The current study investigated the impact of an 8-module internet-based cognitive behaviour therapy for perfectionism (ICBT-P) across a variety of perfectionism subscales. Undergraduate students who identified as having a problem with perfectionism were randomized to receive the intervention (n = 41), and were free to choose the number of treatment modules they completed over a 4-week period, while the control group (N = 48) received access to treatment 8 weeks post-randomisation. Secondary measures included depression, anxiety, stress, body image and self-compassion. Assessments occurred at baseline, 2-, 4- and 8-week time points. A mean of 3.12 (SD = 2.67) modules were completed; 7 participants (17%) completed none and 6 (15%) completed all. Linear mixed modelling (with baseline observation included as a covariate) showed significant Bonferroni-adjusted post-hoc between-group differences for 5 of the 6 perfectionism measures, favouring the intervention group; the most robust between group effect sizes were for the Concern over Mistakes (d = -0.82), High Standards (d = -0.69), and Perfectionistic Standards (d = -0.47) subscales. There were no between-group differences for our secondary measures. ICBT-P was found to be an effective intervention for reducing different components of perfectionism compared to a control group. The relatively low use of modules may have contributed to a lack of effect on secondary measures.

Australian New Zealand Clinical Trials Registry (ANZCTR) Trial Number: ACTRN12620000562976

Objective: Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression. Method: The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated. Results: A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d= 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72).Conclusions: The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

Virtual Reality (VR) can be used as a therapeutic tool to conduct efficacious in-session exposure therapy by presenting virtual equivalents of phobic stimuli, yet past hardware restrictions hindered implementation in routine care and effectiveness studies. The current study examines the effectiveness of a VR-assisted treatment protocol for public speaking anxiety with demonstrated efficacy, this time in routine care, using affordable VR hardware. Participants (n = 23) were recruited via a private clinic and treated by one of four psychologists with only minimal VR-training. Using a single-subject design and dual-slope modeling (adjusting the treatment-onset slope for treatment effects), we found a significant, large decrease in self-rated public speaking anxiety following the primary three-hour session, similar in magnitude to the previous efficacy trial. Multilevel modeling of in-session process measures suggests that the protocol works as intended, by decreasing catastrophic belief expectancy and distress, and increasing perceived performance quality. Adherence to the online transition program that followed-encouraging in-vivo exposure-was relatively poor, yet symptoms decrease continued. No change was observed over the three-month follow-up period. We conclude that VR exposure therapy can be effective under routine care conditions and is an attractive approach for future, large-scale implementation and effectiveness trials.

Objectives: To investigate the effectiveness of Body Project groups delivered virtually (vBP) by peer educators for prevention of eating disorders. Method: In a randomized controlled trial vBP groups (N = 149) were compared with a placebo (expressive writing, EW: N = 148) over 24-month follow-up and to a waitlist control condition (N = 146) over 6-month follow-up among females (15-20 years old) with body image concerns. The primary outcome was incidence of eating disorder onset over 2-year follow-up measured by blinded diagnostic interviews. Waitlist participants were offered the vBP after 6 months. Results: The incidence of eating disorders onset over 24 months follow up were 3 in vBP (2.0%) and 13 in EW (8.8%), a significant difference; Hazard Ratio (Experiment B) = 0.26, 95% confidence interval (CI) [0.075, 0.92], p = .037. Incidence of eating disorder onset in vBP participants was 77% less than in EW participants. The vBP participants generally showed significantly greater reduction in eating disorder symptoms, clinical impairment, body dissatisfaction, and internalization of thin ideal compared with the waitlist participants at postintervention and 6-month follow-up, and in eating disorder symptoms, restraint, body dissatisfaction, and internalization of thin ideal compared with the EW participants at postintervention, and 6-, 12-, 18-, or 24-months follow-up. EW participants reported significantly greater reduction in clinical impairment and body dissatisfaction at postintervention compared with the waitlist participants. Conclusions: The present reduction in the incidence of eating disorders is notable given that the intervention was implemented virtually, rather than in-person. The vBP might be a viable option for future evaluation of scalable prevention of eating disorders.

Study Objectives: Our aim was to compare the effects of Internet-delivered cognitive therapy (CT) and behavior therapy (BT) against a waitlist (WL) condition to better understand their unique contribution in the treatment of insomnia.

Methods: Two hundred and nineteen participants with insomnia disorder were randomized to CT (n = 72), BT (n = 73), or WL (n = 74). The treatment arms consisted of 10 weekly internet-delivered modules with 15 min of telephone support per week. At pre, post, and follow-up, participants completed measures of insomnia severity, sleep diaries, functional impairment, anxiety, depression, quality of life, adverse events, satisfaction and perception of content, workload, and activity in treatment. Measures of completed exercises, modules, therapist support, and platform logins were also measured at posttreatment.

Results: Moderate to large effect sizes for both CT and BT outperformed the WL on the majority of outcomes, with significant differences in favor of both therapy groups. Both treatment groups had significantly larger proportion of treatment remitters (CT: 35.8%, BT: 40%, WL: 2.7%) and responders (CT: 74.6%, BT 58.6%, WL: 10.8%) compared to the WL at posttreatment. There were no significant differences between the two therapy groups in terms of outcomes, except for sleep onset latency in favor of BT (6 min difference at posttreatment) and adverse events in favor of CT (CT 14.1% vs BT 43.2%).

Conclusions: This study indicates that both Internet-delivered CT and BT are effective as stand-alone therapies for insomnia disorder. Results highlight the need for examining which therapy and subcomponents that are necessary for change.

