Internet-delivered cognitive behavior therapy
Cognitive behavior therapy is a psychological treatment that has shown effectiveness for a range of psychiatric and somatic conditions (Butler et al, 2006). Even if CBT is effective for both somatic/functional and psychiatric disorders for adults and children, there is a large gap between the demand and availability of this treatment. There are few CBT trained psychologists in Sweden and in rural areas they are even scarcer. A recent development within the CBT field has been to deliver the treatment over the internet. Since CBT treatments are often manualized it is easy to transfer them to self-help texts, which describes the treatment model and exercises to the patient and deliver this content over the internet. More than 100 studies of internet-delivered CBT (ICBT) have been performed for psychiatric and somatic disorders, with treatment effects similar to those obtained in studies of face-to-face CBT (Hedman et al, 2012). Since 2007, more than 3,000 patients have been treated for depression, panic disorder, and social phobia, at the world’s first internet-based psychiatric clinic, the Internet psychiatry unit (Internetpsykiatrienheten) at the Karolinska University Hospital in Stockholm, Sweden. Dr Ljótsson was co-founder of Internetpsykiatrienheten and programmed the online platform that is still used to deliver the treatment. Ljótsson also developed an ICBT protocol based on exposure principles for irritable bowel syndrome (IBS) that has been evaluated in 5 randomized clinical trials (e.g., Ljótsson, 2014).
Ljótsson’s previous research on ICBT and IBS is continued in the group’s two main research programs, exposure-based ICBT for children and adolescents with functional gastrointestinal disorders and emotion regulation therapy for self-harm, that are presented below.
Key references
- Butler, A., Chapman, J., Forman, E., & Beck, A. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical Psychology Review, 26(1), 17–31.
- Hedman, E., Ljótsson, B., & Lindefors, N. (2012). Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost–effectiveness. Expert Review of Pharmacoeconomics & Outcomes Research, 12(6), 745–764. doi:10.1586/erp.12.67
- Ljótsson, B., Hesser, H., Andersson, E., Lackner, J. M., Alaoui, El, S., Falk, L., et al. (2014). Provoking symptoms to relieve symptoms: A randomized controlled dismantling study of exposure therapy in irritable bowel syndrome. Behaviour Research and Therapy, 55C, 27–39. doi:10.1016/j.brat.2014.01.007
Research program I: Exposure-based ICBT for children and adolescents with functional gastrointestinal disorders
Pain-related functional gastrointestinal disorders (FGIDs; including functional dyspepsia, functional abdominal pain, and irritable bowel syndrome) are characterized by recurrent abdominal pain without an organic explanation. FGIDs are highly prevalent among children and adolescents and are associated with school absenteeism, anxiety, depression, decreased quality of life and high health-care consumption (Saps et al, 2009). There are no pharmacological treatments that benefit pediatric FGIDs.
CBT has shown promising results as a treatment for pediatric FGIDs. Most CBT protocols for this population target maladaptive coping behaviors such as symptom-related avoidance and parental reinforcement of pain behaviors and can also include relaxation exercises, dietary modification, and stress management skills (e.g., Levy et al, 2010). Targeting maladaptive coping is reasonable, given that research has indicated that avoidant responses and parental reinforcement can play a crucial role in maintaining disability in pediatric chronic pain and FGIDs. However, none of the CBT protocols for this population have included exposure therapy as means of reducing the fear or preoccupation of bodily symptoms that underlie the avoidance behaviors (Labus et al, 2007).
Our previous research on CBT for adults with irritable bowel syndrome (IBS; the most common FGID) has indicated that exposure therapy is a crucial intervention to reduce fear of bodily symptoms and associated avoidance behaviors in order to improve symptoms and quality of life (Ljótsson et al, 2011; Ljótsson et al, 2013; Ljótsson et al, 2014). We have therefore developed an exposure-based CBT protocol for pediatric FGIDs that will be evaluated in a series of clinical trials.
Research questions
- Can exposure-based ICBT be an effective treatment, (i. e. decrease symptoms and improve functioning and quality of life) for pediatric FGIDs?
- Can exposure-based ICBT be a cost-effective treatment for pediatric FGIDs?
