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Background: A recent randomized controlled trial (N=140) was indicative of large and sustained average improvements of internet-based exposure for fibromyalgia, as compared to a waitlist. However, little is known about who benefits the most from this treatment. Objectives: To test for potential moderating effects of age, educational attainment, the duration of fibromyalgia, baseline overall fibromyalgia severity, pain intensity, fibromyalgia-related avoidance behavior, and symptom preoccupation on the waitlist-controlled effect of 10-weeks of internet-based exposure for fibromyalgia. Methods: Secondary analysis of a randomized controlled trial (ClinicalTrials.gov NCT02638636). We used linear mixed effects models to determine whether the waitlist-controlled effect of exposure therapy on overall fibromyalgia severity (Fibromyalgia Impact Questionnaire) differed as a function of the potential moderators. Results: Only pain intensity (0-10) was found to be a significant moderator, where a higher baseline pain intensity predicted a more limited waitlist-controlled effect of internet-based exposure (B=3.48, 95% CI: 0.84 – 6.13). Standardized point estimates of effects were small for the sociodemographic variables, and in the moderate range for some clinical variables that did not reach statistical significance such as behavioral avoidance and time with the fibromyalgia diagnosis. Conclusions: Results suggest that internet-based exposure treatment was more useful for participants with lower baseline levels of pain, and less so for participants with higher baseline levels of pain. The treatment had relatively similar effects across the other tested moderators., Funding agency:Söderström‐Königska Foundation

AIMS: Temporomandibular disorders (TMD) are often associated with psychological comorbidities. One such comorbidity is pain catastrophizing, i.e., exaggeration of negative consequences of a painful event. The aim was to investigate catastrophizing in individuals with painful TMD compared to controls and the association between catastrophizing and pain intensity, number of pain sites and functional limitations. METHODS: A community-based sample of 110 individuals (83 women; 20-69 yrs) with painful TMDs (myalgia/arthralgia as per Diagnostic Criteria for TMD), and 190 age- and gender-matched controls (119 women; 20-69 yrs) from the Public Dental services in Västerbotten, Sweden participated. Associations between catastrophizing and functional jaw limitations, respectively, and painful TMD were evaluated with ordinal regression. adjusted for the effect of gender and age. Associations (Spearman's correlation) of the Pain Catastrophizing Scale (PCS) with Jaw Functional Limitation Scale (JFLS-20), pain site number (whole body pain map), and characteristic pain intensity (CPI) and intergroup comparisons (Mann-Whitney U test) of these variables were also calculated. RESULTS: Levels of catastrophizing, were associated with TMD pain (OR 1.6, 95%CI 1.1-2.6). Among individuals with painful TMD, catastrophizing was correlated to pain intensity (r=0.458, p<0.01) and functional limitations (r=0.294-0.321, p≤0.002), but not to number of pain sites. CONCLUSION: Compared to controls, community-based individuals with painful TMD demonstrated higher levels of pain catastrophizing, and this catastrophizing was associated with increased pain intensity and jaw dysfunction. The relatively low scores of pain catastrophizing suggest that even mild catastrophic thinking is associated with pain perception and jaw function, and should be considered in patient management.