ClinicalTrials.gov Identifier: NCT02984670

Attentional bias modification (ABM) aims to attenuate social anxiety by directly modifying the underlying bias that generates and maintains problematic anxiety. Mixed results from previous ABM studies have spurred efforts to boost its effectiveness by introducing more robust bias modification protocols and new technologies. This thesis explored the effects of virtual reality (VR) based ABM training on attentional bias and social anxiety symptoms.

Study I investigated the efficacy of a single-session, VR based dot-probe task in reducing attentional bias and social anxiety symptoms. The results showed no significant differences between active and mock ABM training. No attentional bias was observed at baseline, and the dot-probe training did not alter attentional bias. The use of two-dimensional or three-dimensional stimuli had no significant impact on anxiety symptom or bias. Although we found an overall reduction in anxiety symptoms over time, this reduction was not specific to active training and the magnitude of change was not clinically significant. Study II examined the efficacy of a single-session, VR based person-identity-matching (PIM) task. The results were practically identical to those found in Study I, with no bias observed at baseline and no correlation observed between bias and anxiety. No change in attentional bias was observed post-training. For anxiety symptoms, participants showed a general reduction in their anxiety scores over time. Once again, this reduction was nonspecific and clinically insignificant. Overall, the empirical studies of the current thesis indicated no substantial treatment gains from a single session of VR based ABM. More accurate, reliable, and precise measures of attentional bias are needed before we can properly assess the efficacy of any ABM procedure. Study III took on a broader perspective by compiling and synthesising contemporary expert opinions on the use of virtual reality and mixed reality technologies in the treatment of anxiety and stress-related disorders, with a focus on the current state of technology-assisted psychotherapies and their prospective development. The experts acknowledged that current VR psychotherapies still face some challenges, but the consensus was that the overall outlook for future use of VR psychotherapies remained positive.

Background: Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias towards threatening information. The current study incorporated virtual reality (VR) technology and 3-dimensional stimuli with a person-identity-matching (PIM) task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms.

Methods: One hundred participants with elevated social anxiety were randomised to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-month follow-up.

Results: Change in anxiety did not correlate with change in bias (r = −0.08). A repeated-measures ANOVA showed no significant difference in bias from pre- to post-ABM, or between groups. For anxiety symptoms, a linear mixed-effects model analysis revealed a significant effect of time. Participants showed reduction in anxiety score at each successive assessment (p < .001, Nagelkerke's pseudo r2 = 0.65). However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 4% of participants were classified as ‘recovered’ at 3-month follow-up.

Conclusions: A single session of VR-based PIM task did not change attentional bias. The significant reduction in anxiety was not specific to active training, and the majority of participants remained clinically unchanged.

Depression is an increasing public health concern with rising prevalence. Nevertheless, far from everyone seeks help or receives adequate treatment. Although psychotherapy and antidepressants still constitute the bulk of treatments offered, recent research suggests that physical activity (PA) can be a powerful adjunct therapy while sedentary behavior (SB) is a definite risk factor for developing depression. The aim of the present study was to investigate the relationship between PA, SB and depressive symptoms in a population (n = 962) of applicants for an online treatment study. This study hypothesised that there will be; (1) a positive relationship between SB and depressive symptoms, and (2) a negative relationship between PA and depressive symptoms. In addition we investigated whether the combination of a sedentary lifestyle and physical inactivity increased the risk for depressive symptoms. Finally, we also examined whether gender, age, marital status, educational level, or medication affected the relationship between PA, SB, and depressive symptoms. The results showed a positive correlation between SB and depression. There was, however, no statistically significant support for a negative relation between PA and depressive symptoms. Even though no conclusions about causality can be drawn, our results suggest that high SB, being a woman, being young, not being in a stable relationship, and current or previous medication are risk factors for depression. To be able to determine the causal direction, that is, whether high SB increases the risk for depressive symptoms, or if depressive symptoms increase the likelihood of high SB, further research is needed.

Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias towards threatening information. The current study incorporated virtual reality (VR) technology and 3-dimensional stimuli with a dot-probe task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms. A total of 100 participants were randomised to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-months follow-up. Change in anxiety did not correlate with change in bias. No significant difference in bias was observed from pre- to post-ABM or between groups. For anxiety symptoms, participants showed significant reduction in anxiety scores over time. However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 9% of participants were classified as ‘recovered’ at 3-months follow-up.

Background: Attentional bias modification (ABM) aims to reduce anxiety by attenuating bias toward threatening information. The current study incorporated virtual reality (VR) technology and three-dimensional stimuli with a dot-probe task to evaluate the effects of a VR-based ABM training on attentional bias and anxiety symptoms.

Methods: A total of 100 participants were randomized to four training groups. Attentional bias was assessed at pre- and post-training, and anxiety symptoms were assessed at pre-training, post-training, 1-week follow-up, and 3-months follow-up.

Results: Change in anxiety did not correlate with change in bias (p = 0.24). A repeated-measures ANOVA showed no significant difference in bias from pre- to post-ABM (p = 0.144), or between groups (p = 0.976). For anxiety symptoms, a linear mixed-effects model analysis revealed a significant effect of time. Participants showed reduction in anxiety score at each successive assessment (p < 0.001). However, no other significant main effect or interactions were found. A clinically significant change analysis revealed that 9% of participants were classified as ‘recovered’ at 3-months follow-up.

Conclusion: A single session of VR-based ABM did not change attentional bias. The significant reduction in anxiety was not specific to active training, and the majority of participants remained clinically unchanged.