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Acceptance and Commitment Therapy has gained preliminary evidence for paediatric chronic pain. Several studies show that psychological flexibility/inflexibility is a process driving treatment change in ACT for chronic pain. The literature supporting psychological flexibility as a change process in ACT is typically based on selfreport. The aim of the present study was to investigate psychological flexibility (i.e. acceptance, defusion, values formulation and committed action) as in-treatment behaviour during internet-delivered Acceptance and Commitment Therapy for paediatric chronic pain, by having two independent observers rating patient written statements. The sample was self-recruited and consisted of 28 girls between ages 13 and 17 years. Results showed that psychological flexibility could be operationalised as in-treatment behaviours and reliably assessed using observer ratings. Also, data illustrated a within subject variability in ratings of acceptance and defusion, with a considerable difference in degree of acceptance or defusion evoked by different experiential exercises. Furthermore, analyses showed that a higher average degree of acceptance in patient statements during the early phase of treatment was related to larger treatment effects. Defusion, values formulation and committed action showed no significant influence on outcome. Results should be interpreted with caution due to the small sample size., Funding Agencies|Clas Groschinsky Foundation

Objective: Chronic pain is a common manifestation of Ehlers-Danlos syndrome and hypermobility spectrum disorders; thus it is often suggested that patients undergo generic interdisciplinary pain rehabilitation, despite there being little evidence to support this decision. The aim of this study is to examine the effectiveness of standard rehabilitation programmes for chronic pain on patients with Ehlers-Danlos syndrome and hypermobility spectrum disorders, compared with patients with other chronic pain disorders. Subjects: Data, collected between 2008 and 2016, were extracted from a Swedish national registry. The patient data comprised of 406 cases with Ehlers-Danlos syndrome or hypermobility spectrum disorders, 784 cases with a whiplash -related diagnosis, 3713 cases with diagnoses relating to spinal pain, and 2880 cases of fibromyalgia. Methods: The differences between groups on key outcome measures from pre- to 1 -year follow-up after interdisciplinary pain rehabilitation were analysed using linear mixed effects models. Sensitivity analysis in the form of pattern -mixture modelling was conducted to discern the impact of missing data. Results: No significant differences were found in improvements from pre- to 1 -year follow-up for patients with Ehlers-Danlos syndrome or hypermobility spectrum disorder compared with other diagnostic groups regarding measures of health -related quality of life, mental health, or fatigue. At followup, differences in pain interference (d = -0.34 (95% confidence interval [95% CI] -0.5 to -0.18)), average pain (d = 0.22 (95% CI 0.11-0.62)) and physical functioning (d = 2.19 (95% CI 1.61-2.77)) were detected for the group with spinal -related diagnoses in relation to those with EDS/HSD, largely due to pre-treatment group differences. Sensitivity analysis found little evidence for missing data influencing the results. Conclusion: This study suggests that patients with Ehlers-Danlos syndrome/hypermobility spectrum disorders may benefit from, Funding Agencies|County Council of Ostergoetland; [RO-926131]

Aims: The objective was to compare anxiety, depression, and quality of life (QoL) in individuals living with type 1 (T1D) and type 2 (T2D) diabetes with matched controls during the second wave of the COVID-19 pandemic. Methods: Via randomization, individuals living with diabetes T1D (n = 203) and T2D (n = 413), were identified during February-July 2021 through health-care registers. Population controls (n = 282) were matched for age, gender, and residential area. Questionnaires included self-assessment of anxiety, depression, QoL, and demographics in relation to SARS-CoV-2 exposure. Blood was collected through home-capillary sampling, and SARS-CoV-2 Nucleocapsid (NCP) and Spike antibodies (SC2_S1) were determined by multiplex Antibody Detection by Agglutination-PCR (ADAP) assays. Results: Younger age and health issues were related to anxiety, depression, and QoL, with no differences between the study groups. Female gender was associated with anxiety, while obesity was associated with lower QoL. The SARS-CoV-2 NCP seroprevalence was higher in T1D (8.9 %) compared to T2D (3.9 %) and controls (4.0 %), while the SARS-CoV-2 SC2_S1 seroprevalence was higher for controls (25.5 %) compared to T1D (16.8 %) and T2D (14.0 %). Conclusions: A higher SARS-CoV-2 infection rate in T1D may be explained by younger age and higher employment rate, and the associated increased risk for viral exposure. (c) 2023 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC, Funding Agencies|NIH [SBIR 2R44DK110005-02]; Strategic Research Area Exodiab [2009-1039]; Swedish Foundation for Strategic Research [IRC15-0067]

Objective: Psychological constructs related to the fear-avoidance model such as fear of movement, pain cata-strophizing, and affective distress have been found to be inter-related among patients with chronic pain. How-ever, relationships of these constructs have mostly been examined using regression-based analyses. This cross-sectional study employs a novel analytical approach, network analysis, to illustrate the complex interplays among these variables as well as pain intensity and pain interference.Methods: This study utilized the Swedish Quality Registry for Pain Rehabilitation, including data from 10,436 participants (76.0% women; Mage = 45.0 years). Networks were analyzed separately for patients with different pain extents (i.e., numbers of pain locations) as the interplays may differ qualitatively depending on pain extent. Results: We found that patients with a larger pain extent showed a worse clinical presentation (i.e., more depression and anxiety, increased fear of movement and pain interference), and their network differed from the patients with a smaller number of pain extent in terms of how strongly key variables were interconnected. In all network models, pain interference and catastrophizing showed consistently influential roles.Conclusion: Our findings highlight the interactive nature of psychological aspects of pain and how interrelated associations differ depending on pain extent. Findings are discussed based on ideas on how both fear and pain become overgeneralized., Funding Agencies|AFA insurance; Swedish Research Council; Swedish Research Council for Health, Working Life and Welfare; [DNR 190054]; [2015-02512]; [2017-00177]