- Can potential mediators of treatment of exposure-based ICBT for pediatric FGIDs be identified?
- Can potential prognostic factors for treatment success in exposure-based ICBT for pediatric FGIDs be identified?
Clinical studies
The project consists of six studies, three that include adolescents (ages 13-17) with FGIDs (A1-A3) and three that include children (ages 8-12) with FGIDs (C1-C3). In all studies, at least one parent is required to participate.
A1. Pilot of exposure-based ICBT for adolescents with FGIDs
This is a published study (Bonnert et al, 2014) that included 29 adolescents with FGIDs who underwent 8 weeks of exposure-based ICBT. Post-treatment and 6-month follow-up revealed significant and moderate effects on gastrointestinal symptoms as well as moderate effects on symptom preoccupation and avoidance behaviors. The study is published as open access and can be retrieved here http://dx.doi.org/10.1016/j.invent.2014.07.002.
A2. RCT of exposure-based ICBT for adolescents with IBS
This study (n=100) is ongoing and will evaluate the effects of the exposure-based ICBT (n=50) compared to a waiting list control (n=50) for adolescents with IBS. The treatment protocol from study A1 has been revised to better suit adolescents with IBS. The study will be completed during 2015.
A3. Pilot study exposure-based ICBT for adolescents with functional dyspepsia and functional abdominal pain
This study (n=40) is ongoing and will evaluate the effects of the exposure-based ICBT for adolescents with functional dyspepsia or functional abdominal pain. The treatment protocol from study A1 has been revised to better suit adolescents with these disorders. The study will be completed early 2016.
C1. Pilot of exposure-based CBT in face-to-face format for children with FGIDs
This study (n=20) is an ongoing face-to-face treatment with exposure-based cognitive behavior therapy. The main purpose of this study is to develop and evaluate a treatment protocol, to be used in the next two studies. The study will be completed during 2015.
C2. Pilot of exposure-based ICBT for children with FGIDs
In the second study (n=30) the treatment protocol will be transferred into an Internet treatment. The main purpose of this study is to investigate the feasibility of the Internet treatment and to examine preliminary effect sizes. Projected treatment start is fall 2015.
C3. RCT of exposure-based ICBT for children with FGIDs
The third study (n=120) is a randomized controlled trial where the Internet treatment will be compared to a wait-list control. Projected treatment start is fall 2016.
PhD students
- Marianne Bonnert, psychologist, Department of Clinical Neuroscience, Karolinska Institutet
- Maria Lalouni, psychologist, Department of Medicine Solna, Karolinska Institutet
Collaborators
- Ola Olén (PI for child studies), PhD, child gastroenterologist, Department of Medicine Solna, Karolinska Institutet
- Eva Serlachius, PhD, associate professor, child psychiatrist, Department of Clinical Neuroscience, Karolinska Institutet
- Erik Hedman, PhD, psychologist, psychotherapist, Department of Clinical Neuroscience, Karolinska Institutet
- Henrik Arnell, Department of Medicine Solna, Karolinska Institutet
- Marc A. Benninga, Department of Paediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, The Netherlands
- Magnus Simrén, Department of Internal Medicine & Clinicial Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Research grants
The program is supported by grants from: Vetenskapsrådet, Jane och Dan Olssons stiftelse, Kempe-Carlgrenska fonden, ALF (Stockhols läns landsting), Forte, Bengt Ihres fond, Ruth och Richard Juhlins stiftelse, Majblomman, ìShizu Matsumuraîs fond, Gadelius minnesfond, Stiftelsen Samariten, and Värkstadsstiftelsen.