AIMS: Temporomandibular disorders (TMD) are often associated with psychological comorbidities. One such comorbidity is pain catastrophizing, i.e., exaggeration of negative consequences of a painful event. The aim was to investigate catastrophizing in individuals with painful TMD compared to controls and the association between catastrophizing and pain intensity, number of pain sites and functional limitations. METHODS: A community-based sample of 110 individuals (83 women; 20-69 yrs) with painful TMDs (myalgia/arthralgia as per Diagnostic Criteria for TMD), and 190 age- and gender-matched controls (119 women; 20-69 yrs) from the Public Dental services in Västerbotten, Sweden participated. Associations between catastrophizing and functional jaw limitations, respectively, and painful TMD were evaluated with ordinal regression. adjusted for the effect of gender and age. Associations (Spearman's correlation) of the Pain Catastrophizing Scale (PCS) with Jaw Functional Limitation Scale (JFLS-20), pain site number (whole body pain map), and characteristic pain intensity (CPI) and intergroup comparisons (Mann-Whitney U test) of these variables were also calculated. RESULTS: Levels of catastrophizing, were associated with TMD pain (OR 1.6, 95%CI 1.1-2.6). Among individuals with painful TMD, catastrophizing was correlated to pain intensity (r=0.458, p<0.01) and functional limitations (r=0.294-0.321, p≤0.002), but not to number of pain sites. CONCLUSION: Compared to controls, community-based individuals with painful TMD demonstrated higher levels of pain catastrophizing, and this catastrophizing was associated with increased pain intensity and jaw dysfunction. The relatively low scores of pain catastrophizing suggest that even mild catastrophic thinking is associated with pain perception and jaw function, and should be considered in patient management.

Evidence supporting the effectiveness of cognitive behavior therapy (CBT) for stress-related illness is growing, but little is known about its mechanisms of change. The aim of this study was to investigate potential mediators of CBT for severe stress in form of clinical burnout, using an active psychological treatment as comparator. We used linear mixed models to analyze data from patients (N = 82) with clinical burnout who received either CBT or another psychological treatment in a randomized controlled trial. Potential mediators (i.e., sleep quality, behavioral activation, perceived competence, and therapeutic alliance) and outcome (i.e., symptoms of burnout) were assessed weekly during treatment. The results showed that the positive treatment effects on symptoms of burnout favoring CBT (estimated between-group d = 0.93) were mediated by improvements in sleep quality, ab = -0.017,95% CIasymmetric [-0.037, -0.002], and increase in perceived competence, ab = -0.037, 95% CIasymmetric [-0.070, -0.010]. Behavioral activation, ab = -0.004 [-0.016, 0.007], and therapeutic alliance, ab = 0.002 [-0.006, 0.011], did not significantly mediate the difference in effects between the treatments. Improving sleep quality and increasing perceived competence may thus constitute important process goals in order to attain symptom reduction in CBT for clinical burnout.

Although cognitive behavior therapy (CBT) is an effective treatment for social anxiety disorder, little is known about the processes during treatment that bring about change. The aim of this study was to investigate whether the proposed processes of change according to the cognitive model of social anxiety disorder predicted subsequent symptom reduction in CBT delivered as therapist-guided bibliotherapy. We analyzed data from patients with social anxiety disorder (N = 61) who participated in an effectiveness trial of CBT in primary care. Seven putative processes and outcome (i.e., social anxiety) were assessed on a weekly basis throughout treatment. We used linear mixed models to analyze within-person relations between processes and outcome. The results showed a unidirectional effect of reduced avoidance on subsequent decrease in social anxiety. Further, we found support for reciprocal influences between four of the proposed processes (i.e., estimated probability and cost of adverse outcome, self-focused attention, and safety behaviors) and social anxiety. The remaining two processes, (i.e., anticipatory and post-event processing) did not predict subsequent social anxiety, but were predicted by prior symptom reduction. The findings support that several of the change processes according to the cognitive model of social anxiety disorder are involved in symptom improvement.

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

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.

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.

Social anxiety disorder is one of the most common mental health disorders. Effective treatments exist, but limited access and high costs causes many sufferers to remain untreated. As not all patients accept the CBTmodel of psychopathology, alternative treatments are desirable. We conducted two studies to help establish the efficacy of a psychodynamic model of guided self-help (IPDT). In the first study (N=72) participants were randomized to either ten weeks of IPDT or a waiting list control condition. Mixed-effects models revealed a significant difference at post-treatment in favor of the treatment condition on the primary outcome measure, LSAS-SR, with a large effect size. Rates of remission were comparable to recent face-to-face trials, and improvements were maintained at 6- and 12-month follow-ups. The second study was a pilot preference study where the control group in study 1 chose either IPDT (N=23) or ICBT (N=13). Both treatments led to moderate improvements. Notably, both groups suffered an exacerbation of interpersonal symptoms at 6-month follow-up. In summary, the results suggest that IPDT is effective in the treatment of social anxiety, with effect sizes in the same range as ICBT and face-to-face psychotherapy.