Individuals who experience problems with anger represent a heterogeneous group. Identifying clinically relevant subtypes of anger may advance treatment research. In the current study, latent profile analysis (LPA) was conducted to explore if distinct subtypes of anger could be identified within a sample of individuals seeking treatment for maladaptive anger (N = 538; 55.4% females; mean age = 39.78, SD = 12.28). Furthermore, the utility of the empirical classification was examined based on differences in usage of emotion regulation strategies (cognitive reappraisal, expressive suppression, mindful emotion awareness and relaxation) across subtypes. Four anger profiles were identified in the best-fitted LPA model: Low Anger (n = 153, 28.4%), Anger In (n = 91, 16.9%), Moderate Anger (n = 193, 35.9%) and High Anger (n = 101, 35.5%). Results from the multinominal regression revealed that the use of emotion regulation differed across all profiles. Participants from the High Anger and Anger In profiles exhibited distinct patterns of dysfunctional emotion regulation. The results add to the increasing amount of evidence demonstrating a link between emotion regulation strategies and maladaptive anger. Clinical implications on how to tailor treatments for individuals with maladaptive anger are discussed.

Individuals who experience problems with anger represent a heterogeneous group. Identifying clinically relevant subtypes of anger may advance treatment research. In the current study, latent profile analysis (LPA) was conducted to explore if distinct subtypes of anger could be identified within a sample of individuals seeking treatment for maladaptive anger (N = 538; 55.4% females; mean age = 39.78, SD = 12.28). Furthermore, the utility of the empirical classification was examined based on differences in usage of emotion regulation strategies (cognitive reappraisal, expressive suppression, mindful emotion awareness and relaxation) across subtypes. Four anger profiles were identified in the best-fitted LPA model: Low Anger (n = 153, 28.4%), Anger In (n = 91, 16.9%), Moderate Anger (n = 193, 35.9%) and High Anger (n = 101, 35.5%). Results from the multinominal regression revealed that the use of emotion regulation differed across all profiles. Participants from the High Anger and Anger In profiles exhibited distinct patterns of dysfunctional emotion regulation. The results add to the increasing amount of evidence demonstrating a link between emotion regulation strategies and maladaptive anger. Clinical implications on how to tailor treatments for individuals with maladaptive anger are discussed.

Individuals who experience problems with anger represent a heterogeneous group. Identifying clinically relevant subtypes of anger may advance treatment research. In the current study, latent profile analysis (LPA) was conducted to explore if distinct subtypes of anger could be identified within a sample of individuals seeking treatment for maladaptive anger (N = 538; 55.4% females; mean age = 39.78, SD = 12.28). Furthermore, the utility of the empirical classification was examined based on differences in usage of emotion regulation strategies (cognitive reappraisal, expressive suppression, mindful emotion awareness and relaxation) across subtypes. Four anger profiles were identified in the best-fitted LPA model: Low Anger (n = 153, 28.4%), Anger In (n = 91, 16.9%), Moderate Anger (n = 193, 35.9%) and High Anger (n = 101, 35.5%). Results from the multinominal regression revealed that the use of emotion regulation differed across all profiles. Participants from the High Anger and Anger In profiles exhibited distinct patterns of dysfunctional emotion regulation. The results add to the increasing amount of evidence demonstrating a link between emotion regulation strategies and maladaptive anger. Clinical implications on how to tailor treatments for individuals with maladaptive anger are discussed.

Objective: Psychological constructs related to the fear-avoidance model such as fear of movement, pain cata-strophizing, and affective distress have been found to be inter-related among patients with chronic pain. How-ever, relationships of these constructs have mostly been examined using regression-based analyses. This cross-sectional study employs a novel analytical approach, network analysis, to illustrate the complex interplays among these variables as well as pain intensity and pain interference.Methods: This study utilized the Swedish Quality Registry for Pain Rehabilitation, including data from 10,436 participants (76.0% women; Mage = 45.0 years). Networks were analyzed separately for patients with different pain extents (i.e., numbers of pain locations) as the interplays may differ qualitatively depending on pain extent. Results: We found that patients with a larger pain extent showed a worse clinical presentation (i.e., more depression and anxiety, increased fear of movement and pain interference), and their network differed from the patients with a smaller number of pain extent in terms of how strongly key variables were interconnected. In all network models, pain interference and catastrophizing showed consistently influential roles.Conclusion: Our findings highlight the interactive nature of psychological aspects of pain and how interrelated associations differ depending on pain extent. Findings are discussed based on ideas on how both fear and pain become overgeneralized., Funding Agencies|AFA insurance; Swedish Research Council; Swedish Research Council for Health, Working Life and Welfare; [DNR 190054]; [2015-02512]; [2017-00177]

