried out as a complement to the standard intention-to-treat analysis and that the format of internet-based treatments is particularly well suited to such an analytical approach.

  • 32.
    Hesser, Hugo
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Identifying causal mechanisms in psychotherapy: what can we learn from causal mediation analysis?2022In: Clinical Psychology and Psychotherapy, ISSN 1063-3995, E-ISSN 1099-0879, Vol. 29, no 3, p. 1050-1058Article in journal (Refereed)
    Abstract [en]

    Despite widespread interest in the development of process-based psychotherapies, little is still known about the underlying processes that underpin our most effective therapies. Statistical mediation analysis is a commonly used analytical method to evaluate how, or by which processes, a therapy causes change in an outcome. Causal mediation analysis (CMA) represents a new advancement in mediation analysis that employs causally-defined direct and indirect effects based on potential outcomes. These novel ideas and analytical techniques have been characterized as revolutionary in epidemiology and biostatistics, although they are not (yet) widely known among researchers in clinical psychology. In this paper, I outline the fundamental concepts underlying CMA, clarify the differences between the CMA approach and the traditional approach to mediation, and identify two important data analytical aspects that have been emphasized as a result of these recent advancements. To illustrate the key ideas, assumptions, and mathematical definitions intuitively, an applied clinical example from a previously published randomized controlled trial is used. CMA's main contributions are discussed, as well as some of the key challenges. Finally, it is argued that the most significant contribution of CMA is the formalization of mediation in a unified causal framework with clear assumptions.

  • 33.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    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)
  • 34.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Modeling individual differences in randomized experiments using growth models: Recommendations for design, statistical analysis and reporting of results of internet interventions2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 2, p. 110-120Article in journal (Refereed)
    Abstract [en]

    Growth models (also known as linear mixed effects models, multilevel models, and random coefficients models) have the capability of studying change at the group as well as the individual level. In addition, these methods have documented advantages over traditional data analytic approaches in the analysis of repeated-measures data. These advantages include, but are not limited to, the ability to incorporate time-varying predictors, handle dependence among repeated observations in a veryflexible manner, and to provide accurate estimates with missing data under fairly unrestrictive missing data assumptions. Theflexibility of the growth curve modeling approach to the analysis of change makes it the preferred choice in the evaluation of direct, indirect and moder-ated intervention effects. Although offering many benefits, growth models present challenges in terms of design, analysis and reporting of results. This paper provides a nontechnical overview of growth models in the analysis of change in randomized experiments and advocates for their use in thefield of internet interventions. Practical recommendations for design, analysis and reporting of results from growth models are provided.

  • 35.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Division of Psychology, Linköping University, Linköping, Sweden.
    Tinnitus2019In: Somatisk sjukdom: ett biopsykosocialt perspektiv / [ed] Ali Sarkohi, Gerhard Andersson, Lund: Studentlitteratur AB, 2019, 1, p. 217-243Chapter in book (Other academic)
  • 36.
    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. 523-528Article 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 1710 min) 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.

    Place, publisher, year, edition, pages
    Elsevier, 2009
    Keywords
    Tinnitus, Acceptance, Defusion, Process, Tinnitus distress, In-session behavior
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:oru:diva-78121 (URN)10.1016/j.brat.2009.02.002 (DOI)000266752700011 ()19268281 (PubMedID)2-s2.0-67349188394 (Scopus ID)
    Available from: 2020-01-22 Created: 2020-01-22 Last updated: 2024-01-11Bibliographically 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, E-ISSN 1939-1544, 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.

    Place, publisher, year, edition, pages
    American Psychological Association (APA), 2009
    Keywords
    tinnitus, control, tinnitus interference, cognitive functioning, experiential avoidance
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:oru:diva-78120 (URN)10.1037/a0017565 (DOI)000272331600004 ()19929119 (PubMedID)2-s2.0-73549103080 (Scopus ID)
    Available from: 2020-01-22 Created: 2020-01-22 Last updated: 2024-01-11Bibliographically approved
    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 60 min sessions. The TRT treatment consisted of one 150 min session, one 30 min follow-up and continued daily use of wearable sound generators for a recommended period of at least 8 h/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, Tinnitus Retraining Therapy, Randomised controlled trial, Tinnitus
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:oru:diva-78112 (URN)10.1016/j.brat.2011.08.001 (DOI)2-s2.0-80053571098 ()21864830 (PubMedID)2-s2.0-80053571098 (Scopus ID)
    Available from: 2020-01-22 Created: 2020-01-22 Last updated: 2024-01-11Bibliographically approved
    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
    American Psychological Association (APA), 2012
    National Category
    Otorhinolaryngology Applied Psychology
    Identifiers
    urn:nbn:se:oru:diva-63455 (URN)10.1037/a0027021 (DOI)000306861800011 ()22250855 (PubMedID)2-s2.0-84868376964 (Scopus ID)
    Available from: 2017-12-19 Created: 2017-12-19 Last updated: 2024-01-15Bibliographically 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
    2014 (English)In: Journal of behavioral medicine, ISSN 0160-7715, E-ISSN 1573-3521, Vol. 37, no 4, p. 756-767Article in journal (Refereed) Published
    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.

    Place, publisher, year, edition, pages
    Springer, 2014
    Keywords
    Tinnitus, Acceptance, Mechanisms of change, Internet-delivered self-help, Cognitive behavior therapy
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:oru:diva-78095 (URN)10.1007/s10865-013-9525-6 (DOI)000339113200016 ()23881309 (PubMedID)2-s2.0-84905001266 (Scopus ID)
    Available from: 2020-01-22 Created: 2020-01-22 Last updated: 2024-01-11Bibliographically 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, E-ISSN 1932-6203, Vol. 8, no 5, article id e64540Article in journal (Refereed) 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.

