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  • 1. Boraxbekk, C. J.
    et al.
    Hagkvist, Filip
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Umeå University, Sweden; Karolinska Institutet, Sweden.
    Motor and mental training in older people: Transfer, interference, and associated functional neural responses2016In: Neuropsychologia, ISSN 0028-3932, E-ISSN 1873-3514, Vol. 89, p. 371-377Article in journal (Refereed)
    Abstract [en]

    Learning new motor skills may become more difficult with advanced age. In the present study, we randomized 56 older individuals, including 30 women (mean age 70.6 years), to 6 weeks of motor training, mental (motor imagery) training, or a combination of motor and mental training of a finger tapping sequence. Performance improvements and post-training functional magnetic resonance imaging (fMRI) were used to investigate performance gains and associated underlying neural processes. Motor only training and a combination of motor and mental training improved performance in the trained task more than mental-only training. The fMRI data showed that motor training was associated with a representation in the premotor cortex and mental training with a representation in the secondary visual cortex. Combining motor and mental training resulted in both premotor and visual cortex representations. During fMRI scanning, reduced performance was observed in the combined motor and mental training group, possibly indicating interference between the two training methods. We concluded that motor and motor imagery training in older individuals is associated with different functional brain responses. Furthermore, adding mental training to motor training did not result in additional performance gains compared to motor-only training and combining training methods may result in interference between representations, reducing performance.

  • 2.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Enoh, M.
    Ma, Lichen
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Unified protocol vs. diagnostic specific treatment of social anxiety – a randomized treatment study with a factorial design2018Conference paper (Other academic)
  • 3.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Enoh, Matilda
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Unified protocol vs. diagnostic specific treatment of social anxiety: a randomized treatment study with a factorial design2018In: Scientific Programme: Nurturing processes of change in iCBTs, 2018Conference paper (Refereed)
    Abstract [en]

    Traditionally, Cognitive Behavior Therapy researchers have developed and tested diagnostic specific treatment manuals. Most of which are efficacious. However, since comorbidity between anxiety and mood disorders is common and as the choice of the best suited treatment manual for each patient can be hard when delivering the treatment via the internet, transdiagnostic interventions have been put forward.

    The purpose of this study was to compare the effect of unified protocol vs. diagnostic specific treatment in a group of 147 individuals with social anxiety. The score on Liebowitz Social Anxiety Scale at pre-treatment was M=52.7.

    The interventions were both delivered via the internet during 9 weeks. In addition, the relative effect of no guidance vs. guidance on demand was investigated in a factorial design with 25 % of the patients randomized into each of the four groups. The preliminary results at week 9 show large within group effects (average Cohen’s d = 1,03), but no significant between-group differences as measured with the self-report MINI-SPIN-R and OASIS/ODSIS.

    At the time of the conference 6-month follow-up data will be available in addition to the already collected post-assessment data (analyzed according to the intention-to-treat principle).

  • 4.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hassmén, Peter
    Nyström, Markus
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    The relative effects of behavioral activation vs. physical exercise in the treatment of mild to moderate depression2016Conference paper (Refereed)
    Abstract [en]

    Aim: Despite their potential as low-threshold, low-cost and high-flexibility treatments of depression, behavioral activation and physical exercise have not yet been directly compared. This study has examined the effects of these interventions, administered via the Internet.

    Method: In this randomized controlled trial a total of 312 participants meeting the diagnostic criteria for mild to moderate major depression, recruited in multiple cycles and randomized to either a waiting list control group with delayed treatment, or one of the four active treatment groups: (1) physical exercise without a clear psychological treatment rationale; (2) physical exercise with a psychological treatment rationale; (3) behavioral activation a la Lewinsohn; or (4) behavioral activation a la Martel.

    Results: A total of 72% were women and the average age of the participants were M=42.3 years (SD=13,5). More than half (53,9%) had a history of previous psychological treatment. Primary outcome measure was the 9-item Patient Health Questionnaire. Assessments were made on a weekly basis for the full duration of the acute treatment which was 12 weeks.

    Conclusion: The preliminary results are in line with previous online studies showing that all active treatment groups were superior to the waitlist (large effect sizes) and that only minor differences could be identified between the four active groups (large within effect sizes). At the time of the conference 6-month follow-up data will be available in addition to the already collected post- assessment data (analyzed according to the intention-to-treat principle).

  • 5.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Fagernäs, S.
    Andersen, J.
    Sigeman, M.
    Furmark, T.
    Andersson, Gerhard
    The efficacy of internet-based virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial2017Conference paper (Other academic)
    Abstract [en]

    Fear of public speaking is common and for some individuals this interferes significantly with the person's life and causes marked distress. We wanted to test a newly developed virtual reality assisted 1-session in-person treatment (3 hours). The therapist guided session consisted of a series of behavioral experiments based on the expectancy violation principle. This was followed by a 4-week booster intervention delivered via the internet. Following a diagnostic interview a total of 50 individuals with a score of ≥ 60 on the Personal Report of Public Speaking Anxiety questionnaire were randomized to a treatment or a control condition. A total of 78% also met criteria for social anxiety disorder. Considering only having had one treatment session in-person the preliminary results were promising with a between group effect size on the primary outcome (Public Speaking Anxiety Scale) of Cohen’s d=1.32 before commencing the internet-based booster program. Four weeks later the between-group effect size was d=1.90. However, on the secondary outcome measures the effect sizes were more often moderate than large. At the time of the conference 6-month follow-up data will be available in addition to the already collected post-assessment data (analyzed according to the intention-to-treat principle).

  • 6.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    What is so frightening about spiders? Self-rated and self-disclosed impact of different characteristics and associations with phobia symptoms2019Conference paper (Other academic)
    Abstract [en]

    Spider phobia is a common and impairing mental disorder, yet little is known about what characteristics of spiders that spider phobic individuals find frightening. Using screening data from a clinical trial, we explored which characteristics that spider-fearful individuals (n=194) rated as having the greatest impact on fear, used factor analysis to group specific characteristics, and explored linear associations with self-reported phobia symptoms. Second, a guided text-mining approach was used to extract the most common words in free-text responses to the question: "What is it about spiders that you find frightening?". Both analysis types suggested that movement-related characteristics of spiders were the most important, followed by appearance characteristics. There were, however, no linear associations with degree of phobia symptoms. Our findings reveal the importance of targeting movement-related fears in in-vivo exposure therapy for spider phobia and using realistically animated spider stimuli in computer-based experimental paradigms and clinical interventions such as Virtual Reality exposure therapy.

  • 7.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Fagernäs, S.
    Andersen, J.
    Sigeman, M.
    Andersson, G.
    Furmark, T.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Therapist and Internet Administered One-Session Virtual Reality Exposure Therapy for Public Speaking Anxiety: A Randomized Controlled Trial2018Conference paper (Other academic)
    Abstract [en]

    Fear of public speaking is common and for some individuals this interferes significantly with the person's life and causes marked distress. We wanted to test a newly developed virtual reality assisted 1-session in-person treatment (3 hours). The therapist guided session consisted of a series of behavioral experiments based on the expectancy violation principle. This was followed by a 4-week booster intervention delivered via the internet. Following a diagnostic interview a total of 50 individuals with a score of ≥ 60 on the Personal Report of Public Speaking Anxiety questionnaire were randomized to a treatment or a control condition. A total of 78% also met criteria for social anxiety disorder. Considering only having had one treatment session in-person the preliminary results were promising with a between group effect size on the primary outcome (Public Speaking Anxiety Scale) of Cohen’s d=1.32 before commencing the internet-based booster program. Four weeks later the between-group effect size was d=1.90. However, on the secondary outcome measures the effect sizes were more often moderate than large. At the time of the conference 6-month follow-up data will be available in addition to the already collected post-assessment data (analyzed according to the intention-to-treat principle).

  • 8.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hamilton, William
    Andersson, Gerhard
    ITSY: A gamified one-session virtual reality app with 12-month follow-up data2017Conference paper (Other academic)
    Abstract [en]

    Introduction: This is the first large randomized-controlled trial to evaluate whether commercially available VR hardware and software can be used for exposure therapy. The aim of this study was to compare gold-standard One Session Therapy (OST) for reduction of spider phobia symptoms and avoidance behavior using in vivo spiders and a human therapist, to a newly developed single-session gamified Virtual Reality Exposure Therapy (VRET) application with modern, consumer-available VR hardware, virtual spiders, and a virtual therapist. Method: Subjects (N=100) with spider phobia, diagnosed, and meeting inclusion criteria were recruited from the general population and randomized to 2 treatment arms. In 1-week intervals, pre-measurement, 3-hr treatment and post-measurement were completed with an in-vivo behavioral approach test (BAT) serving as the primary outcome measure for both groups. This study was powered to detect a non-inferiority margin of a 2-point between-group difference on the BAT, with a standard deviation of 4 (at 80% power). Results: 98 patients commenced treatment and 97 patients completed post-measurement. Per protocol analysis indicated VR was not non-inferior to OST. Repeated-measures ANOVA identified a significant main effect of time.