Objective: Psychological constructs related to the fear-avoidance model such as fear of movement, pain cata-strophizing, and affective distress have been found to be inter-related among patients with chronic pain. How-ever, relationships of these constructs have mostly been examined using regression-based analyses. This cross-sectional study employs a novel analytical approach, network analysis, to illustrate the complex interplays among these variables as well as pain intensity and pain interference.Methods: This study utilized the Swedish Quality Registry for Pain Rehabilitation, including data from 10,436 participants (76.0% women; Mage = 45.0 years). Networks were analyzed separately for patients with different pain extents (i.e., numbers of pain locations) as the interplays may differ qualitatively depending on pain extent. Results: We found that patients with a larger pain extent showed a worse clinical presentation (i.e., more depression and anxiety, increased fear of movement and pain interference), and their network differed from the patients with a smaller number of pain extent in terms of how strongly key variables were interconnected. In all network models, pain interference and catastrophizing showed consistently influential roles.Conclusion: Our findings highlight the interactive nature of psychological aspects of pain and how interrelated associations differ depending on pain extent. Findings are discussed based on ideas on how both fear and pain become overgeneralized., Funding Agencies|AFA insurance; Swedish Research Council; Swedish Research Council for Health, Working Life and Welfare; [DNR 190054]; [2015-02512]; [2017-00177]

The study set out to explore different mathematical difficulties among 877 second-grade children and to test the effect of memorization versus conceptual practices with number combinations. It used a latent profile analysis of baseline measurements of digit writing speed, number combination fluency, multidigit calculation, and number sense skills to identify six latent classes: three mathematical learning difficulty classes, two typical classes, and one high-achieving class. The memorization practice produced superior improvement for all classes of students except the high-achievers class. These results suggest that memorization practice with basic number combinations should not be considered poor teaching practice. It is important for teachers to incorporate practices with number combinations that focus on speed and memorization, even for children who struggle with mathematics., Funding Agencies|Swedish Research Council [2016-05287]

A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a., Funding Agencies|Region Stockholm [ALF project]; Swedish Research Council [521-2013-2846]; Jane and Dan Olsson foundation [4-1559/2013]; Swedish Research Council for Health, Working life and Welfare [2014-4052]

Objective: This study aimed to investigate the interrelations between emotion regulation strategies and different types of anger using network analysis.Method: Data were drawn from a cross-sectional sample of 538 adults (55% females; mean age = 39.8 years, SD = 12.3) seeking treatment for anger. Data were collected between March and November 2019 in Sweden. Participants completed measures of anger problems (anger expression, anger suppression, angry reactions, anger rumination, trait anger, hostility, physical aggression, and verbal aggression) and emotion regulation (cognitive reappraisal, expressive suppression, anger relaxation, and five mindfulness strategies). To determine whether distinct clusters of anger nodes would emerge, exploratory graph analysis was employed. Based on clustering of nodes, we estimated separate networks including all measures of emotion regulation.Results: Two clusters emerged: one consisting primarily of cognitive components of anger, and another of behavioral. Across networks, anger nodes were strongly interconnected, and anger rumination and anger suppression were especially influential. Several direct links were found between specific emotion regulation strategies and cognitive components of anger, whereas most strategies were only indirectly related to angry behavior. Cognitive reappraisal showed no direct link with any of the anger nodes.Conclusions: Our findings reveal potential pathways by which different emotion regulation strategies may influence different types of anger, which could serve as therapeutic targets.

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

IntroductionRepetitive negative thinking (RNT) has been described as a maintaining transdiagnostic factor for psychopathology within the areas of depression, anxiety and insomnia. We investigated the effects of rumination-focused cognitive-behaviour therapy (RF-CBT) in a group format at a primary health care centre on symptoms of depression, anxiety, insomnia, RNT, and quality of life. The participants presented clinical symptom levels of worry and at least two disorders among anxiety disorders, major depressive disorder, and insomnia disorder.MethodsA randomised controlled superiority parallel arm trial was used. 73 participants were included and randomised in pairs to either group-administered RF-CBT or a waiting list condition. The primary outcomes were self-rated worry and transdiagnostic symptoms (depression, anxiety, and insomnia). Intention-to-treat analyses of group differences were conducted using linear mixed models. Adverse side effects and incidents were presented descriptively.ResultsGroup RF-CBT significantly reduced self-reported insomnia at post-treatment and self-reported insomnia and depression at the 2 month-follow-up, relative to the wait-list control group. There was no significant difference in change in RNT, anxiety, or quality of life.DiscussionThe current study suggests that group-administered RF-CBT may be effective for insomnia and potentially effective for depression symptomatology. However, the study was underpowered to detect small and moderate effects and the results should therefore be interpreted with caution., Funding Agencies|County Council in Varmland [LIVFOU-763591]

A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a., Funding Agencies|Region Stockholm [ALF project]; Swedish Research Council [521-2013-2846]; Jane and Dan Olsson foundation [4-1559/2013]; Swedish Research Council for Health, Working life and Welfare [2014-4052]

The study set out to explore different mathematical difficulties among 877 second-grade children and to test the effect of memorization versus conceptual practices with number combinations. It used a latent profile analysis of baseline measurements of digit writing speed, number combination fluency, multidigit calculation, and number sense skills to identify six latent classes: three mathematical learning difficulty classes, two typical classes, and one high-achieving class. The memorization practice produced superior improvement for all classes of students except the high-achievers class. These results suggest that memorization practice with basic number combinations should not be considered poor teaching practice. It is important for teachers to incorporate practices with number combinations that focus on speed and memorization, even for children who struggle with mathematics., Funding Agencies|Swedish Research Council [2016-05287]