Key references
- Bonnert, M., Ljótsson, B., Hedman, E., Andersson, J., Arnell, H., Benninga, M. A., et al. (2014). Internet-delivered cognitive behavior therapy for adolescents with functional gastrointestinal disorders — An open trial. Internet Interventions, 1(3), 141–148. doi:10.1016/j.invent.2014.07.002
- Labus, J., Mayer, E. A., Chang, L., Bolus, R., & Naliboff, B. (2007). The central role of gastrointestinal-specific anxiety in irritable bowel syndrome: further validation of the visceral sensitivity index. Psychosomatic Medicine, 69(1), 89–98. doi:10.1097/PSY.0b013e31802e2f24
- Levy, R. L., Langer, S. L., Walker, L. S., Romano, J. M., Christie, D. L., Youssef, N., et al. (2010). Cognitive-Behavioral Therapy for Children With Functional Abdominal Pain and Their Parents Decreases Pain and Other Symptoms. American Journal of Gastroenterology, 105(4), 946–956. doi:10.1038/ajg.2010.106
- Ljótsson, B. et al , Hedman, E., Andersson, E., Hesser, H., Lindfors, P., Hursti, T., et al. (2011). Internet-delivered exposure-based treatment vs. stress management for irritable bowel syndrome: a randomized trial. American Journal of Gastroenterology, 106(8), 1481–1491. doi:10.1038/ajg.2011.139
- Ljótsson, B., Hesser, H., Andersson, E., Lackner, J. M., Alaoui, El, S., Falk, L., et al. (2014). Provoking symptoms to relieve symptoms: A randomized controlled dismantling study of exposure therapy in irritable bowel syndrome. Behaviour Research and Therapy, 55C, 27–39. doi:10.1016/j.brat.2014.01.007
- Ljótsson, B., Hesser, H., Andersson, E., Lindfors, P., Hursti, T., Rück, C., et al. (2013). Mechanisms of change in an exposure-based treatment for irritable bowel syndrome. Journal of Consulting and Clinical Psychology, 81(6), 1113–1126. doi:10.1037/a0033439
- Saps, M., Seshadri, R., Sztainberg, M., Schaffer, G., Marshall, B. M., & Di Lorenzo, C. (2009). A prospective school-based study of abdominal pain and other common somatic complaints in children. The Journal of Pediatrics, 154(3), 322–326. doi:10.1016/j.jpeds.2008.09.047
Research program II: Emotion regulation therapy for self-harm
Non-suicidal self-injury (NSSI) is a serious global health problem that refers to direct and deliberate destruction of one’s own body tissue in the absence of suicidal intent (Nock, 2010) such as cutting or burning oneself. NSSI is common among both adults and adolescents and is associated with psychiatric illness, suicide attempts, and large societal costs.
Anger, aggression and impulsivity are psychological traits associated with both completed and attempted suicide and there is preliminary evidence that individuals who engage in both NSSI and suicide attempts have more complex psychopathology, lower psychosocial functioning and more self- and other-directed aggression than individuals with NSSI alone or suicide attempts alone (Victor & Klonsky, 2014). Individuals with NSSI may represent a group with more impaired self-control, which in turn may constitute an increased risk factor for both interpersonal violence and suicide attempts (Gvion & Apter, 2011).
Theoretical and empirical literature emphasizes the central role of emotion regulation in the development and maintenance of NSSI, highlighting the clinical utility of targeting emotion regulation difficulties in the treatment of this behavior. Emotion regulation group therapy (ERGT) is a 14-week adjunctive acceptance-based behavioral intervention that aims to reduce NSSI by teaching the participants more adaptive ways of responding to their emotions and improving emotion regulation. ERGT has shown promising results in several efficacy trials including adult patients (Gratz, Tull, & Levy, 2013) but no studies have investigated the effect of emotion regulation therapy for adolescents.
Research questions
- Is emotion regulation therapu a feasible, acceptable and effective treatment in terms of reducing NSSI and psychological problems for adult women with repeated NSSI when administrated in Swedish psychiatric health care?
- Is emotion regulation individual therapy in face-to-face format or internet-format a feasible, acceptable and effective treatment in terms of reducing NSSI and psychological problems for adolescents with repeated NSSI?
- What are the characteristics and as clinical correlates of individuals with NSSI including healthcare utilization patterns, psychiatric comorbidity, gender differences, suicidality and long-term prognosis?
Research projects
A Swedish Nationwide Effectiveness Study of Emotion Regulation Group Therapy (ERGT) for Nonsuicidal Self-Injury.