  • 9.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Reuterskiöld, Lotta
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hamilton, William
    Andersson, Gerhard
    ITSY: A Gamified One-Session Virtual Reality App With 12-Month Follow-Up Data2017In: Program Book, 2017, p. 396-396Conference paper (Refereed)
    Abstract [en]

    Introduction: This is the first large randomized-controlled trial to evaluate whether commercially available VR hardware and software can be used for exposure therapy. The aim of this study was to compare gold-standard One Session Therapy (OST) for reduction of spider phobia symptoms and avoidance behavior using in vivo spiders and a human therapist, to a newly developed single-session gamified Virtual Reality Exposure Therapy (VRET) application with modern, consumer-available VR hardware, virtual spiders, and a virtual therapist.

    Method: Subjects (N=100) with spider phobia, diagnosed, and meeting inclusion criteria were recruited from the general population and randomized to 2 treatment arms. In 1-week intervals, pre-measurement, 3-hr treatment and post-measurement were completed with an in-vivo behavioral approach test (BAT) serving as the primary outcome measure for both groups. This study was powered to detect a non-inferiority margin of a 2-point between-group difference on the BAT, with a standard deviation of 4 (at 80% power).

    Results: 98 patients commenced treatment and 97 patients completed post-measurement. Per protocol analysis indicated VR was not non-inferior to OST. Repeated-measures ANOVA identified a significant main effect of time (p < .001) and time x group effect (p < .05). Both OST and VR participants experienced large BAT within-group effect sizes (d=2.28 and d=1.45, respectively). By the time of the conference there will be 12-month follow-up data including prediction analysis and the effect of treatment credibility and working alliance (with the virtual therapist).

    Conclusion: OST is the superior treatment option for spider phobia. VRET is an effective alternative if OST cannot be provided, as pure self-help, as the initial intervention in a stepped-care model, or as a possible post-OST booster.

  • 10.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Nettelblad, Hedvig
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Segell, Victor
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Nyström, Markus
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hassmén, Peter
    Andersson, Gerhard
    The effects of a 12-week relapse prevention program following acute depression treatment: A randomised controlled trial2019Conference paper (Refereed)
    Abstract [en]

    Context: Depression can be effectively treated using internet interventions. However, the relapse rate is non-ignorable. Methods: 286 participants were randomized to an additional relapse prevention program or a control group. Monthly telephone calls using the MINI diagnostic interview as well as online assessments were carried out for 24 months. Intervention: Standard cognitive behaviour therapy via the internet without guidance. Results: Relapse rates of 27.1% and 22.0% were reported in the relapse prevention program group and the control group respectively. A log-rank test of the Kaplan-Meier model did not show any significant difference between the prevention program group and the control group (χ2(1) = 0.87; p = .352) in terms of relapse rates. At the one-year follow-up, 79.2% in the prevention program group and 82.9% of the participants in the control group had PHQ-9 scores indicating them to be in remission. By the second-year follow-up the rate of remission was 75.8% in the relapse prevention program group and 81.2% in the control group. No significant differences could be seen neither at the one-year follow-up (χ2(1) = 0.36; p = .552) nor the two-year follow-up (χ2(1) = 0.53; p = .467). Conclusions: Don’t do it!

  • 11.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Nystrom, M.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Martell, C.
    Forsberg, L.
    Ström, L.
    Andersson, Gerhard
    Hassmén, Peter
    The effects on depression of Internet-administered behavioral activation vs. physical exercise2015Conference paper (Other academic)
    Abstract [en]

    Despite their potential as low-threshold, low-cost and high-flexibility treatments of depression, behavioral activation and physical exercise have not yet been directly compared. This study has examined the effects of these interventions, administered via the Internet. In this randomized controlled trial a total of 312 participants meeting the diagnostic criteria for mild to moderate major depression, recruited in multiple cycles and randomized to either a waiting list control group with delayed treatment, or one of the four active treatment groups: (1) physical exercise without a clear psychological treatment rationale; (2) physical exercise with a psychological treatment rationale; (3)behavioral activation a la Lewinsohn; or (4) behavioral activation a la Martel. A total of 72% were women and the average age of the participants were M=42.3 years (SD=13,5). More than half (53,9%) had a history of previous psychological treatment. Primary outcome measure was the 9-item Patient Health Questionnaire. Assessments were made on a weekly basis for the full duration of the acute treatment which was 12 weeks. The preliminary results are in line with previous online studies showing that all active treatment groups were superior to the waitlist (large effect sizes) and that only minor differences could be identified between the four active groups (large within effect sizes). At the time of the conference 6-month follow-up data will be available in addition to the already collected post-assessment data (analyzed according to the intention-to-treat principle).

  • 12.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Nystrom, Markus
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Martell, Christopher
    Forsberg, Lars
    Ström, Lars
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Hassmén, Peter
    Behavioral Activation vs. Physical Exercise in the Treatment of Mild to Moderate Depression2015Conference paper (Other academic)
    Abstract [en]

    Despite their potential as low-threshold, low-cost and high-flexibility treatments of depression, behavioral activation and physical exercise have not yet been directly compared. This study has examined the effects of these interventions, administered via the Internet. In this randomized controlled trial a total of 312 participants meeting the diagnostic criteria for mild to moderate major depression, recruited in multiple cycles and randomized to either a waiting list control group with delayed treatment, or one of the four active treatment groups: (1) physical exercise without a clear psychological treatment rationale; (2) physical exercise with a psychological treatment rationale; (3) behavioral activation a la Lewinsohn; or (4) behavioral activation a la Martel. A total of 72% were women and the average age of the participants were M=42.3 years (SD=13,5). More than half (53,9%) had a history of previous psychological treatment. Primary outcome measure was the 9-item Patient Health Questionnaire. Assessments were made on a weekly basis for the full duration of the acute treatment which was 12 weeks. The preliminary results are in line with previous online studies showing that all active treatment groups were superior to the waitlist (large effect sizes) and that only minor differences could be identified between the four active groups (large within effect sizes). At the time of the conference 6-month follow-up data will be available in addition to the already collected post-assessment data (analyzed according to the intention-to-treat principle).

  • 13.
    Carlbring, Per
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Nyström, Markus
    Stenling, Andreas
    Neely, Gregory
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Martell, Christopher R.
    Hassmén, Peter
    Behavioral Activation Versus Physical Activity Via the Internet: A Randomized Controlled Trial2017In: Program Book, 2017, p. 396-396Conference paper (Refereed)
    Abstract [en]

    A major problem today is that only about fifty percent of those affected by depression seeks help. One way to reach more sufferers would be by offering easily accessible internet based treatments. The purpose of this study was to compare/evaluate four therapist supported internet administered treatments. Two hundred eighty six participants were included. The treatment period lasted twelve weeks, consisting of the following treatments: 1) physical activity without treatment rational, 2) physical activity with treatment rational, 3) behavioral activation without treatment rational and 4) behavioral activation with treatment rational. All groups (including a control-group) showed a significant decrease in depressive symptoms. When the treatment groups were pooled and compared to the control group, there were significant differences from pretest to posttest (Hedges g av treatment =1.01, control group =0.47).This held true also when each of the four treatment groups was compared to the control group, with one exception: Physical activity without treatment rationale. The differences between how many modules the participants completed could indicate that there are other factors than the treatments that caused the symptom reduction, however, the dose-response analysis did not detect any significant differences on account of modules completed. The results support the positive effects of internet administered treatments for depression, and highlights the importance of psychoeducation, which tends to affect both the treatment outcome and the probability of remaining in treatment. These aspects need to be considered when developing and conducting new treatments for depression, since they would increase the likelihood of positive treatment outcomes.

  • 14. Fagernäs, Simon
    et al.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersen, Joel
    Sigeman, Martin
    Furmark, Tomas
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Moderating effects of presence and adherence in internetbased CBT with virtual reality exposure therapy for public speaking anxiety2017Conference paper (Refereed)
    Abstract [en]

    Introduction: Previous research has revealed that Virtual Reality Exposure Therapy (VRET) is an effective method for reducing symptoms of public speaking anxiety (PSA). Research about presence in the virtual environment indicates a moderating effect on physiological arousal, but more ambiguous effect on treatment effects where some research indicates a small effect while other indicate no effect. Furthermore, previous research has found adherence to home work assignments to moderate treatment outcome. In this treatment study which aimed for treating public speaking anxiety with VRET and a internetbased CBT-program, we investigated whether presence in the virtual environment and adherence to home work moderated treatment effects.

    Methods: N=25 adult participants from the general public with clinically significant PSA were recruited to a wait-list to another study. After five weeks on waitlist, they started the treatment with a self-guided in virtuo exposure session followed by a four week online maintenance promoting in-vivo exposure. Participants got a simple VR headset by post. The three-hour exposure session included psychoeducation in text, and the participants conducted speech exercises, framed as behavioral experiments targeting idiosyncratic catastrophic beliefs, in front of virtual audiences, and listening to audio recording afterwards. Primary outcome measure was self-reported PSA. To measure moderating effects of presence on the primary outcome measure a self-reported validated scale with subscales for presence (iGroup Presence Questionnaire, IPQ) were used, and for adherence a score were manually calculated based on the number of completed home-work assignments in both a linear model and a binary model dividing participants in two groups: one with at least one completed home work assignment and one with no completed home work assignment. The analysis on presence included both the effects of the VRET-session alone and in combination with the internetbased CBT-program. Data were analyzed using mixed effects modeling.