Introduction: A best practice physiotherapy model of care (BetterBack MoC) for low back pain (LBP) aimed to improve patients illness perceptions and self-care enablement, according to the Common-Sense Model of Self-Regulation (CSM). Objective: To confirm if illness perceptions and patient self-care enablement, in line with the CSM, are mediators of treatment effects on disability and pain of the BetterBack MoC for patients with LBP compared to routine primary care. A secondary aim was to explore if illness perceptions and patient self-care enablement are mediators of guideline adherent care. Methods: Pre-planned single mediation analyses tested whether hypothesized mediators at 3 months mediated the treatment effect of the MoC (n = 264) compared to routine care (n = 203) on disability and pain at 6 months. Secondary mediation analyses compared guideline adherent care with non-adherent care. Results: No indirect effects were identified. The BetterBack intervention did not have superior effects over routine care on the hypothesized mediators. Illness perceptions and self-care enablement were significantly associated with disability and pain at 6 months. Secondary analyses showed significant indirect effects of guideline adherent care through tested mediators. Conclusion: Despite no indirect effects, patients illness perceptions and self-care enablement were associated with disability and back pain intensity outcomes and are potentially relevant treatment targets., Funding Agencies|Swedish Research Council [2017?x?01444]; Research Council in Southeast Sweden [FORSSx?660371, FORSS?x?757721, FORSS?x?931966]; Region of Ostergotland [RO-938179, RO-921021]

Introduction: A best practice physiotherapy model of care (BetterBack MoC) for low back pain (LBP) aimed to improve patients illness perceptions and self-care enablement, according to the Common-Sense Model of Self-Regulation (CSM). Objective: To confirm if illness perceptions and patient self-care enablement, in line with the CSM, are mediators of treatment effects on disability and pain of the BetterBack MoC for patients with LBP compared to routine primary care. A secondary aim was to explore if illness perceptions and patient self-care enablement are mediators of guideline adherent care. Methods: Pre-planned single mediation analyses tested whether hypothesized mediators at 3 months mediated the treatment effect of the MoC (n = 264) compared to routine care (n = 203) on disability and pain at 6 months. Secondary mediation analyses compared guideline adherent care with non-adherent care. Results: No indirect effects were identified. The BetterBack intervention did not have superior effects over routine care on the hypothesized mediators. Illness perceptions and self-care enablement were significantly associated with disability and pain at 6 months. Secondary analyses showed significant indirect effects of guideline adherent care through tested mediators. Conclusion: Despite no indirect effects, patients illness perceptions and self-care enablement were associated with disability and back pain intensity outcomes and are potentially relevant treatment targets., Funding Agencies|Swedish Research Council [2017?x?01444]; Research Council in Southeast Sweden [FORSSx?660371, FORSS?x?757721, FORSS?x?931966]; Region of Ostergotland [RO-938179, RO-921021]

The study set out to explore different mathematical difficulties among 877 second-grade children and to test the effect of memorization versus conceptual practices with number combinations. It used a latent profile analysis of baseline measurements of digit writing speed, number combination fluency, multidigit calculation, and number sense skills to identify six latent classes: three mathematical learning difficulty classes, two typical classes, and one high-achieving class. The memorization practice produced superior improvement for all classes of students except the high-achievers class. These results suggest that memorization practice with basic number combinations should not be considered poor teaching practice. It is important for teachers to incorporate practices with number combinations that focus on speed and memorization, even for children who struggle with mathematics., Funding Agencies|Swedish Research Council [2016-05287]

Objective: Psychological constructs related to the fear-avoidance model such as fear of movement, pain cata-strophizing, and affective distress have been found to be inter-related among patients with chronic pain. How-ever, relationships of these constructs have mostly been examined using regression-based analyses. This cross-sectional study employs a novel analytical approach, network analysis, to illustrate the complex interplays among these variables as well as pain intensity and pain interference.Methods: This study utilized the Swedish Quality Registry for Pain Rehabilitation, including data from 10,436 participants (76.0% women; Mage = 45.0 years). Networks were analyzed separately for patients with different pain extents (i.e., numbers of pain locations) as the interplays may differ qualitatively depending on pain extent. Results: We found that patients with a larger pain extent showed a worse clinical presentation (i.e., more depression and anxiety, increased fear of movement and pain interference), and their network differed from the patients with a smaller number of pain extent in terms of how strongly key variables were interconnected. In all network models, pain interference and catastrophizing showed consistently influential roles.Conclusion: Our findings highlight the interactive nature of psychological aspects of pain and how interrelated associations differ depending on pain extent. Findings are discussed based on ideas on how both fear and pain become overgeneralized., Funding Agencies|AFA insurance; Swedish Research Council; Swedish Research Council for Health, Working Life and Welfare; [DNR 190054]; [2015-02512]; [2017-00177]