Social anxiety disorder is one of the most common mental health disorders. Effective treatments exist, but limited access and high costs causes many sufferers to remain untreated. As not all patients accept the CBTmodel of psychopathology, alternative treatments are desirable. We conducted two studies to help establish the efficacy of a psychodynamic model of guided self-help (IPDT). In the first study (N=72) participants were randomized to either ten weeks of IPDT or a waiting list control condition. Mixed-effects models revealed a significant difference at post-treatment in favor of the treatment condition on the primary outcome measure, LSAS-SR, with a large effect size. Rates of remission were comparable to recent face-to-face trials, and improvements were maintained at 6- and 12-month follow-ups. The second study was a pilot preference study where the control group in study 1 chose either IPDT (N=23) or ICBT (N=13). Both treatments led to moderate improvements. Notably, both groups suffered an exacerbation of interpersonal symptoms at 6-month follow-up. In summary, the results suggest that IPDT is effective in the treatment of social anxiety, with effect sizes in the same range as ICBT and face-to-face psychotherapy.

Social anxiety disorder is one of the most common mental health disorders. Effective treatments exist, but limited access and high costs causes many sufferers to remain untreated. As not all patients accept the CBTmodel of psychopathology, alternative treatments are desirable. We conducted two studies to help establish the efficacy of a psychodynamic model of guided self-help (IPDT). In the first study (N=72) participants were randomized to either ten weeks of IPDT or a waiting list control condition. Mixed-effects models revealed a significant difference at post-treatment in favor of the treatment condition on the primary outcome measure, LSAS-SR, with a large effect size. Rates of remission were comparable to recent face-to-face trials, and improvements were maintained at 6- and 12-month follow-ups. The second study was a pilot preference study where the control group in study 1 chose either IPDT (N=23) or ICBT (N=13). Both treatments led to moderate improvements. Notably, both groups suffered an exacerbation of interpersonal symptoms at 6-month follow-up. In summary, the results suggest that IPDT is effective in the treatment of social anxiety, with effect sizes in the same range as ICBT and face-to-face psychotherapy.

Social anxiety disorder is one of the most common mental health disorders. Effective treatments exist, but limited access and high costs causes many sufferers to remain untreated. As not all patients accept the CBTmodel of psychopathology, alternative treatments are desirable. We conducted two studies to help establish the efficacy of a psychodynamic model of guided self-help (IPDT). In the first study (N=72) participants were randomized to either ten weeks of IPDT or a waiting list control condition. Mixed-effects models revealed a significant difference at post-treatment in favor of the treatment condition on the primary outcome measure, LSAS-SR, with a large effect size. Rates of remission were comparable to recent face-to-face trials, and improvements were maintained at 6- and 12-month follow-ups. The second study was a pilot preference study where the control group in study 1 chose either IPDT (N=23) or ICBT (N=13). Both treatments led to moderate improvements. Notably, both groups suffered an exacerbation of interpersonal symptoms at 6-month follow-up. In summary, the results suggest that IPDT is effective in the treatment of social anxiety, with effect sizes in the same range as ICBT and face-to-face psychotherapy.