    Results: No significant results were found in moderating effects of presence with its subscales on the primary outcome measure for either the VRET-session (p = .375-.616) nor in combination with the internetbased CBT-program (p = .454 - .877). Moderating effects of adherence on primary outcome measure neither revealed no significant results in the linear model (p = .368) nor the binary model (p = .113).

    Conclusions: The findings of this study indicate, in line with some previous research, that presence in the virtual environment has no significant moderating effect on treatment outcome. Furthermore, in contrast to previous research, this study found no significant moderating effect on adherence to home work assignments on primary treatment outcome. Internal- and external validity and other potential explanations are discussed in detail in the poster.

  • 15.
    Ivanova, Ekaterina
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Using the Random Forest Algorithm on Customer Gambling Data for Predicting Gambling Freezes in an Online Gambling PlatformManuscript (preprint) (Other academic)
    Abstract [en]

    Background. Data on gambling behaviors routinely collected on online gambling platforms can be used to detect individuals at risk of developing or having gambling problems. As only data on gambling activity is available on gambling platforms, it is important to find a proxy measure for gambling problems. Temporarily freezing one or several gambling categories has potential to serve this purpose. Aim. To predict gambling freeze in a sample of active users of an online gambling platform one week before the freeze, based on one week of behavioral data tracked on the platform. Method. N = 105 predictors were created, covering total values, frequencies, variations, and trajectories of monetary and time-related gambling involvement, number and type of games played, point in time when gambling occurred, age, and gender. The random forest algorithm was applied to a sample of N = 2618 gamblers (of which N = 1309 freezers), with the sample divided 70/30 into a training and testing data set. Results. The accuracy of random forest applied to the testing data set was 0.615, with sensitivity of 0.543 and specificity of 0.686. The five most predictive variables were current age, age on registration date, average session length, average sum of winnings per session, and total session length. Discussion. The predictive accuracy of the algorithm in the current study was relatively low, suggesting the need for a more suitable target variable. Also, analyzing data collected during a longer period might be needed to create a tool that could be used to identify at-risk gamblers.

  • 16.
    Ivanova, Ekaterina
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Dahlin, M.
    Ly, H.
    Vernmark, K.
    Andersson, Gerhard
    Linköpings universitet & Karolinska Institutet.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Guided and unguided CBT for social anxiety disorder and/or panic disorder via the Internet and a smartphone application2015In: Abstracts from the 7th Swedish Congress on internet interventions (SWEsrii), Linköping: Linköping University Press , 2015, p. 9-9Conference paper (Other academic)
    Abstract [en]

    Background: As Acceptance and Commitment Therapy (ACT) becomes a part of the clinical practice, the interest for alternative ways of providing it continue to grow. Internet-based CBT, both guided and unguided, has proved to be effective for the treatment of a wide range of psychiatric disorders, including anxiety disorders. Moreover, the tremendous accessibility of smartphones makes them a potentially powerful instrument for providing psychological treatment. The purpose of this study was to investigate the effects of an Internet-based ACT-program for social anxiety disorder and panic disorder using both computers and smartphones, and with and without therapist support. Method: The participants were recruited from the general public by filling out an online screening form, which consisted of LSAS, PDSS-SR, GAD-7, PHQ-9, QOLI (the scales later served as outcome measures) and demographic questions. The individuals who met the inclusion criteria were contacted for a diagnostic telephone interview. The 152 people chosen for participation were then randomized into two treatment groups (guided and unguided) and a waiting list control group. The participants in the treatment groups were given access to an Internet-provided ACT-based treatment program consisting of 8 modules, as well as a smartphone application with content that corresponded to the Internet treatment program. Additionally, the participants in the guided group received minimum therapist support (15 min/week) through the smartphone application from psychology students undergoing their clinical training. The participants worked with the program for 10 weeks. They were evaluated twice during treatment, once after completing treatment, and once again 12-months later as a follow-up measure. A mixed effect model was used to analyze the data. Results: Regardless of diagnosis, as a whole the treated groups showed significant decreases in anxiety, with a moderate within-group effect size. This improvement appeared to be maintained when the groups were evaluated again during the follow-up. The participants suffering primarily from social anxiety disorder showed significant improvements, with moderate within-group effect sizes in both the guided (Cohen's d = 0.79) and unguided group (Cohen's d = 0.71). This improvement also appeared to be maintained when these participants were evaluated during the follow-up. No significant changes were observed in the symptoms of the participants suffering primarily from panic disorder. Discussion: Internet-delivered ACT-based treatment provided via both computer and smartphone can be effective for reducing general anxiety symptoms, as well as social anxiety symptoms. The guided treatment was not clearly superior to the unguided treatment. Some of the study’s uncertainties are likely due to the presence of a large number of different components, which made it difficult to isolate the effects of each individual component.

  • 17.
    Ivanova, Ekaterina
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Dahlin, Mats
    Vernmark, Kristofer
    Ly, Kien Hoa
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Guided and unguided transdiagnostic Acceptance and Commitment Therapy for anxiety disorders provided via a computer and a smartphone application: A randomized controlled trial2016In: EABCT 2016 Abstract Book: Total Awareness, 2016, p. 530-530Conference paper (Refereed)
    Abstract [en]

    Technology-assisted psychological treatments are becoming well-known in the scientific networks throughout the world and are being implemented into routine health care in a number of countries. The interest in evaluating the potential of different devices is growing. The main objective of the current study was to evaluate the effects of guided and unguided computerand smartphone-based Acceptance and Commitment Therapy (ACT) for social anxiety disorder (SAD) and panic disorder (PD).

    A total of 152 participants were randomized into a guided treatment group, an unguided treatment group and a waiting list control group. Both treatment groups got access to a computer-based ACT-treatment and a smartphone application (app) with corresponding content. The eight modules treatment program covered a number of topics such as the nature of anxiety, functional analyses, acceptance, mindfulness and valued actions. The purpose of the app was to make it easier for the participants to access the key points of the program and to do homework assignments in their everyday life. Automatic messages in the app aimed to give feedback to the participants on their work as well as to prompt them to continue with the program. In addition to that, the participants in the guided group got therapist support via the app. The therapists were encouraged to work with each of their patient 15 min/week during the 10 weeks treatment period and focus on motivating, validating and correcting mistakes. On the whole group level GAD-7 was used as the primary outcome measure. LSAS and PDSS-SR were used for subgroup analyses in SAD and PD participants respectively. The measurements were collected at pre-, mid- and post-treatment and at 12-months follow-up.

    There were no significant differences in adherence between the treatment groups except for significantly higher rates of smartphone usage in the guided group. No significant differences in treatment outcome were found between the treatment groups with moderate within-group effects (Cohen’s d = 0.75 for the guided and Cohen’s d = 0.66 for the unguided group). The treated participants improved significantly in comparison to the control group both on the whole group level (between group Cohen’s d = 0.39) and for the participants suffering primarily from SAD (between group Cohen’s d = 0.70). Within group effect sizes were large for the PD-participants (Cohen’s d = 1.00) but the study was very underpowered in this part.

    Discussion. The treatment program as it was used in the present study appeared to be effective in treating social anxiety disorder and decreasing general anxiety symptoms, but the effects are smaller than seen in previous studies. The guided treatment was not clearly superior to the unguided one. The study contributes to the growing body of evidence on technology-assisted ACT.

    Conclusion. Computer- and smartphone-based ACT can be made into an effective treatment for anxiety disorders. A smartphone application seems to have a clear potential to partly compensate for the absence of therapist support which needs to be studied further.

  • 18.
    Ivanova, Ekaterina
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Ly, Kien Hoa
    Dahlin, Mats
    Vernmark, Kristofer
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial2016In: Journal of Anxiety Disorders, ISSN 0887-6185, E-ISSN 1873-7897, Vol. 44, p. 27-35Article in journal (Refereed)
    Abstract [en]

    Acceptance and Commitment Therapy (ACT) can be effective in treating anxiety disorders, yet there has been no study on Internet-delivered ACT for social anxiety disorder (SAD) and panic disorder (PD), nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application. In the current trial, n = 152 participants diagnosed with SAD and/or PD were randomized to therapist-guided or unguided treatment, or a waiting-list control group. Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application. Outcome measures were self-rated general and social anxiety and panic symptoms. Treatment groups saw reduced general (d = 0.39) and social anxiety (d = 0.70), but not panic symptoms (d = 0.05) compared to the waiting-list group, yet no differences in outcomes were observed between guided and unguided interventions. We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD. Smartphone applications may partially compensate for lack of therapist support.

  • 19.
    Ivanova, Ekaterina
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Rafi, Jonas
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Stockholm County Council, Sweden.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Experiences of responsible gambling tools among non-problem gamblers: A survey of active customers of an online gambling platform2019In: Addictive Behaviors Reports, ISSN 2352-8532, E-ISSN 2076-3387, Vol. 9, article id 100161Article in journal (Refereed)
    Abstract [en]

    Introduction: Responsible gambling (RG) tools, aiming at helping gamblers to avoid gambling-related harms, are common in online gambling platforms. Gambling industry, policy makers, and researchers have warned that RG tools can potentially disturb recreational gamblers, channeling them to less protective operators. No evidence exists to support these concerns, and they can hinder the development of effective RG tools. The current study aimed to investigate the recreational gamblers' experiences of RG tools.