Objective: To evaluate the relative impact of three brief therapist-supported internet-delivered emotion regulation treatments for maladaptive anger (mindful emotion awareness [MEA], cognitive reappraisal [CR], and mindful emotion awareness + cognitive reappraisal [MEA + CR]) and to test whether baseline levels of anger pathology moderate treatment outcome. Method: Treatments were evaluated in a randomized controlled trial. In total, 234 participants (59% female; mean age = 41.1, SD = 11.6) with maladaptive anger were randomized to MEA (n = 78), CR (n = 77), or MEA + CR (n = 79). Self-reported primary and secondary outcomes were followed up at primary endpoint, 3 months after treatment termination (88% retention). Primary outcomes were also assessed weekly during a prolonged baseline phase (4 weeks) and an active treatment phase (4 weeks). Results: At the primary endpoint, the MEA + CR was superior in terms of anger expression (d = 0.27 95% confidence interval, CI [0.03, 0.51]), aggression (d = 0.43 [0.18, 0.68]), and anger rumination (d = 0.41 [0.18, 0.63]). MEA + CR was particularly effective in reducing anger expression (d = 0.66 [0.21, 1.11]), aggression (d = 0.90 [0.42, 1.39]), and anger rumination (d = 0.80 [0.40, 1.20]) for individuals who reported high values (+1SD) of the outcomes at baseline. Conclusions: Brief therapist-supported internet-delivered MEA and CR treatments are effective interventions for maladaptive anger. Combining MEA and CR is especially effective in reducing anger expression and aggression, particularly, in individuals who report higher levels of initial anger pathology. The present study highlights the importance of emotion regulation as an important treatment target for reducing maladaptive anger., Funding Agencies|Knut and Alice Wallenberg Foundation [KAW 2018.0426]

Individuals who experience problems with anger represent a heterogeneous group. Identifying clinically relevant subtypes of anger may advance treatment research. In the current study, latent profile analysis (LPA) was conducted to explore if distinct subtypes of anger could be identified within a sample of individuals seeking treatment for maladaptive anger (N = 538; 55.4% females; mean age = 39.78, SD = 12.28). Furthermore, the utility of the empirical classification was examined based on differences in usage of emotion regulation strategies (cognitive reappraisal, expressive suppression, mindful emotion awareness and relaxation) across subtypes. Four anger profiles were identified in the best-fitted LPA model: Low Anger (n = 153, 28.4%), Anger In (n = 91, 16.9%), Moderate Anger (n = 193, 35.9%) and High Anger (n = 101, 35.5%). Results from the multinominal regression revealed that the use of emotion regulation differed across all profiles. Participants from the High Anger and Anger In profiles exhibited distinct patterns of dysfunctional emotion regulation. The results add to the increasing amount of evidence demonstrating a link between emotion regulation strategies and maladaptive anger. Clinical implications on how to tailor treatments for individuals with maladaptive anger are discussed.

Objective: Psychological constructs related to the fear-avoidance model such as fear of movement, pain cata-strophizing, and affective distress have been found to be inter-related among patients with chronic pain. How-ever, relationships of these constructs have mostly been examined using regression-based analyses. This cross-sectional study employs a novel analytical approach, network analysis, to illustrate the complex interplays among these variables as well as pain intensity and pain interference.Methods: This study utilized the Swedish Quality Registry for Pain Rehabilitation, including data from 10,436 participants (76.0% women; Mage = 45.0 years). Networks were analyzed separately for patients with different pain extents (i.e., numbers of pain locations) as the interplays may differ qualitatively depending on pain extent. Results: We found that patients with a larger pain extent showed a worse clinical presentation (i.e., more depression and anxiety, increased fear of movement and pain interference), and their network differed from the patients with a smaller number of pain extent in terms of how strongly key variables were interconnected. In all network models, pain interference and catastrophizing showed consistently influential roles.Conclusion: Our findings highlight the interactive nature of psychological aspects of pain and how interrelated associations differ depending on pain extent. Findings are discussed based on ideas on how both fear and pain become overgeneralized., Funding Agencies|AFA insurance; Swedish Research Council; Swedish Research Council for Health, Working Life and Welfare; [DNR 190054]; [2015-02512]; [2017-00177]

Individuals who experience problems with anger represent a heterogeneous group. Identifying clinically relevant subtypes of anger may advance treatment research. In the current study, latent profile analysis (LPA) was conducted to explore if distinct subtypes of anger could be identified within a sample of individuals seeking treatment for maladaptive anger (N = 538; 55.4% females; mean age = 39.78, SD = 12.28). Furthermore, the utility of the empirical classification was examined based on differences in usage of emotion regulation strategies (cognitive reappraisal, expressive suppression, mindful emotion awareness and relaxation) across subtypes. Four anger profiles were identified in the best-fitted LPA model: Low Anger (n = 153, 28.4%), Anger In (n = 91, 16.9%), Moderate Anger (n = 193, 35.9%) and High Anger (n = 101, 35.5%). Results from the multinominal regression revealed that the use of emotion regulation differed across all profiles. Participants from the High Anger and Anger In profiles exhibited distinct patterns of dysfunctional emotion regulation. The results add to the increasing amount of evidence demonstrating a link between emotion regulation strategies and maladaptive anger. Clinical implications on how to tailor treatments for individuals with maladaptive anger are discussed.