Social anxiety disorder is one of the most common mental health disorders. Effective treatments exist, but limited access and high costs causes many sufferers to remain untreated. As not all patients accept the CBTmodel of psychopathology, alternative treatments are desirable. We conducted two studies to help establish the efficacy of a psychodynamic model of guided self-help (IPDT). In the first study (N=72) participants were randomized to either ten weeks of IPDT or a waiting list control condition. Mixed-effects models revealed a significant difference at post-treatment in favor of the treatment condition on the primary outcome measure, LSAS-SR, with a large effect size. Rates of remission were comparable to recent face-to-face trials, and improvements were maintained at 6- and 12-month follow-ups. The second study was a pilot preference study where the control group in study 1 chose either IPDT (N=23) or ICBT (N=13). Both treatments led to moderate improvements. Notably, both groups suffered an exacerbation of interpersonal symptoms at 6-month follow-up. In summary, the results suggest that IPDT is effective in the treatment of social anxiety, with effect sizes in the same range as ICBT and face-to-face psychotherapy.

Social anxiety disorder is one of the most common mental health disorders. Effective treatments exist, but limited access and high costs causes many sufferers to remain untreated. As not all patients accept the CBTmodel of psychopathology, alternative treatments are desirable. We conducted two studies to help establish the efficacy of a psychodynamic model of guided self-help (IPDT). In the first study (N=72) participants were randomized to either ten weeks of IPDT or a waiting list control condition. Mixed-effects models revealed a significant difference at post-treatment in favor of the treatment condition on the primary outcome measure, LSAS-SR, with a large effect size. Rates of remission were comparable to recent face-to-face trials, and improvements were maintained at 6- and 12-month follow-ups. The second study was a pilot preference study where the control group in study 1 chose either IPDT (N=23) or ICBT (N=13). Both treatments led to moderate improvements. Notably, both groups suffered an exacerbation of interpersonal symptoms at 6-month follow-up. In summary, the results suggest that IPDT is effective in the treatment of social anxiety, with effect sizes in the same range as ICBT and face-to-face psychotherapy.

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.

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., Funding Agencies:Stockholm County CouncilKarolinska InstitutetSwedish Society of Medicine (Söderströmska Königska sjukhemmet)

Introduction: Internet interventions have a great potential for alleviating emotional distress and promoting mental health. A number of clinical trials have demonstrated their efficacy for several psychiatric conditions, and Internet interventions will likely become a common alternative to face-to-face treatments. Meanwhile, research has paid little attention to the potential negative effects associated with treatment, warranting further investigation of the possibility that some patients might deteriorate or experience adverse events. Evidence from face-to-face treatments suggests that negative effects afflict 5-10% of all patients undergoing treatment in terms of deterioration alone. However, there is currently a lack of consensus on how to define and measure negative effects in psychotherapy research in general, leaving researchers without practical guidelines for monitoring and reporting negative effects in clinical trials. Method: The current paper seeks to provide recommendations that could promote the study of negative effects in Internet interventions with the aim of increasing the knowledge of its occurrence and characteristics. Ten leading experts in the field of Internet interventions were invited to participate and share their perspective on how to explore negative effects, using the Delphi technique to facilitate a dialogue and reach an agreement. Results: The importance of conducting further research on negative effects is emphasized, and suggestions on how to classify and measure negative effects in Internet interventions are provided, involving methods from both quantitative and qualitative research. Potential mechanisms underlying negative effects are also presented, differentiating common factors shared with face-to-face treatments from those unique to treatments delivered via the Internet. Conclusion: Negative effects are to be expected and need to be acknowledged to a greater extent, advising researchers to systematically probe for negative effec

BACKGROUND: As relapse after completed cognitive behavior therapy (CBT) for obsessive-compulsive disorder (OCD) is common, many treatment protocols include booster programs to improve the long-term effects. However, the effects of booster programs are not well studied. In this study, we investigated the long-term efficacy of Internet-based CBT (ICBT) with therapist support for OCD with or without an Internet-based booster program. METHOD: A total of 101 participants were included in the long-term follow-up analysis of ICBT. Of these, 93 were randomized to a booster program or no booster program. Outcome assessments were collected at 4, 7, 12 and 24 months after receiving ICBT. RESULTS: The entire sample had sustained long-term effects from pre-treatment to all follow-up assessments, with large within-group effect sizes (Cohen's d = 1.58-2.09). The booster group had a significant mean reduction in OCD symptoms compared to the control condition from booster baseline (4 months) to 7 months, but not at 12 or 24 months. Participants in the booster group improved significantly in terms of general functioning at 7, 12 and 24 months, and had fewer relapses. Kaplan-Meier analysis also indicated a significantly slower relapse rate in the booster group. CONCLUSIONS: The results suggest that ICBT has sustained long-term effects and that adding an Internet-based booster program can further improve long-term outcome and prevent relapse for some OCD patients.