    Methods: A total of 10,200 active customers of an online gambling service were invited to complete an online survey and rate their overall reactions, attitudes, disturbance and irritation towards RG tools, as well as their inclination to abandon a gambling service due to overexposure to RG tools. N = 1223 surveys were completed.

    Results: Non-problem gamblers had positive experiences of RG tools. Moderate-risk gamblers had more positive overall reaction and less irritation to previous experiences of RG tools compared to non-problem gamblers. Problem gamblers had least positive attitudes, most disturbance and most irritation towards RG pictures. Non-problem gamblers had lowest rates of having abandoned a service because of perceived overexposure to RG tools (5.2% compared to 25.9% of problem gamblers), with a significant between-group difference (OR [95%CI] = 7.17 [3.61–14.23], p < .001).

    Conclusions: Non-problem gamblers were not particularly disturbed by RG tools and were not at risk of abandoning online gambling services because of overexposure to RG tools. The study found no grounds for limiting the design and implementation of RG tools due to fears of disturbing recreational gamblers.

  • 20.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    The Next Generation of Virtual Reality Interventions for Mental Health2019In: Proceedings of the 9th World Congress of Behavioural & Cognitive Therapies: Volume I. Research, Applied Issues / [ed] Thomas Heidenreich, Philip Tata, Tübingen: dgvt-Verlag , 2019, Vol. 1, p. 174-174Conference paper (Other academic)
    Abstract [en]

    Decades of research have shown that Virtual Reality (VR) technology can be used efficaciously to treat anxiety disorders, and for pain management, stress reduction, and other mental health purposes. Yet it is only with the recently advent of consumer VR platforms that widespread clinical implementation and scalable dissemination of self-help application have become possible. The time is thus ripe to move VR interventions out from university labs and into clinics and the hands of regular patients. This talk will present recent research on the efficacy, effectiveness and real-world usage of automated, gamified VR self-help applications, as well as three on-going effectiveness studies in regular healthcare: VR pain-distraction at a post-operative ward, VR relaxation at a psychiatric inpatient clinic, and VR exposure therapy for public speaking anxiety at a general mental health clinic. The unique and inherent clinical capabilities of VR technology will be discussed, as will lessons learned from implementation and dissemination efforts.

  • 21.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institute, Sweden.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Flodman, Erik
    Hebert, Amanda
    Poysti, Stephanie
    Hagkvist, Filip
    Johansson, Robert
    Zetterqvist Westin, Vendela
    Berger, Thomas
    Andersson, Gerhard
    Does cognitive flexibility predict treatment gains in Internet-delivered psychological treatment of social anxiety disorder, depression, or tinnitus?2016In: PeerJ, ISSN 2167-8359, E-ISSN 2167-8359, Vol. 4, article id E1934Article in journal (Refereed)
    Abstract [en]

    Little is known about the individual factors that predict outcomes in Internet-administered psychological treatments. We hypothesized that greater cognitive flexibility (i.e. the ability to simultaneously consider several concepts and tasks and switch effortlessly between them in response to changes in environmental contingencies) would provide a better foundation for learning and employing the cognitive restructuring techniques taught and exercised in therapy, leading to greater treatment gains. Participants in three trials featuring Internet-administered psychological treatments for depression (n = 36), social anxiety disorder (n = 115) and tinnitus (n = 53) completed the 64-card Wisconsin Card Sorting Test (WCST) prior to treatment. We found no significant associations between perseverative errors on the WCST and treatment gains in any group. We also found low accuracy in the classification of treatment responders. We conclude that lower cognitive flexibility, as captured by perseverative errors on the WCST, should not impede successful outcomes in Internet-delivered psychological treatments.

  • 22.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Flodman, Erik
    Poysti, Stephanie
    Hagkvist, Filip
    Johansson, Robert
    Zetterqvist Westin, Vendela
    Berger, Thomas
    Andersson, Gerhard
    Cognitive flexibility does not predict symptom reduction in Internet interventions2015Conference paper (Other academic)
    Abstract [en]

    PURPOSE: Little is known about whether individual differences in executive functions predict outcomes after Internet-delivered psychological treatments. We hypothesized that learning and utilizing skills taught in treatment is reliant on cognitive flexibility, as measurable by perseverative errors (PE) on the 64-card Wisconsin Card Sorting Test (WCST). We tested this by correlating PE scores with symptom reduction following treatment for social anxiety disorder (n=116), depression (n=42) and tinnitus discomfort (n=28). METHOD: In all groups, the WCST was administered online prior to treatment and partial correlation (controlling for age) were calculated between PE and percentage symptom reduction on the respective primary outcome measure. RESULTS: Number of PE did not correlate with pre-treatment symptom scores in any group. There was no generic association between symptom reduction and PE, and, after outlier removal, no group-specific associations either. CONCLUSIONS: Lower cognitive flexibility does not appear to impede symptom reduction in Internet-delivered psychological treatments.

  • 23.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Karolinska Institutet, Sweden; Stockholm County Council, Sweden.
    Flodin, Pär
    Budhiraja, Meenal
    Savic, Ivanka
    Jokinen, Jussi
    Tiihonen, Jari
    Hodgins, Sheilagh
    Associations of Psychopathic Traits With Local and Global Brain Network Topology in Young Adult Women2018In: Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, ISSN 2451-9022, Vol. 3, no 12, p. 1003-1012Article in journal (Refereed)
    Abstract [en]

    Background: Psychopathic traits vary dimensionally in the population and are associated with multiple negative outcomes. The impaired integration theory (IIT) proposes that psychopathic traits are associated with abnormal neural network topology, such that disturbed integration of neural networks results in a self-perpetuating impairment in rapid integration and learning from multiple components of information. The IIT is based on findings from male offenders presenting high scores on all psychopathic traits. The present study investigated whether IIT predictions of topology abnormalities were associated with psychopathic traits, measured dimensionally, in young adult women with subsyndromal scores.

    Methods: Seventy-three women, with an average age of 25 years, were assessed using the Psychopathy Checklist–Revised and completed resting-state magnetic resonance imaging. Preprocessed time series from 90 anatomical regions were extracted to form connectivity matrices and used to calculate network topology based on graph theory. Correlations between total psychopathy and factor scores with both the raw connectivity matrix and global and local graph theory measures were computed.

    Results: Total psychopathy scores and behavioral factor scores were related to connectivity between several pairs of regions, primarily limbic/paralimbic. Psychopathic traits were not associated with global topology measures. Topology abnormalities, robust across network formation thresholds, were found in nodes of the default mode network and in hubs connecting several resting-state networks.

    Conclusions: IIT predictions of abnormal topology of hubs and default mode network nodes with dimensionally measured psychopathic traits were confirmed in a sample of young women. Regional abnormalities, accompanied by preserved global topology, may underlie context-specific abnormal information processing and integration.

  • 24.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm Center for Dependence Disorders, Stockholm County Council, Sweden.
    Flodin, Pär
    Larm, Peter
    Budhiraja, Meenal
    Savic-Berglund, Ivanka
    Jokinen, Jussi
    Tiihonen, Jari
    Hodgins, Sheilagh
    Amygdala-orbitofrontal structural and functional connectivity in females with anxiety disorders, with and without a history of conduct disorder2018In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 8, article id 1101Article in journal (Refereed)
    Abstract [en]

    Conduct disorder (CD) and anxiety disorders (ADs) are often comorbid and both are characterized by hyper-sensitivity to threat, and reduced structural and functional connectivity between the amygdala and orbitofrontal cortex (OFC). Previous studies of CD have not taken account of ADs nor directly compared connectivity in the two disorders. We examined three groups of young women: 23 presenting CD and lifetime AD; 30 presenting lifetime AD and not CD; and 17 with neither disorder (ND). Participants completed clinical assessments and diffusion-weighted and resting-state functional MRI scans. The uncinate fasciculus was reconstructed using tractography and manual dissection, and structural measures extracted. Correlations of resting-state activity between amygdala and OFC seeds were computed. The CD + AD and AD groups showed similarly reduced structural integrity of the left uncinate compared to ND, even after adjusting for IQ, psychiatric comorbidity, and childhood maltreatment. Uncinate integrity was associated with harm avoidance traits among AD-only women, and with the interaction of poor anger control and anxiety symptoms among CD + AD women. Groups did not differ in functional connectivity. Reduced uncinate integrity observed in CD + AD and AD-only women may reflect deficient emotion regulation in response to threat, common to both disorders, while other neural mechanisms determine the behavioral response.

  • 25.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Frykheden, Ola
    Andersson, Erik
    Ljótsson, Brjann
    Hedman, Erik
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    The Brunnsviken Brief Quality of life scale (BBQ): a novel, free self-rating scale of subjective quality of life2015Conference paper (Other academic)
  • 26.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Frykheden, Ola
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Erik
    Ljótsson, Brjánn
    Hedman, Erik
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    The Brunnsviken Brief Quality of Life Scale (BBQ): Development and Psychometric Evaluation2016In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 45, no 3, p. 182-195Article in journal (Refereed)
    Abstract [en]

    Measurements of subjective quality of life (QoL) are an important complement to symptom ratings in clinical research and practice. Despite there being several established QoL self-rating scales, we identified a need for a freely accessible, easy-to-use inventory, validated for use with both clinical and non-clinical samples, based on the overall life satisfaction conceptualization of QoL. The Brunnsviken Brief Quality of life scale (BBQ) was designed to meet these requirements. Items were selected by performing a factor analysis on a large data-set of QoL ratings collected previously. Six life areas (Leisure time, View on life, Creativity, Learning, Friends and Friendship, and View of self) were identified as important for overall QoL and were included in the BBQ. A psychometric evaluation was performed using two independent samples: healthy undergraduate students (n = 163), and a sample seeking treatment for social anxiety disorder (n = 568). Results suggested a unifactorial structure, with good concurrent and convergent validity, high internal and test-retest reliability, and accurate classification ability. We conclude that the BBQ is a valid and reliable measure of subjective QoL for use in clinical and research settings. The BBQ is presently available in 31 languages and can be freely downloaded from www.bbqscale.com.