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

IntroductionRepetitive negative thinking (RNT) has been described as a maintaining transdiagnostic factor for psychopathology within the areas of depression, anxiety and insomnia. We investigated the effects of rumination-focused cognitive-behaviour therapy (RF-CBT) in a group format at a primary health care centre on symptoms of depression, anxiety, insomnia, RNT, and quality of life. The participants presented clinical symptom levels of worry and at least two disorders among anxiety disorders, major depressive disorder, and insomnia disorder.MethodsA randomised controlled superiority parallel arm trial was used. 73 participants were included and randomised in pairs to either group-administered RF-CBT or a waiting list condition. The primary outcomes were self-rated worry and transdiagnostic symptoms (depression, anxiety, and insomnia). Intention-to-treat analyses of group differences were conducted using linear mixed models. Adverse side effects and incidents were presented descriptively.ResultsGroup RF-CBT significantly reduced self-reported insomnia at post-treatment and self-reported insomnia and depression at the 2 month-follow-up, relative to the wait-list control group. There was no significant difference in change in RNT, anxiety, or quality of life.DiscussionThe current study suggests that group-administered RF-CBT may be effective for insomnia and potentially effective for depression symptomatology. However, the study was underpowered to detect small and moderate effects and the results should therefore be interpreted with caution., Funding Agencies|County Council in Varmland [LIVFOU-763591]

A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a., Funding Agencies|Region Stockholm [ALF project]; Swedish Research Council [521-2013-2846]; Jane and Dan Olsson foundation [4-1559/2013]; Swedish Research Council for Health, Working life and Welfare [2014-4052]

Background Suppressing intrusive thoughts can result in a post-suppression rebound effect where the same thoughts become hyperaccessible. The current study aimed to investigate if similar so-called rebound effects could be observed when people attempted to mentally suppress awareness of nonsensical auditory stimuli. Based on previous research on thought suppression and mental control in other domains, we hypothesized that attempting to suppress awareness of a task-irrelevant sound while under cognitive load would impact evaluations of the sound on affective dimensions and loudness, and result in increased general vigilance, as evidenced by faster responding on subsequent tasks. Methods We performed two experiments where participants in a suppression condition were initially instructed to mentally suppress awareness of a sound while performing a mentally challenging task. Participants in a control condition performed the same task without receiving any instructions regarding the sound. In Experiment 1, the sound was affectively neutral, while in Experiment 2 participants were presented with an inherently aversive (tinnitus-like) sound. After this initial phase, participants performed tasks measuring vigilance and attention, and were also asked to give subjective ratings of the sounds on a number of affective dimensions and loudness. Results In Experiment 1, participants in the suppression condition showed faster response times on both a visual search task and an auditory spatial cueing task, as compared to participants in the control condition. Contrary to our predictions, participants in the suppression condition did not rate the distractor sound as louder than participants in the control condition, and there were no differences on affective dimensions. In Experiment 2, results revealed that participants in the suppression condition made more errors on a visual search task, specifically on trials where the previously suppressed sound was presented. In contrast to re, Funding Agencies|Swedish National Research Council (Vetenskapsradet)Swedish Research Council [DNR 2016-02283]; Linkoping University

Background Suppressing intrusive thoughts can result in a post-suppression rebound effect where the same thoughts become hyperaccessible. The current study aimed to investigate if similar so-called rebound effects could be observed when people attempted to mentally suppress awareness of nonsensical auditory stimuli. Based on previous research on thought suppression and mental control in other domains, we hypothesized that attempting to suppress awareness of a task-irrelevant sound while under cognitive load would impact evaluations of the sound on affective dimensions and loudness, and result in increased general vigilance, as evidenced by faster responding on subsequent tasks. Methods We performed two experiments where participants in a suppression condition were initially instructed to mentally suppress awareness of a sound while performing a mentally challenging task. Participants in a control condition performed the same task without receiving any instructions regarding the sound. In Experiment 1, the sound was affectively neutral, while in Experiment 2 participants were presented with an inherently aversive (tinnitus-like) sound. After this initial phase, participants performed tasks measuring vigilance and attention, and were also asked to give subjective ratings of the sounds on a number of affective dimensions and loudness. Results In Experiment 1, participants in the suppression condition showed faster response times on both a visual search task and an auditory spatial cueing task, as compared to participants in the control condition. Contrary to our predictions, participants in the suppression condition did not rate the distractor sound as louder than participants in the control condition, and there were no differences on affective dimensions. In Experiment 2, results revealed that participants in the suppression condition made more errors on a visual search task, specifically on trials where the previously suppressed sound was presented. In contrast to re, Funding Agencies|Swedish National Research Council (Vetenskapsradet)Swedish Research Council [DNR 2016-02283]; Linkoping University

Public Significance Statement Difficulties in regulating emotions have been linked to disordered eating. This study suggests that individual differences in emotion dysregulation can be used for subtyping individuals with EDs in a clinically meaningful way. This study aimed to investigate whether individuals with eating disorders (ED; N = 857) could be empirically classified into qualitatively distinct subgroups based on their emotion dysregulation profiles. A series of increasingly complex models (factor analysis; FA, latent class analysis; LCA, and factor mixture models; FMM) were evaluated to determine whether the structure of psychopathology was best characterized by emotional dysregulation subtypes, dimensions, or a combination of the two. The subscales of the difficulties in emotion regulation scale were used as indicators. Data were split into an exploratory and confirmatory dataset, and the best-fitting models in the exploratory set were compared and validated against clinically relevant variables in the confirmatory set. Results confirmed that individuals could be grouped into three latent classes that were clearly distinguishable on ED pathology and psychiatric comorbidity. Specifically, individuals belonging to the class with more severe emotion dysregulation had higher levels of ED pathology and were more likely to engage in vomiting and binge eating as well as substance abuse and self-harm. These results provide initial support for emotional dysregulation profiling as a viable transdiagnostic approach to classification in the field of EDs., Funding Agencies: This study was approved by the Swedish Ethical Review Authority (EPN Dnr: 2017/272-31).