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.

An internet-delivered cognitive behavioral treatment (ICBT) based on systematic exposure exercises has previously shown beneficial effects for patients with irritable bowel syndrome (IBS). Exposure exercises may be perceived as difficult for patients to perform because of the elicited short-term distress and clinicians may be reluctant to use these interventions. The aim of this study was to compare ICBT with the same protocol without systematic exposure (ICBT-WE) to assess if exposure had any incremental value. This randomized controlled dismantling study included 309 participants diagnosed with IBS. The treatment interventions lasted for 10 weeks and included online therapist contact. ICBT-WE comprised mindfulness, work with life values, acceptance, and encouraged reduced avoidance behaviors, while ICBT also included systematic exposure to IBS symptoms and related situations. Severity of IBS symptoms was measured with the Gastrointestinal Symptom Rating Scale-IBS version (GSRS-IBS). The between-group Cohen's don GSRS-IBS was 0.47(95% CI: 0.23-0.70) at post-treatment and 0.48 (95% CI: 0.20-0.76) at 6-month follow-up, favoring ICBT. We conclude that the systematic exposure included in the ICBT protocol has incremental effects over the other components in the protocol. This study provides evidence for the utility of exposure exercises in psychological treatments for IBS.

OBJECTIVE: Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care. METHOD: We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR). RESULTS: Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen's d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up. CONCLUSION: This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

BACKGROUND: Severe health anxiety is a common condition associated with functional disability, making it a costly disorder from a societal perspective. Internet-based cognitive behaviour therapy (ICBT) is a promising treatment but no previous study has assessed the cost-effectiveness or long-term outcome of ICBT for severe health anxiety. The aim of this study was to investigate the cost-effectiveness and 1-year treatment effects of ICBT for severe health anxiety. Method Cost-effectiveness and 1-year follow-up data were obtained from a randomized controlled trial (RCT) comparing ICBT (n = 40) to an attention control condition (CC, n = 41). The primary outcome measure was the Health Anxiety Inventory (HAI). A societal perspective was taken and incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap sampling. RESULTS: The main ICER was -£1244, indicating the societal economic gain for each additional case of remission when administering ICBT. Baseline to 1-year follow-up effect sizes on the primary outcome measure were large (d = 1.71-1.95). CONCLUSIONS: ICBT is a cost-effective treatment for severe health anxiety that can produce substantial and enduring effects.

Background: Psychodynamic psychotherapy is a psychological treatment approach that has a growing empirical base. Research has indicated an association between therapist-facilitated affective experience and outcome in psychodynamic therapy. Affect-phobia therapy (APT), as outlined by McCullough et al., is a psychodynamic treatment that emphasizes a strong focus on expression and experience of affect. This model has neither been evaluated for depression nor anxiety disorders in a randomized controlled trial. While Internet-delivered psychodynamic treatments for depression and generalized anxiety disorder exist, they have not been based on APT. The aim of this randomized controlled trial was to investigate the efficacy of an Internet-based, psychodynamic, guided self-help treatment based on APT for depression and anxiety disorders. Methods: One hundred participants with diagnoses of mood and anxiety disorders participated in a randomized (1:1 ratio) controlled trial of an active group versus a control condition. The treatment group received a 10-week, psychodynamic, guided self-help treatment based on APT that was delivered through the Internet. The treatment consisted of eight text-based treatment modules and included therapist contact (9.5 min per client and week, on average) in a secure online environment. Participants in the control group also received online therapist support and clinical monitoring of symptoms, but received no treatment modules. Outcome measures were the 9-item Patient Health Questionnaire Depression Scale (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7). Process measures were also included. All measures were administered weekly during the treatment period and at a 7-month follow-up. Results: Mixed models analyses using the full intention-to-treat sample revealed significant interaction effects of group and time on all outcome measures, when comparing treatment to the control group. A large between-group effect size of Cohen's d, Funding Agency:Linköping University