  • 27.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm Health Care Services, Sweden.
    Hamilton, William
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    How to Treat Depression With Low-Intensity Virtual Reality Interventions: Perspectives on Translating Cognitive Behavioral Techniques Into the Virtual Reality Modality and How to Make Anti-Depressive Use of Virtual Reality–Unique Experiences2019In: Frontiers in Psychiatry, ISSN 1664-0640, E-ISSN 1664-0640, Vol. 10, article id 792Article in journal (Refereed)
    Abstract [en]

    Depression is a common mental disorder with a large treatment gap. Low-intensity, automated virtual reality (VR) interventions (not requiring a therapist) is a scalable and promising solution now that VR is an accessible and mature, consumer technology. Yet unlike with phobias, there have been few attempts at translating evidence-based cognitive behavioral therapeutic (CBT) techniques for depression into the VR modality. In this paper, we discuss how specific CBT techniques can be made into VR experiences, including psychoeducation, behavioral activation, cognitive restructuring, and social skills training. We also discuss how VR-unique experiences, such as alternative embodiment and virtual pet interactions, can be made therapeutic. Creating a pre-clinical and clinical evidence base for these types of novel interventions should be considered a research priority, and high-quality development on par with other consumer VR applications will be essential to the success of any consumer-targeted intervention. If this is achieved, low-intensity VR interventions for depression have great potential to make an impact on public mental health.

  • 28.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Fagernäs, Simon
    Andersen, Joel
    Sigeman, Martin
    Andersson, Gerhard
    Furmark, Tomas
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Therapist-led and at-home one-session Virtual Reality exposure therapy for public speaking anxiety using consumer hardware and software, with online maintenance: A randomized controlled trial2017Conference paper (Refereed)
    Abstract [en]

    Introduction: Exposure therapy is an effective treatment of public speaking anxiety (PSA), yet inherent logistic challenges prevent widespread dissemination. Previous research has revealed that Virtual Reality (VR) may be effectively used for realistic stimuli presentation, but past generations of VR hardware have been inaccessible and expensive. We reasoned that VR stimuli, delivered using modern consumer hardware and software, would enable one-session treatment of PSA, both in the form of traditional therapist-led treatment and as an internet intervention.

    Methods: N=50 adult participants from the general public with clinically significant PSA were recruited and randomized to either therapist-led one-session treatment followed by online maintenance promoting in-vivo exposure, or waiting-list. The three-hour exposure session included psychoeducation and had participants conducting speech exercises, framed as behavioral experiments targeting idiosyncratic catastrophic beliefs, in front of virtual audiences, and listening to audio recording afterwards. Primary outcome measure was selfreported PSA, assessed using a validated instrument, measured before and after the treatment session, weekly during the four-week maintenance period, and at the end. After the first phase of the study, the waiting-list group received a simple VR headset by post and were given access to an online version of the same treatment (including the maintenance program), conducted their own one-session treatment followed by the same maintenance program, and reported PSA using the same intervals as before. Data were analyzed using mixed effects modeling.

    Results: A significant time*group effect was found such that the treatment group reported a 6.92-point larger decrease in PSA symptoms per treatment step than the waiting-list, corresponding to a between-group d=0.84 after the one-session treatment, growing to d=1.56 after the maintenance period. Piece-wise modeling of the waiting-list group’s PSA scores before and after they received their at-home equivalent treatment revealed a 6.39-point difference in decrease (per step) after receiving treatment compared to before, corresponding to a within-group d=1.22 after the at-home one-session treatment, growing to d=1.78 after the maintenance period.

    Conclusions: This trial demonstrates that simple, consumer VR hardware and software can be used to treat PSA using a one-session format, with large effect sizes. To our knowledge, this is the first study to evaluate the potential of internet-administered, at-home VR treatment, the results of which are promising.

  • 29.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Fagernäs, Simon
    Andersen, Joel
    Sigeman, Martin
    Andersson, Gerhard
    Furmark, Tomas
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Therapist-led and self-led one-session Virtual Reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial2018Conference paper (Other academic)
    Abstract [en]

    Public speaking anxiety (PSA) is a common condition which can be treated effectively with exposure therapy. However, inherent difficulties in stimuli presentation and control limits dissemination and the therapeutic potential. Virtual Reality (VR) technology has the potential to resolve these issues and provide a scalable platform for self-help interventions. No previous study has examined whether this can be achieved using the first generation of consumer VR hardware and software. In the current trial, n=25+25 participants were randomized to either one-session VR exposure therapy for PSA followed by a four-week internet-administered VR to in-vivo transition program, or a waiting-list. Linear mixed effects modeling revealed significant, large (within Cohen’s d=1.67) decreases in self-reported PSA. The waiting-list was then given access to an internet-administered, self-led version of the same VR exposure therapy to be conducted at home, followed by the same transition program. Dual-slope mixed effects modeling revealed significant, large (d=1.35) decreases in self-reported PSA. Results were maintained or improved at the six-month follow-up. We show for the first time that low-cost, off-the-shelf consumer VR hardware and software can be used to conduct exposure therapy for PSA, both in the traditional, previously unpractical one-session format, and in a novel self-led, at-home format.

  • 30.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm County Council, Sweden.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Fagernäs, Simon
    Andersen, Joel
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Sigeman, Martin
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Furmark, Tomas
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial2019In: Journal of Anxiety Disorders, ISSN 0887-6185, E-ISSN 1873-7897, Vol. 61, p. 45-54Article in journal (Refereed)
    Abstract [en]

    Public speaking anxiety (PSA) is a common condition which can be treated effectively with exposure therapy. However, inherent difficulties in stimuli presentation and control limits dissemination and the therapeutic potential. Virtual Reality (VR) technology has the potential to resolve these issues and provide a scalable platform for self-help interventions. No previous study has examined whether this can be achieved using the first generation of consumer VR hardware and software. In the current trial, n = 25 + 25 participants were randomized to either one-session therapist-led VR exposure therapy for PSA followed by a four-week internet-administered VR to in-vivo transition program, or a waiting-list. Linear mixed effects modeling revealed significant, large (within Cohen’s d = 1.67) decreases in self-reported PSA. The waiting-list was then given access to an internet-administered, self-led version of the same VR exposure therapy to be conducted at home, followed by the same transition program. Dual-slope mixed effects modeling revealed significant, large (d = 1.35) decreases in self-reported PSA. Results were maintained or improved at six- and twelve-month follow-ups. We show for the first time that low-cost, off-the-shelf consumer VR hardware and software can be used to conduct exposure therapy for PSA, both in the traditional, previously impractical one-session format, and in a novel self-led, at-home format.

  • 31.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hamilton, William
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    The Potential of Consumer-Targeted Virtual Reality Relaxation Applications: Descriptive Usage, Uptake and Application Performance Statistics for a First-Generation Application2019In: Frontiers in Psychology, ISSN 1664-1078, E-ISSN 1664-1078, Vol. 10, article id 132Article in journal (Refereed)
    Abstract [en]

    Virtual Reality (VR) technology can be used to create immersive environments that promote relaxation and distraction, yet it is only with the recent advent of consumer VR platforms that such applications have the potential for widespread dissemination, particularly in the form of consumer-targeted self-help applications available at regular digital marketplaces. If widely distributed and used as intended, such applications have the potential to make a much-needed impact on public mental health. In this study, we report real-world aggregated uptake, usage and application performance statistics from a first-generation consumer-targeted VR relaxation application which has been publicly available for almost 2 years. While a total of 40,000 unique users signals an impressive dissemination potential, average session duration was lower than expected, and the data suggests a low number of recurrent users. Usage of headphones and auxiliary input devices was relatively low, and some application performance issues were evident (e.g., lower than intended framerate and occurrence of overheating). These findings have important implications for the design of the future VR relaxation applications, revealing primarily that user engagement needs to be addressed in the early stage of development by including features that promote prolonged and recurrent use (e.g., gamification elements).