Objectives The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders. Methods Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined. Results A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms. Conclusion The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales., Funding Agencies|None Funding Source: Medline

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

Background Suppressing intrusive thoughts can result in a post-suppression rebound effect where the same thoughts become hyperaccessible. The current study aimed to investigate if similar so-called rebound effects could be observed when people attempted to mentally suppress awareness of nonsensical auditory stimuli. Based on previous research on thought suppression and mental control in other domains, we hypothesized that attempting to suppress awareness of a task-irrelevant sound while under cognitive load would impact evaluations of the sound on affective dimensions and loudness, and result in increased general vigilance, as evidenced by faster responding on subsequent tasks. Methods We performed two experiments where participants in a suppression condition were initially instructed to mentally suppress awareness of a sound while performing a mentally challenging task. Participants in a control condition performed the same task without receiving any instructions regarding the sound. In Experiment 1, the sound was affectively neutral, while in Experiment 2 participants were presented with an inherently aversive (tinnitus-like) sound. After this initial phase, participants performed tasks measuring vigilance and attention, and were also asked to give subjective ratings of the sounds on a number of affective dimensions and loudness. Results In Experiment 1, participants in the suppression condition showed faster response times on both a visual search task and an auditory spatial cueing task, as compared to participants in the control condition. Contrary to our predictions, participants in the suppression condition did not rate the distractor sound as louder than participants in the control condition, and there were no differences on affective dimensions. In Experiment 2, results revealed that participants in the suppression condition made more errors on a visual search task, specifically on trials where the previously suppressed sound was presented. In contrast to re, Funding Agencies|Swedish National Research Council (Vetenskapsradet)Swedish Research Council [DNR 2016-02283]; Linkoping University

Objectives The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders. Methods Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined. Results A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms. Conclusion The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales., Funding Agencies|None Funding Source: Medline

Public Significance Statement Difficulties in regulating emotions have been linked to disordered eating. This study suggests that individual differences in emotion dysregulation can be used for subtyping individuals with EDs in a clinically meaningful way. This study aimed to investigate whether individuals with eating disorders (ED; N = 857) could be empirically classified into qualitatively distinct subgroups based on their emotion dysregulation profiles. A series of increasingly complex models (factor analysis; FA, latent class analysis; LCA, and factor mixture models; FMM) were evaluated to determine whether the structure of psychopathology was best characterized by emotional dysregulation subtypes, dimensions, or a combination of the two. The subscales of the difficulties in emotion regulation scale were used as indicators. Data were split into an exploratory and confirmatory dataset, and the best-fitting models in the exploratory set were compared and validated against clinically relevant variables in the confirmatory set. Results confirmed that individuals could be grouped into three latent classes that were clearly distinguishable on ED pathology and psychiatric comorbidity. Specifically, individuals belonging to the class with more severe emotion dysregulation had higher levels of ED pathology and were more likely to engage in vomiting and binge eating as well as substance abuse and self-harm. These results provide initial support for emotional dysregulation profiling as a viable transdiagnostic approach to classification in the field of EDs., Funding Agencies: This study was approved by the Swedish Ethical Review Authority (EPN Dnr: 2017/272-31).

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

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156, Funding Agencies|Fredrik and Ingrid Thuring foundation; Strategic Research Area Healthcare Science (SFO-V)

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156, Funding Agencies|Fredrik and Ingrid Thuring foundation; Strategic Research Area Healthcare Science (SFO-V)

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials. © 2022 The Authors, Funding Agencies|Forskningsrådet om Hälsa, Arbetsliv och Välfärd, FORTE: 14099, 2014-4052

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials. © 2022 The Authors, Funding Agencies|Forskningsrådet om Hälsa, Arbetsliv och Välfärd, FORTE: 14099, 2014-4052

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials. © 2022 The Authors, Funding Agencies|Forskningsrådet om Hälsa, Arbetsliv och Välfärd, FORTE: 14099, 2014-4052

Background Suppressing intrusive thoughts can result in a post-suppression rebound effect where the same thoughts become hyperaccessible. The current study aimed to investigate if similar so-called rebound effects could be observed when people attempted to mentally suppress awareness of nonsensical auditory stimuli. Based on previous research on thought suppression and mental control in other domains, we hypothesized that attempting to suppress awareness of a task-irrelevant sound while under cognitive load would impact evaluations of the sound on affective dimensions and loudness, and result in increased general vigilance, as evidenced by faster responding on subsequent tasks. Methods We performed two experiments where participants in a suppression condition were initially instructed to mentally suppress awareness of a sound while performing a mentally challenging task. Participants in a control condition performed the same task without receiving any instructions regarding the sound. In Experiment 1, the sound was affectively neutral, while in Experiment 2 participants were presented with an inherently aversive (tinnitus-like) sound. After this initial phase, participants performed tasks measuring vigilance and attention, and were also asked to give subjective ratings of the sounds on a number of affective dimensions and loudness. Results In Experiment 1, participants in the suppression condition showed faster response times on both a visual search task and an auditory spatial cueing task, as compared to participants in the control condition. Contrary to our predictions, participants in the suppression condition did not rate the distractor sound as louder than participants in the control condition, and there were no differences on affective dimensions. In Experiment 2, results revealed that participants in the suppression condition made more errors on a visual search task, specifically on trials where the previously suppressed sound was presented. In contrast to re, Funding Agencies|Swedish National Research Council (Vetenskapsradet)Swedish Research Council [DNR 2016-02283]; Linkoping University