In this project 96 adult women with BPD or subthreshold BPD features and repeated NSSI were enrolled at 14 different psychiatric outpatient clinics from all over Sweden. This trial used a within-group study design with assessments at pre-treatment, weekly, post-treatment and 6-month follow-up. Study therapists (N = 28) had different professional backgrounds and received brief intensive training in delivering ERGT prior to trial onset and weekly supervision during the trial. The group sessions were video recorded and reviewed for adherence and competence. Six month follow-up data are currently being collected. The treatment will be evaluated in terms of reduced frequency of self harm and other self-destructive behaviors, increased mental health, and reduced societal costs.
Emotion Individual Therapy for Adolescents (ERITA) with repeated NSSI.
The overall objective of this project is to develop and evaluate a guided internet-based treatment that can be easily and widely implemented, for adolescents that engage in NSSI. The treatment is called ERITA and is based on the ERGT-manual, adapted for adolescents. Three studies are planned in collaboration with the Stockholm County Council and the school health service in a stepwise fashion. Study 1 is an open pilot study (N=30), with pretest-posttest design, of face-to-face ERITA. Study 2 is also an open pilot study (N=30) with pretest-posttest design, of Internet-based ERITA and study 3 is a randomized controlled trial (N=60) of Internet-based ERITA. The objectives for the three studies are to study if the treatment, delivered face-to-face or through the internet is a feasible, acceptable and effective treatment in terms of reducing NSSI and other self-destructive behaviors and psychological problems for adolescents with repeated NSSI. In addition to this we will study possible mechanisms of change in therapy and the treatments cost effectiveness from a societal perspective.
Co-occurring interpersonal violence in individuals with deliberate self-harm – a population based cohort study
This project aims to investigate the association between deliberate self-harm (DSH) and interpersonal violence. Evidence regarding this association this far is inconclusive and based on small, clinical samples. Through the use of Swedish registers, large samples using comprehensive, longitudinal data enable more precise comparisons. In an open cohort study of all Swedish citizens ≥ 15 years, who received somatic or psychiatric in- or outpatient care for DSH between 2004-2009 will be compared to the rest of the population on acts of interpersonal aggression as measured by criminal convictions. Other exposures such as psychiatric comorbidity, lethality of DSH and repetition of DSH will be analyzed in relation to levels of violent outcomes stratified by sex and age.
PhD students
- Johan Bjureberg, psychologist, Department of Clinical Neuroscience, Karolinska Institutet
- Hanna Sahlin, psychologist, psychotherapy, Department of Clinical Neuroscience, Karolinska Institutet
Collaborators
- Clara Gumpert (PI), PhD, psychiatrist, Department of Clinical Neuroscience, Karolinska Institutet
- Erik Hedman, PhD, psychologist, psychotherapist, Department of Clinical Neuroscience, Karolinska Institutet
- Jussi Jokinen, PhD, professor, psychiatrist, Department of Clinical Neuroscience, Karolinska Institutet
- Kim L Gratz, PhD, professor, psychologist, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, USA.
- Matthew T Tull, PhD, psychologist, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, USA.
Research grants
The program is supported by grants from: Marcus & Amalia Wallenberg Foundation, Kempe-Carlgrenska Foundation, ALF and PPG (Stockhols läns landsting), The Sven Jerring Foundation, Ingrid Thuring’s Foundation, and The psychiatry fund (Psykiatrifonden).
Key references
- Gratz, K. L., Tull, M. T., & Levy, R. (2013). Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Psychological Medicine, 1–14. doi:10.1017/S0033291713002134
- Gvion, Y., & Apter, A. (2011). Aggression, impulsivity, and suicide behavior: a review of the literature. Archives of Suicide Research : Official Journal of the International Academy for Suicide Research, 15(2), 93–112. doi:10.1080/13811118.2011.565265
- Nock, M. K. (2010). Self-Injury. Annual Review of Clinical Psychology, 6(1), 339–363. doi:10.1146/annurev.clinpsy.121208.131258
- Victor, S. E., & Klonsky, E. D. (2014). Correlates of suicide attempts among self-injurers: A meta-analysis. Clinical Psychology Review, 34(4), 282–297. doi:10.1016/j.cpr.2014.03.005