  • 32.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hamilton, William
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Mimerse, Sweden.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Powers, Mark B.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Creating state of the art, next-generation Virtual Reality exposure therapies for anxiety disorders using consumer hardware platforms: Design considerations and future directions2017In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 46, no 5, p. 404-420Article in journal (Refereed)
    Abstract [en]

    Decades of research and more than 20 randomized controlled trials show that Virtual Reality exposure therapy (VRET) is effective in reducing fear and anxiety. Unfortunately, few providers or patients have had access to the costly and technical equipment previously required. Recent technological advances in the form of consumer Virtual Reality (VR) systems (e.g. Oculus Rift and Samsung Gear), however, now make widespread use of VRET in clinical settings and as self-help applications possible. In this literature review, we detail the current state of VR technology and discuss important therapeutic considerations in designing self-help and clinician-led VRETs, such as platform choice, exposure progression design, inhibitory learning strategies, stimuli tailoring, gamification, virtual social learning and more. We illustrate how these therapeutic components can be incorporated and utilized in VRET applications, taking full advantage of the unique capabilities of virtual environments, and showcase some of these features by describing the development of a consumer-ready, gamified self-help VRET application for low-cost commercially available VR hardware. We also raise and discuss challenges in the planning, development, evaluation, and dissemination of VRET applications, including the need for more high-quality research. We conclude by discussing how new technology (e.g. eye-tracking) can be incorporated into future VRETs and how widespread use of VRET self-help applications will enable collection of naturalistic “Big Data” that promises to inform learning theory and behavioral therapy in general.

  • 33.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Predicting treatment outcomes after Virtual Reality exposure therapy using gaze proxy data collected during exposure: Preliminary findings2018Conference paper (Other academic)
    Abstract [en]

    BACKGROUND: Virtual Reality exposure therapy (VRET) is an efficacious treatment of phobias and allows for automatic data collection during standardized yet naturalistic exposure paradigms, yet next to no research has explored the clinical potential of such data. GOALS: To explore the predictive potential of using gaze proxy data collected during VRET to predict treatment outcomes. METHODS: Gaze focus proxy data from n=29 participants undergoing gamified, self-help VRET for spider phobia were extracted, compiled, and modeled. The VRET session featured eight levels with increasingly frightening spiders, each with an approach task requiring participants to keep looking at the phobic object for a specified time. Relative spider gaze focus was defined as time spent looking at each spider at each level (derived from head movement and overlap) divided by total time in level. High- versus low-improvement was defined using median-split on subsequent improvements on an in-vivo behavioral approach task. RESULTS: During the final three levels of the exposure session, relative spider focus time was initially lower among high-improvers (p=.039) and the decrease was lower over levels than among the low-improvers (p=.029). This suggests that non-improvers experienced a fear level mismatch during the final exposure phase. There were no differences in gaze patterns during other phases of the session. CONCLUSIONS: These preliminary results suggest that gaze proxy data automatically collected during VRET, even when rudimentary, can be used to predict treatment outcomes, and may thus be used to automatically personalize the exposure design of VRET self-help applications during actual use, to increase efficacy.

  • 34.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm County Council, Sweden.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    What is so frightening about spiders? Self‐rated and self‐disclosed impact of different characteristics and associations with phobia symptoms2019In: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 60, no 1, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Spider phobia is a common and impairing mental disorder, yet little is known about what characteristics of spiders that spider phobic individuals find frightening. Using screening data from a clinical trial, we explored which characteristics that spider‐fearful individuals (n = 194) rated as having the greatest impact on fear, used factor analysis to group specific characteristics, and explored linear associations with self‐reported phobia symptoms. Second, a guided text‐mining approach was used to extract the most common words in free‐text responses to the question: “What is it about spiders that you find frightening?” Both analysis types suggested that movement‐related characteristics of spiders were the most important, followed by appearance characteristics. There were, however, no linear associations with degree of phobia symptoms. Our findings reveal the importance of targeting movement‐related fears in in‐vivo exposure therapy for spider phobia and using realistically animated spider stimuli in computer‐based experimental paradigms and clinical interventions such as Virtual Reality exposure therapy.

  • 35.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Zetterlund, Elin
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Attitudes Toward and Familiarity With Virtual Reality Therapy Among Practicing Cognitive Behavior Therapists: A Cross-Sectional Survey Study in the Era of Consumer VR Platforms2019In: Frontiers in Psychology, ISSN 1664-1078, E-ISSN 1664-1078, Vol. 10, article id 176Article in journal (Refereed)
    Abstract [en]

    Virtual reality exposure therapy (VRET) is an efficacious treatment for fear and anxiety and has the potential to solve both logistic issues for therapists and be used for scalable self-help interventions. However, VRET has yet to see large-scale implementation in clinical settings or as a consumer product, and past research suggests that while therapists may acknowledge the many advantages of VRET, they view the technology as technically inaccessible and expensive. We reasoned that after the 2016 release of several consumer virtual reality (VR) platforms and associated public acquaintance with VR, therapists' concerns about VRET may have evolved. The present study surveyed attitudes toward and familiarity with VR and VRET among practicing cognitive behavior therapists (n = 185) attending a conference. Results showed that therapists had an overall positive attitude toward VRET (pros rated higher than cons) and viewed VR as applicable to conditions other than anxiety. Unlike in earlier research, high financial costs and technical difficulties were no longer top-rated negative aspects. Average negative attitude was a larger negative predictor of self-rated likelihood of future use than positive attitude was a positive predictor and partially mediated the positive association between VRET knowledge and likelihood of future use, suggesting that promotional efforts should focus on addressing concerns. We conclude that therapist's attitudes toward VRET appear to have evolved in recent years, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.

  • 36.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Miloff, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Zetterlund, Elin
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Attitudes towards and familiarity with Virtual Reality therapy among practicing cognitive behavior therapists: A first survey study in the era of consumer VR platforms2018Conference paper (Other academic)
    Abstract [en]

    Objectives: To survey attitudes towards, knowledge of and familiarity with Virtual Reality (VR) technology and VR exposure therapy among practicing cognitive behavior therapists, after the recent release of consumer VR platforms, with the aim of identifying potential human barriers to implementing this technology and therapeutic method in regular care. Participants: 185 practicing cognitive behavior therapists attending a conference.Measures: Self-rated likelihood of future use of VR in a clinical setting, applicability of VR to treating specific mental disorders, as well as ratings of different positive and negative aspects of VR exposure therapy – all assessed using a standardized survey.Results: Very few respondents reported having used VR clinically. Therapists had an overall positive attitude toward VRET (pros rated higher than cons) and viewed VR as applicable to conditions other than anxiety. Unlike in earlier research, a high financial cost was no longer a top-rated negative aspects. Average negative attitude was a larger negative predictor of self-rated likelihood of future use than positive attitude was a positive predictor.Conclusions: We conclude that therapist’s attitudes towards VRET appear to have evolved in recent years, coinciding with the release of consumer VR platforms, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.

  • 37.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Nordby, Kent
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Svartdal, Frode
    Domain-specific quality of life across five European countries: Cross-cultural validation of the Brunnsviken Brief Quality of life (BBQ) scale2016In: EABCT 2016 Abstract Book: Total Awareness, 2016, p. 590-590Conference paper (Refereed)
    Abstract [en]

    The Brunnsviken Brief Quality of life (BBQ) scale is a valid, reliable and accessible self-report measure of subjective quality of life for use with both clinical and non-clinical populations. Although the BBQ has been professionally translated from original Swedish into over thirty languages, psychometric evaluations of other language versions are so far lacking. BBQ data was collected as part of an international study on procrastination in students and employees: n = 749 from Finland, n = 599 from Sweden, n = 542 from Norway, n = 411 from Germany, and n = 315 from Italy. Weighted satisfaction ratings (score range 0-16) for each of the BBQ’s six domains (Leisure, View on life, Creativity, Learning, Friends and friendships, and View on self), along with a total sum score and Cronbach’s alphas, were calculated and compared. Samples did not differ in BBQ total scores (F[4,2611] = 1.006, p = .403). Although there were some differences between samples on specific items, these were small (total difference M = 0.00, SD = 0.74) and confidence intervals overlapped, with the exception of the German sample that rated lower Learning than all other samples (p < .05, Bonferroni-adjusted). Cronbach’s alpha ranged from 0.752 (Finland) to 0.674 (Italy). Convergent validity (as assessed by correlations with scores on the Satisfaction With Life Scale) was high, ranging from r = .64 (Finland) to r = .42 (Italy). The BBQ is a valid measure of subjective quality of life in the examined languages. There are only minor cross-country differences in the quality of life domains measured by the BBQ.

  • 38.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Karolinska Institutet.
    Nyström, Markus B.T.
    Hassmén, Peter
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Who seeks ICBT for depression and how do they get there?: effects of recruitment source on patient demographics and clinical characteristics2015In: Internet Interventions, ISSN 2214-7829, Vol. 2, no 2, p. 221-225Article in journal (Refereed)
    Abstract [en]

    Studies on internet-administered cognitive behavior therapy (ICBT) frequently use several different sources of recruitment, yet no study has investigated whether different recruitment sources produce different clinical and demographic profiles among participants. Using data from a large sample (n = 982) seeking ICBT for depression, we compared these characteristics on the basis of self-reported recruitment source. Recruitment sources that imply more active treatment-seeking behaviors (Google searches, viewing postings on mental health websites) presented more severe depression and anxiety than those recruited through more passive sources of information (newspaper advertisements, referrals by friends and family). In addition, a number of demographic differences between groups were found. These findings have important implications for ICBT research projects and clinical programs who employ open recruitment procedures and multi-modal recruitment strategies, and who wish to recruit representative samples or target specific subgroups. Replications in other countries will however be required to establish cross-cultural patterns.