Background: Several studies show that psychological treatments relieve symptoms for patients suffering from irritable bowel syndrome (IBS). However, there are no consistent findings that show what patient characteristics make a psychological treatment more or less likely to result in improvement. We have previously conducted a study of a newly developed internet-delivered cognitive behavioral therapy (ICBT) that emphasized exposure to IBS symptoms and IBS-related situations and reduced symptom-related avoidance. The study showed that the treatment led to improvement in IBS symptoms compared to a waiting list and that treatment gains were maintained over a 15-18 month follow-up period. The aim of the present study was to investigate several possible predictors of short-and long-term treatment outcome in terms of symptom improvement, based on data collected in the previously conducted treatment trial. Methods: Demographics, comorbid psychological distress, IBS-related fear and avoidance behaviors, and IBS-related disability were investigated as predictors of treatment outcome in the sample consisting of 79 participants diagnosed with IBS who had undergone 10 weeks of ICBT. Predictors that were significantly correlated with symptom levels at post-treatment and follow-up were entered into multiple regression analyses that controlled for pre-treatment symptom levels. Results: There were measures within each domain, i.e., comorbid psychological distress, IBS-related fear and avoidance behaviors, and IBS-related disability, with the exception of demographic data, that were correlated with the symptom levels at post-treatment and follow-up. However, when these were entered into a multiple regression analyses that controlled for pre-treatment levels, none remained a significant predictor of the post-treatment and follow-up symptomatic status. Conclusions: The study did not find any individual characteristics that made patients more or less likely to respond to the exposure-b

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.

Objective: The aim of this study was to identify mediators of change in a previously published randomized controlled trial that compared Internet-delivered cognitive behavioral treatment based on exposure exercises (ICBT) with Internet-delivered stress management (ISM) for irritable bowel syndrome (IBS). ICBT and ISM targeted distinct proposed mechanisms of illness maintenance and symptom exacerbation, gastrointestinal symptom-specific anxiety (GSA), and stress reactivity, respectively. The original study found that ICBT was more effective than ISM in improving IBS symptoms. Method: Weekly measurements of GSA and stress reactivity (putative mediators) and treatment outcome were obtained from 195 participants with IBS, who had been randomized to ICBT or ISM. Results: Parallel process growth mediational analyses revealed that the larger reduction of IBS symptoms from ICBT compared to ISM was mediated by changes in GSA, alpha beta = 0.42, 95% CIasymmetric [-0.71, -0.16]. In contrast, changes in stress reactivity did not mediate the difference in outcomes between treatments, alpha beta = 0.04, 95% CIasymmetric [-0.09, 0.20]. Analyses of the temporal sequence of week-to-week changes in process and outcome measures showed that only GSA displayed a pattern consistent with a causal model in which change in process preceded and contributed to symptom change. Furthermore, engagement in treatment specific activities was related to change in GSA but not to stress reactivity in the ICBT arm, whereas treatment specific activities were not related to change in any of the putative processes in the ISM arm. Conclusions: We conclude that ICBT works through directly targeting GSA, rather than by means of reducing stress reactivity.