    Place, publisher, year, edition, pages
    Public Library of Science, 2013
    National Category
    Applied Psychology
    Identifiers
    urn:nbn:se:oru:diva-78104 (URN)10.1371/journal.pone.0064540 (DOI)000318852400071 ()23675540 (PubMedID)2-s2.0-84877613642 (Scopus ID)
    Note

    Funding Agency:

    Swedish Research Council (HEAD Linneaus grant)

    Available from: 2020-01-22 Created: 2020-01-22 Last updated: 2024-01-11Bibliographically approved
  • 37.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    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.

  • 38.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    The role of anxiety sensitivity and behavioral avoidance in tinnitus disability2009In: International Journal of Audiology, ISSN 1499-2027, E-ISSN 1708-8186, 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.

  • 39.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, Gerhard
    Introduktion till metaanalys och systematiska översikter2015Book (Other academic)
  • 40.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Axelsson, S.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Bäcke, V.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Engstrand, J.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Gustafsson, T.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Holmgren, E.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Jeppsson, U.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Pollack, M.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Nordén, K.
    Alternative to Violence, Jönköping, Sweden.
    Rosenqvist, D.
    Alternative to Violence, Jönköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, 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 (8weeks), 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.
  • 41.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Bånkestad, E.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, 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.

  • 42.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Gustafsson, Tore
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Lundén, Charlotte
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Henrikson, Oskar
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Fattahi, Kidjan
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Johnsson, Erik
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Zetterqvist Westin, Vendela
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Carlbring, Per
    Department of Psychology, Umeå University, Umeå, Sweden.
    Mäki-Torkko, Elina
    Örebro University, School of Medical Sciences. Department of Clinical and Experimental Medicine, Division of Technical Audiology, Linköping University, Linköping, Sweden; Department of ENT-Head Neck Surgery UHL, County Council of Östergötland, Linköping, Sweden.
    Kaldo, Viktor
    Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Gerhard
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden.
    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.

  • 43.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hedman, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden.
    Lindfors, P.
    Department of Internal Medicine Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, 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.

  • 44.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Lindfors, Perjohan
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, 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.

  • 45.
    Hesser, Hugo
    et al.
    Örebro University, School of Law, Psychology and Social Work. Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden.
    Lindfors, Perjohan
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Internal Medicine Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
    Andersson, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Behavioral avoidance moderates the effect of exposure therapy for irritable bowel syndrome: A secondary analysis of results from a randomized component trial2021In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 141, article id 103862Article in journal (Refereed)
    Abstract [en]

    Past research has failed to identify consistent moderators of outcomes in psychological treatments for irritable bowel syndrome (IBS). The aim of this study was to test previously identified mediators as potential moderators of the effects of exposure therapy on IBS symptoms in a previously published randomized component trial. In total, 309 participants with IBS were randomized to internet-delivered cognitive behavioral treatment that included exposure (ICBT) or to the same treatment protocol without exposure (ICBT-WE) and were asked to report on gastrointestinal symptoms at pretreatment, posttreatment and weekly during the treatment. Pretreatment scores of The Visceral Sensitivity Index (VSI) and The Irritable Bowel Syndrome Behavioral Responses Questionnaire (IBS-BRQ) (i.e., gastrointestinal anxiety and avoidance behavior) were evaluated as predictors and moderators. Piecewise latent growth curve models were employed to evaluate moderators during distinct phases of the trial, prior to and following the onset of exposure in ICBT. Results revealed that pretreatment scores on IBS-BRQ (avoidance) moderated the effect of exposure therapy during the specific phase in which exposure was implemented in ICBT, with higher avoidance scores linked to stronger positive effects of exposure. VSI did not serve as predictor nor moderator. Adding exposure to CBT seems to be especially important for persons with moderate to high levels of avoidance behaviors in order to reduce gastrointestinal symptoms.

  • 46.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Hesser, H.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institute, Stockholm, Sweden.
    Special Issue on Tinnitus2013In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 42, no 2, p. 81-83Article in journal (Refereed)
  • 47.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Molander, P.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Jungermann, M.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Swede.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Psychiatry Section, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
    Costs of Suppressing Emotional Sound and Countereffects of a Mindfulness Induction: An Experimental Analog of Tinnitus Impact2013In: PLOS ONE, E-ISSN 1932-6203, Vol. 8, no 5, article id e64540Article in journal (Refereed)
    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.

  • 48.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Pain Treatment Service, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
    Pereswetoff-Morath, C. E.
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    Consequences of Controlling Background Sounds: The Effect of Experiential Avoidance on Tinnitus Interference2009In: Rehabilitation Psychology, ISSN 0090-5550, E-ISSN 1939-1544, 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.

  • 49.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linnaeus Centre, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Weise, C.
    Department of Behavioural Sciences and Learning, Linnaeus Centre, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Rief, W.
    Department of Clinical Psychology, University of Marburg, Marburg, Germany.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linnaeus Centre, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    The effect of waiting: A meta-analysis of wait-list control groups in trials for tinnitus distress2011In: Journal of Psychosomatic Research, ISSN 0022-3999, E-ISSN 1879-1360, 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.

  • 50.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Weise, C.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Westin, V. Z.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Andersson, G.
    Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm, Sweden.
    A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress2011In: Clinical Psychology Review, ISSN 0272-7358, E-ISSN 1873-7811, 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 (Hedges's g = 0.70. and Hedges's 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.

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