  • 39.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Rozental, Alexander
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Forsström, David
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Furmark, Tomas
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Differential impact of performance and interaction related types of social anxiety symptoms on different quality of life domains2016In: EABCT 2016 Abstract Book: Total Awareness, 2016, p. 748-748Conference paper (Refereed)
    Abstract [en]

    Social anxiety disorder (SAD) is a common disorder associated with impaired quality of life (QoL), that indexes anxious distress and avoidance related to social situations. The DSM-5 features a specifier to delineate those with only performance-related social anxiety, yet little is known whether performance- and interaction-related anxieties have a differential impact on total QoL and on different QoL domains. To investigate this, we pooled screening data from eight intervention studies for SAD (n = 2017). Total sample mean age was 35.28 (SD = 12.26) and 69% were female. SAD symptoms were measured using the self-rated Liebowitz Social Anxiety Scale with items classified as measuring either performance or interaction anxiety. QoL, both total and across four domains, was measured using the Quality of Life Inventory. Data was analyzed using multiple regression models featuring the two anxiety scores as predictors, and by simulating the Performance-only specifier through 2˙2 median-split subgrouping and standard ANOVAs. Both interaction and performance anxieties were independently associated with lower QoL in general and across domains. Interaction anxiety had a larger negative impact on Personal Growth- and Achievement-related QoL than performance anxiety. The High-Performance/Low-Interaction-group rated higher Achievement-related QoL compared to the Low-Performance/High-Interaction-group (p = .012), yet groups were matched on total QoL and on other domains. Other group differences were in the expected direction.

    QoL impairments in SAD is primarily driven by number of feared social situations, and only secondarily by types of fear social situations, with interaction anxiety having a larger, negative impact on some QoL domains.

  • 40.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Silijehom, Ola
    Johansson, Magnus
    Forster, Martin
    Andreasson, Sven
    Hammberg, Anders
    Combining online community reinforcement and family training with a parent training program for parents with partners suffering from alcohol use disorder: Study protocol for a randomized controlled trial2018Conference paper (Other academic)
    Abstract [en]

    Introduction: Partners and children of individuals with alcohol use disorder (AUD) present impaired quality of life and mental health, yet seldom seek or participate in traditional supportive interventions. Engaging the parent/partner without AUD in treatment is a promising way of supporting behavior change in both the child and the parent with AUD. Universal parent training (PT) programs are effective in increasing children´s well-being and decreasing problem behaviors, but have yet to be tailored for children with a parent with AUD. Community reinforcement approach and family training (CRAFT) programs are conceptually similar, and aim to promote behavior change in individuals with AUD by having a concerned significant other change environmental contingencies. There has been no study on whether these two interventions can be combined and tailored for partners of individuals with AUD with common children, and delivered as accessible, online self-help. Methods and analysis: N=300 participant who share a child showing mental health problems with a person with AUD, but do not present AUD themselves, will be recruited from the general public and randomized 1:1 to either a four-module, online combined PT and CRAFT program, or a psychoeducation-only comparison intervention. Primary outcome will be the child’s mental health. Additional outcomes will cover the partner’s drinking, the participants own mental health and drinking, the child’s social adjustment, treatment-seeking in all three parties, and parental self-efficacy. Measures will be collected pre-, mid- and post-intervention, and three times during a two-year follow-up period. Data will be analyzed using mixed effects modeling. Trial status: This trial is currently recruiting.

  • 41.
    Lindner, Philip
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm County Council, Sweden.
    Siljeholm, Ola
    Johansson, Magnus
    Forster, Martin
    Andreasson, Sven
    Hammarberg, Anders
    Combining online Community Reinforcement and Family Training (CRAFT) with a parent-training programme for parents with partners suffering from alcohol use disorder: study protocol for a randomised controlled trial2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 8, article id e020879Article in journal (Refereed)
    Abstract [en]

    Introduction: Partners and children of individuals with alcohol use disorder (AUD) present with impaired quality of life and mental health, yet seldom seek or participate in traditional supportive interventions. Engaging the parent/partner without AUD in treatment is a promising way of supporting behavioural change in both the child and the parent with AUD. Universal parent-training (PT) programmes are effective in increasing children’s well-being and decreasing problem behaviours, but have yet to be tailored for children with a parent with AUD. Community Reinforcement Approach And Family Training (CRAFT) programmes are conceptually similar, and aim to promote behavioural change in individuals with AUD by having a concerned significant other change environmental contingencies. There has been no study on whether these two interventions can be combined and tailored for partners of individuals with AUD with common children, and delivered as accessible, online self-help.

    Methods and analysis: n=300 participants with a child showing mental health problems and partner (co-parent) with AUD, but who do not themselves present with AUD, will be recruited from the general public and randomised 1:1 to either a four-module, online combined PT and CRAFT programme or a psychoeducation-only comparison intervention. Primary outcome will be the child’s mental health. Additional outcomes will cover the partner’s drinking, the participants own mental health and drinking, the child’s social adjustment, treatment seeking in all three parties and parental self-efficacy. Measures will be collected preintervention, mid-intervention and postintervention, and three times during a 2-year follow-up period. Data will be analysed using mixed-effects modelling.

    Ethics and dissemination: This study has been approved by the Stockholm Regional Ethical Review Board (2016/2179-31). The results will be presented at conferences and published as peer-reviewed publications.

    Trial registration number: ISRCTN38702517; Pre-results.

  • 42.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm Health Care Services, Stockholm County, Sweden.
    Dafgård, Peter
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Deak, Stefan
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Garke, Maria
    Hamilton, William
    Heinsoo, Julia
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Kristoffersson, Glenn
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Rafi, Jonas
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Sindemark, Kerstin
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Sjölund, Jessica
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Zenger, Maria
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Automated virtual reality exposure therapy for spider phobia vs. in-vivo one-session treatment: A randomized non-inferiority trial2019In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 118, p. 130-140Article in journal (Refereed)
    Abstract [en]

    This study compared the efficacy of a technician-assisted single-session virtual reality exposure therapy (VRET) for the treatment of spider phobia featuring low-cost consumer-available hardware and novel automated software to gold-standard in-vivo one-session treatment (OST), using a parallel group randomized non-inferiority design. Method Participants (N = 100) were randomized to VRET and OST arms. Assessors blinded to treatment allocation evaluated participants at pre- and post-treatment as well follow-up (3 and 12 months) using a behavioral approach test (BAT) and self-rated fear of spider, anxiety, depression and quality-of-life scales. A maximum post-treatment difference of 2-points on the BAT qualified as non-inferiority margin. Results Linear mixed models noted large, significant reductions in behavioral avoidance and self-reported fear in both groups at post-treatment, with VRET approaching the strong treatment benefits of OST over time. Non-inferiority was identified at 3- and 12- months follow-up but was significantly worse until 12-months. There was no significant difference on a questionnaire measuring negative effects. Conclusions Automated VRET efficaciously reduced spider phobia symptoms in the short-term and was non-inferior to in-vivo exposure therapy in the long-term. VRET effectiveness trials are warranted to evaluate real-world benefits and non-specific therapeutic factors accruing from the presence of a technician during treatment. ClinicalTrials.gov (NCT02533310).

  • 43.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Hamilton, W.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: A randomized-controlled trial2016Conference paper (Refereed)
    Abstract [en]

    Introduction: Traditional one-session therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3hrs in a one-session format has been found effective for the treatment of specific phobias. However, many suffering from specific phobia are reluctant to seek help and access to care is lacking. Virtual reality (VR) exposure therapy using a smartphone may improve upon existing techniques by facilitating access, lowering cost, and increasing acceptability and effectiveness. The aim of this study was to compare traditional OST with in-vivo spiders and a human therapist to a newly developed single-session gamified VR exposure therapy application with modern VR headsets, virtual spiders and a virtual therapist.

    Method: Participants with specific phobia to spiders (N=100) were recruited from the general public, screened and randomized to either OST (N=50) or VR exposure therapy (N=50) using the smartphone-based Samsung Gear VR system. A behavioral approach test using in-vivo spiders served as the primary outcome measure. Secondary outcome measures included spider phobia questionnaires, and self-reported anxiety, depression and quality of life. Outcomes were assessed 1-week before and after treatment and at follow-up (12 and 52 weeks).

    Results: At the time of submitting this abstract all participants have been included and randomized and a large portion has also received the allotted treatment. However, since the study uses strict blinding, results will not be available until March 2016.

    Discussion: VR exposure therapy has previously been evaluated as a treatment for specific phobias but there has been a lack of high-quality randomized controlled trials. A new generation of modern VR devices are being released which advance upon existing technology and have the potential to improve clinical availability and treatment effectiveness.

    Conclusion: Preliminary clinical observations suggest that single-session gamified virtual reality exposure therapy using a smartphone is effective for the treatment of spider phobia.