Introduction: Cognitive behaviour therapy delivered in the format of guided self-help via the internet has been found to be effective for a range of conditions, including depression and anxiety disorders. Recent results indicate that guided self-help via the internet is a promising treatment format also for psychodynamic therapy. However, to date and to our knowledge, no study has evaluated internet-delivered psychodynamic therapy as a transdiagnostic treatment. The affect-phobia model of psychopathology by McCullough et al provides a psychodynamic conceptualisation of a range of psychiatric disorders. The aim of this study will be to test the effects of a transdiagnostic guided self-help treatment based on the affect-phobia model in a sample of clients with depression and anxiety. Methods and analysis: This study will be a randomised controlled trial with a total sample size of 100 participants. The treatment group receives a 10-week, psychodynamic, guided self-help treatment based on the transdiagnostic affect-phobia model of psychopathology. The treatment consists of eight text-based treatment modules and includes therapist contact in a secure online environment. Participants in the control group receive similar online therapist support without any treatment modules. Outcome measures are the 9-item Patient Health Questionnaire Depression Scale and the 7-item Generalised Anxiety Disorder Scale (GAD-7). Process measures that concerns emotional processing and mindfulness are included. All outcome and process measures will be administered weekly via the internet and at 6-month follow-up. Discussion: This trial will add to the body of knowledge on internet-delivered psychological treatments in general and to psychodynamic treatments in particular. We also hope to provide new insights in the effectiveness and working mechanisms of psychodynamic therapy based on the affect-phobia model., Funding Agency:Linköping University

OBJECTIVES: Our research group has developed an internet-delivered cognitive behavioral treatment (ICBT) for irritable bowel syndrome (IBS). We compared ICBT with internet-delivered stress management (ISM) for IBS to assess whether the effects of ICBT are specific. METHODS: This was a randomized controlled trial, including 195 self-referred participants diagnosed with IBS. The treatment interventions lasted for 10 weeks and included an online therapist contact. The ICBT emphasized acceptance of symptoms through exposure to IBS symptoms and related negative feelings. The ICBT also included mindfulness training. The ISM emphasized symptom control through relaxation techniques, dietary adjustments, and problem-solving skills. Severity of IBS symptoms was measured with the gastrointestinal symptom rating scale-IBS version (GSRS-IBS). Credibility of the treatments and expectancy of improvement were assessed with the treatment credibility scale. The participants' perceived therapeutic alliance with their online therapist was measured with the working alliance inventory. RESULTS: At post-treatment and 6-month follow-up, 192 (99%) and 169 (87%) participants returned data, respectively. At post-treatment and 6-month follow-up, we found significant differences on the GSRS-IBS, favoring ICBT. The difference on GSRS-IBS scores was 4.8 (95% confidence interval (CI): 1.2-8.4) at post-treatment and 5.9 (95% CI: 1.9-9.9) at 6-month follow-up. There were no significant differences on the treatment credibility scale or the working alliance inventory between the groups. CONCLUSIONS: Internet-delivered CBT has specific effects that cannot be attributed only to treatment credibility, expectancy of improvement, therapeutic alliance, or attention. Furthermore, a treatment based on exposure exercises specifically tailored for IBS may be a better treatment option than general stress and symptom management for IBS patients. ICBT is a promising treatment modality for IBS as it can be offered, Funding Agencies:Stockholm Centre for Psychiatry Research, Linköping University Söderström-Königska Foundation Bror Gadelius Foundation

The present study investigated the efficacy of self-help based on cognitive behaviour therapy in combination with Internet support in the treatment of bulimia nervosa and binge eating disorder. After confirming the diagnosis with an in-person interview, 73 patients were randomly allocated to treatment or a waiting list control group. Treated individuals showed marked improvement after 12 weeks of self-help compared to the control group on both primary and secondary outcome measures. Intent-to-treat analyses revealed that 37% (46% among completers) had no binge eating or purging at the end of the treatment and a considerable number of patients achieved clinically significant improvement on most of the other measures as well. The results were maintained at the 6-month follow-up, and provide evidence to support the continued use and development of self-help programmes. © 2006 Elsevier Ltd. All rights reserved.