Public Significance Statement Difficulties in regulating emotions have been linked to disordered eating. This study suggests that individual differences in emotion dysregulation can be used for subtyping individuals with EDs in a clinically meaningful way. This study aimed to investigate whether individuals with eating disorders (ED; N = 857) could be empirically classified into qualitatively distinct subgroups based on their emotion dysregulation profiles. A series of increasingly complex models (factor analysis; FA, latent class analysis; LCA, and factor mixture models; FMM) were evaluated to determine whether the structure of psychopathology was best characterized by emotional dysregulation subtypes, dimensions, or a combination of the two. The subscales of the difficulties in emotion regulation scale were used as indicators. Data were split into an exploratory and confirmatory dataset, and the best-fitting models in the exploratory set were compared and validated against clinically relevant variables in the confirmatory set. Results confirmed that individuals could be grouped into three latent classes that were clearly distinguishable on ED pathology and psychiatric comorbidity. Specifically, individuals belonging to the class with more severe emotion dysregulation had higher levels of ED pathology and were more likely to engage in vomiting and binge eating as well as substance abuse and self-harm. These results provide initial support for emotional dysregulation profiling as a viable transdiagnostic approach to classification in the field of EDs., Funding Agencies: This study was approved by the Swedish Ethical Review Authority (EPN Dnr: 2017/272-31).

Objectives The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders. Methods Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined. Results A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms. Conclusion The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales., Funding Agencies|None Funding Source: Medline

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

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156, Funding Agencies|Fredrik and Ingrid Thuring foundation; Strategic Research Area Healthcare Science (SFO-V)

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials. © 2022 The Authors, Funding Agencies|Forskningsrådet om Hälsa, Arbetsliv och Välfärd, FORTE: 14099, 2014-4052

Objectives: Hearing loss is common and a major contributor to the global number of years lived with disability. An increasing number of studies have begun to consider the specific psychological processes by which distressing thoughts, emotional experiences and non-adaptive behaviours exert an influence on functioning and health among those who suffer from audiological disorders. Psychological acceptance has recently been proposed to be a core process but has to date not been systematically examined among individuals with hearing problems. This study examined the reliability, factor structure and the validity of the Hearing Acceptance Questionnaire (HAQ). Design: The HAQ was developed from similar questionnaires for other chronic health conditions and was evaluated using data from an online screening of hearing ability (N=1351). Measures included a hearing test (speech-in-noise), standardized and validated self-report measurements of anxiety and depression symptoms (the Hospital Anxiety and Depression scale), hearing related disability (the Amsterdam Inventory of Hearing Disability and Handicap), and quality of life (the Quality of Life Inventory). Factor structure of the HAQ was evaluated with confirmatory factor analysis, and the unique contribution of psychological acceptance in accounting for variance in hearing disability was examined by hierarchical multiple regression analyses. Results: Findings supported the reliability, factor structure and validity of the HAQ. Confirmatory factor analysis supported a two-factor model with one subscale measuring Avoidance with 9 items; alpha = 0.84) and the other Activity Engagement (3 items; alpha = 0.76). Both subscales of the HAQ explained unique variance in disability after hearing ability, depression and anxiety symptoms were statistically taken into account. Theoretical and clinical implications of psychological acceptance in adults with hearing problems are discussed. Conclusions: This paper evaluated the psychometric

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10–17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials. © 2022 The Authors, Funding Agencies|Forskningsrådet om Hälsa, Arbetsliv och Välfärd, FORTE: 14099, 2014-4052

What is the public health significance of this article? Little is known about why cognitive behavioral therapy for insomnia leads to improvement. This study highlights the importance of reducing dysfunctional beliefs and, to some extent, monitoring and safety behaviors to achieve a positive treatment effect. Objective: To examine if the processes in the cognitive model mediate cognitive therapy (CT) and behavior therapy (BT) for insomnia. Method: Individuals diagnosed with insomnia disorder (n = 219) were randomized to telephone-supported internet-delivered CT (n = 72), BT (n = 73), or a wait-list (WL; n = 74). Cognitive processes (worry, dysfunctional beliefs, monitoring, and safety behaviors) proposed to maintain insomnia and treatment outcome (insomnia severity index) were assessed biweekly. Criteria for evaluating mediators were assessed via parallel process growth modeling and cross-lagged panel models. Results: Parallel process growth modeling showed that dysfunctional beliefs, monitoring, and safety behaviors significantly mediated the effects of both CT and BT. Cross-lagged panel models confirmed that dysfunctional beliefs and monitoring (approaching significance) influenced subsequent within-individual change in insomnia severity in CT. In BT, however, prior changes in insomnia severity predicted subsequent changes in worry and monitoring, and reciprocal influences among processes and outcomes were observed for dysfunctional beliefs and safety behaviors. Furthermore, the effect of safety behaviors on outcome was significantly larger for BT compared to CT. Conclusion: Together, the findings support the role of dysfunctional beliefs and monitoring as processes of change in CT and safety behaviors as a specific mediator in BT. Limited evidence was provided for worry as a mediator. The findings could improve clinical management and increase our conceptual understanding of insomnia and its maintaining factors by underscoring the relevance of these three processe, Funding Agencies|Swedish Research Council [421-2013-996]