  • 44.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Hamilton, William
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Is virtual reality treatment for spider phobia noninferior to traditional one-session treatment? The results of a randomized-controlled trial2016In: EABCT 2016 Abstract Book: Total Awareness, 2016, p. 753-753Conference paper (Other (popular science, discussion, etc.))
    Abstract [en]

    This is the first large randomized-controlled trial to evaluate whether commercially available VR hardware and software can be used for exposure therapy. The aim of this study is to compare gold-standard One Session Treatment (OST) for reduction of spider phobia symptoms and avoidance behaviour using in vivo spiders and a human therapist, to a newly developed single-session gamified Virtual Reality Exposure Therapy (VRET) application with modern, consumer-available VR hardware, virtual spiders, and a virtual therapist. Subjects (N = 100) with spider phobia, diagnosed, and meeting inclusion criteria were recruited from the general population and randomized to 2 treatment arms. In 1-week intervals, pre-measurement, 3-hr treatment and post-measurement were completed with an in-vivo behavioral approach test (BAT) serving as the primary outcome measure for both groups. This study was powered to detect a non-inferiority margin of a 2-point between-group difference on the BAT, with a standard deviation of 4 (at 80% power). 98 patients commenced treatment and 97 patients completed post-measurement. Per protocol analysis indicated VR was not non-inferior to OST. Repeated-measures ANOVA identified a significant main effect of time (p < .001) and time x group effect (p < .05). Both OST and VR participants experienced large BAT within-group effect sizes (d = 2.28 and d = 1.45, respectively). OST is the superior treatment option for spider phobia. VRET is an effective alternative if OST cannot be provided, as pure self-help, as the initial intervention in a stepped-care model, or as a possible post-OST booster. Future studies will benefit from evaluating effectiveness of VRET when conducted at home.

  • 45.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden.
    Hamilton, William
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Mimerse, Stockholm, Sweden.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial2016In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 17, article id 60Article in journal (Refereed)
    Abstract [en]

    Background: Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist. Methods/design: Participants with specific phobia to spiders (N = 100) will be recruited from the general public, screened, and randomized to either VR exposure therapy (n = 50) or traditional OST (n = 50). A behavioral approach test using in vivo spiders will serve as the primary outcome measure. Secondary outcome measures will include spider phobia questionnaires and self-reported anxiety, depression, and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1, 12, and 52 weeks after treatment. Discussion: VR exposure therapy has previously been evaluated as a treatment for specific phobias, but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices is being released that are advancing existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable for taking advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation. This study compares a market-ready, gamified VR spider phobia exposure application, delivered using consumer VR hardware, with the current gold standard treatment. Implications are discussed.

  • 46.
    Miloff, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Hamilton, William
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    VIMSE - Gamified exposure therapy for use on modern VR headsets2015In: SWEsrii 2015: Swedish Congress on Internet Interventions, 2015, p. 17-17Conference paper (Other academic)
    Abstract [en]

    VIMSE is a new spider phobia exposure application developed for use on next generation VR headsets. Developed by Mimerse AB for the Stockholm University Department of Psychology the application advances exposure technology along a number of important fronts. VIMSE uses gamification to increase user engagement and learning, is fully automated with a virtual therapist to allow at home-self care, contains multiple open-ended environments and lighting to ensure exposure in multiple contexts, as well as a range of spiders, spider behaviors and stimuli intensity levels to ensure gradually increasing exposure levels. Collaboration with a for-profit corporation ensures the application is market-ready and scalable rather than restricted to a research environment. VIMSE is currently completing clinical trials comparing it to gold-standard one session therapy phobia treatment in a group of 100 spider phobics.

  • 47. Molander, Olof
    et al.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Karolinska Institutet, Sweden; Stockholm Center for Dependency Disorders, Sweden.
    Bjureberg, Johan
    Ramnerö, Jonas
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Berman, Anne H.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences. Karolinska Institutet, Sweden; Stockholm Center for Dependency Disorders, Sweden.
    Internet-based Cognitive Behavior Therapy for Gambling Disorder and Psychiatric Co-morbidities: A Pilot Study Protocol2019Conference paper (Refereed)
    Abstract [en]

    Context: Although cognitive behavioral therapy (CBT) is recommended to address the high prevalence of co-occurring mental ill health in problem gamblers, there are, to our knowledge, no specific treatment protocols available targeting psychiatric co-morbidities. Furthermore, psychiatric co-morbidities are seldom addressed in gambling treatment studies.

    Intervention: We are currently developing a new internet-based CBT protocol based on the Pathways model [1]. Briefly, this etiological model states that there are distinct pathways for development and maintenance of gambling problem in conjunction with psychiatric co-morbidities. Our treatment will offer tailored behavioral interventions targeting the specific maintenance processes for each gambling pathway proposed by the Pathway model.

    Methods: Treatment-seeking participants (N=20) with Gambling Disorder and psychiatric co-morbidities will be recruited in a first pilot study delivered via the internet. In addition to evaluating feasibility and potential efficacy, we will examine moderators according to the proposed maintenance processes in the Pathways model.

    Results: The pilot study is planned to commence spring 2019.

    Conclusion: The results of the pilot study will hopefully contribute to specific knowledge regarding treatment interventions for gamblers with psychiatric co-morbidities, as well as to the research field as a whole.

  • 48. Nyström, M.
    et al.
    Stenling, A.
    Sjöström, E.
    Neely, G.
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hassmén, P.
    Andersson, Gerhard
    Martell, C.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Behavioral activation versus physical activity via the internet: A randomized controlled trial2017Conference paper (Refereed)
    Abstract [en]

    Background: A major problem today is that only about fifty percent of those affected by depression seek help. One way to reach more sufferers would be by offering easily accessible internet based treatments. The purpose of this study was to compare/evaluate four therapist supported internet administered treatments.

    Method /Results: Two hundred eighty six participants were included. The treatment period lasted twelve weeks, consisting of the following treatments: 1) physical activity without treatment rational, 2) physical activity with treatment rational, 3) behavioral activation based on Lewinshon’s (1974) model and 4) behavioral activation based on Martell’s model (Martell et al., 2010). All groups (including a control-group) showed a significant decrease in depressive symptoms. When the treatment groups were pooled and compared to the control group, there were significant differences from pretest to posttest (Hedges gav treatment = 1.01, control group = 0.47). This held true also when each of the four treatment groups was compared to the control group, with one exception: Physical activity without treatment rationale.

    Limitations: The differences between how many modules the participants completed could indicate that there are other factors than the treatments that caused the symptom reduction, however, the dose-response analysis did not detect any significant differences on account of modules completed.

    Conclusions: The results support the positive effects of internet administered treatments for depression and highlights the importance of psychoeducation, which tends to affect both the treatment outcome and the probability of remaining in treatment. These aspects need to be considered when developing and conducting new treatments for depression since they would increase the likelihood of positive treatment outcomes.

  • 49. Nyström, Markus B. T.
    et al.
    Stenling, Andreas
    Sjöström, Emma
    Neely, Gregory
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Hassmén, Peter
    Andersson, Gerhard
    Martell, Christopher
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Behavioral activation versus physical activity via the internet: A randomized controlled trial2017In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 215, p. 85-93Article in journal (Refereed)
    Abstract [en]

    Background: A major problem today is that only about fifty percent of those affected by depressionseeks help. One way to reach more sufferers would be by offering easily accessible internet based treatments. The purpose of this study was to compare/evaluate four therapist supported internet administered treatments.

    Method/results: Two hundred eighty six participants were included. The treatment period lasted twelve weeks, consisting of the following treatments: 1) physical activity without treatment rational, 2) physical activity with treatment rational, 3) behavioral activation without treatment rational and 4) behavioral activation with treatment rational. All groups (including a control-group) showed a significant decrease in depressive symptoms. When the treatment groups were pooled and compared to the control group, there were significant differences from pretest to posttest (Hedges gav treatment =1.01, control group =0.47). This held true also when each of the four treatment groups was compared to the control group, with one exception: Physical activity without treatment rationale.

    Limitations: The differences between how many modules the participants completed could indicate that there are other factors than the treatments that caused the symptom reduction, however, the dose-response analysis did not detect any significant differences on account of modules completed.

    Conclusions: The results support the positive effects of internet administered treatments for depression, and highlights the importance of psychoeducation, which tends to affect both the treatment outcome and the probability of remaining in treatment. These aspects need to be considered when developing and conducting new treatments for depression, since they would increase the likelihood of positive treatment outcomes.

  • 50.
    Ramnerö, Jonas
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Molander, Olof
    Lindner, Philip
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Stockholm County Council, Sweden.
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    What can be learned about gambling from a learning perspective?: A narrative review2019In: Nordic Psychology, ISSN 1901-2276, E-ISSN 1904-0016, Vol. 71, no 4, p. 303-322Article, review/survey (Refereed)
    Abstract [en]

    Gambling is a field that harbors both harmless recreational activities and pathological varieties that may be considered an addictive disorder. It is also a field that deserves special interest from a learning theoretical perspective, since pathological gambling represents both a pure behavioral addiction involving no ingestion of substances and behavior that exhibits extreme resistance to extinction. As the field of applied psychology of learning, or behavior analysis, espouses a bottom-up approach, the basis of understanding begins in basic research on behavioral principles. This article provides a narrative review of the field of laboratory experiments conducted to disentangle the learning processes of gambling behavior. The purpose of this review is to give an overview of learning principles in gambling that has been demonstrated under lab conditions and that may be of importance in the development of clinical applications when gambling has become a problem. Several processes, like the importance of delay and probability discounting, reinforcement without actual winning, and rule governed behavior have been experimentally verified. The common denominator appears to be that they impede extinction. Other areas, especially Pavlovian conditioning, are scarce in the literature. Our recommendations for the future would be to study Pavlovian and instrumental conditioning in interaction. Treatment programs should profit from strategies that serve to enhance extinction learning. We also conclude that online gambling should provide a promising environment for controlled research on how to limit excessive gambling, provided that the gambling companies are interested in that.

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