I chose the theme of obsessive-compulsive disorder as a topic of my thesis. The main reason was that it is a disorder I have worked as a therapist in individual or group therapy frequently. Also I have participated in several studies as evaluator in Psychiatric Centre, and I collected data from dozens of patients. In the first part the thesis deals with the symptoms, clinical picture, prevalence, aetiology and treatment of OCD. Thesis is focuses on behavioural and cognitive models of the disorder in detail, because the treatment used in the present group of patients was CBT. Various models of cognitive behavioural therapy I discuss in more detail, because they allow different views of what happens to the patient and how to change it. The practical part has two parts. The first deals with the effectiveness of group cognitive behavioral approach for OCD patients, who use antidepressants but were resistant to previous treatment and were attended a daycare center at the Prague Psychiatric Center. The second part of the thesis deals with finding a predictor of successful cognitive behavioral therapy in these patients. The aim was to determine whether certain demographic or clinical factors that we evaluated before treatment may predict success outcome. The result is the finding that severity of the...

Anxiety disorders share the feature of excessive fear, anxiety and related behavioural disturbances. Fear is defined as the emotional response to a real or a perceived imminent threat and anxiety is the anticipation of a future threat. The anxiety disorders covered in this thesis are panic disorder with or without agoraphobia, social phobia, post-traumatic stress disorder, generalized anxiety disorder and anxiety disorder not otherwise specified. Cognitive behavioural treatment protocols are typically designed to target one specific disorder and falls under the definition of disorder-specific cognitive behavioural therapy. It is however unclear if this is the most optimal approach in regards to the high comorbidity between anxiety disorders and depressive disorders. Internet-based cognitive behavioural therapy has in the past generally been disorder-specific and from above mentioned predicament two alternative treatment approaches emerged, the tailored and the transdiagnostic approach that aims to simultaneously treat both principal and comorbid disorders. Previous trials on internet-based cognitive behavioural therapy have targeted adults in general and relatively few target adolescents, young adults and older adults. The aims of this thesis were to further develop and test the effects of tailored internet-based cognitive behavioural therapy on the basis of age, for adolescents, young adults and older adults. Specifically by developing and testing the effects of individually tailored internet-based cognitive behavioural therapy for adolescents with anxiety and comorbid depressive symptoms and by adapting and testing the effects of individually tailored internet-based cognitive behavioural therapy for young adults and older adults with anxiety and comorbid depressive symptoms. These aims were tested in two pilot effectiveness studies (Paper I and III) and two efficacy randomised controlled trials (Paper II and IV). The results from these four trials showed significant results across all outcome measures with overall moderate to large effect sizes. The tentative conclusion based on these results is that tailoring internet-based cognitive behavioural therapy can be a feasible approach in the treatment of anxiety symptoms and comorbid depressive symptoms for adolescents, young adults and older adults. Despite the positive findings of the studies in this thesis, there is a need for more research examining the acceptability and effectiveness of internet-based cognitive behavioural therapy for adolescents, young adults and older adults with anxiety and depression before implementation on a larger scale.

Background: Accrual of continuing medical education credits is part of licensure in family medicine but opinions are mixed as to whether the training has an impact on clinical practice. Literature does suggest that practice change is most likely when training involves multiple interactive exposures, and when the benefit to patients is apparent. Aim: To determine whether an interactive peer-lead educational intervention for General Practitioners in British Columbia, the Practice Support Program Mental Health Module, resulted in measureable change in clinical practice of the Vancouver Island participants. Method: Administrative information from British Columbia Ministry of Health databases was obtained for analysis regarding physician billing and prescribing, and hospitalizations on Vancouver Island. Paired t-tests were used to compare physician-patient interactions among module participants before and after the training regarding a) initiation of antidepressants and anti-anxiety medication, and b) use of the mental health plan billing code, used to support patients who struggle with activities of daily living. In addition, mental health hospitalizations among participants' patients before and after training were used to measure its impact on patient outcomes. Results: One-hundred and ninety-seven General Practitioners on Vancouver Island completed the mental health module between 2008 and 2011. While no significant difference was found in the numbers of mental health patients seen during the pre- and post- periods (M=142.06, SD=97.45) and (M=144.44, SD=103.00); t(196)=-0.679, p=0.498, α=.05, the change in the proportion of new prescriptions between pre-period mean (M=0.0796, SD=.06527) and post-period means (M=.0530, SD=.03877); t(195)=6.668, p<0.001 was found to be significant and indicative of a relative decrease between 31.2 and 33.4%. The change in the proportion of mental health plans was also found to be significant between pre-period (M=0.1142, SD=.018598) and post-period means (M=.1674, SD=.23973); t(180)=-3.586, p<0.001. This indicated a relative increase between 42.0 and 46.6%. No significant change in patient hospitalizations was found between the pre- and post-period means: (M=0.039, SD=.0612) and (M=.0392, SD=.0978); t(192)=-0.055, p=0.956. Conclusion: This educational intervention appears to have resulted in significant changes in the practice patterns of the physician participants. Future research using better indicators may reveal more about the impact of physician training on patient outcomes. / Graduate

Introduction: Chronic orofacial pain (COFP) is distressing and disabling to sufferers and can be costly to patients, health services and society. Frequently, no underlying medical pathology can be found to account for the condition. Despite this, patients are treated according to a biomedical model, often by mechanistic and invasive procedures, which tend to be unsuccessful and not evidence based. Evidence suggests that cognitive behavioural therapy (CBT) based management may produce improved outcomes for patients. However, published studies can tell us little about which intervention components are effective, or recommend an optimum way for these components to be applied. Aim: To develop an evidence based intervention for the management of COFP that is feasible and acceptable to patients and practitioners. Method: The Medical Research Council’s guidelines for developing complex interventions were used as a framework for the research. Evidence from multiple sources was synthesised to produce the draft components of an intervention to manage COFP. An exploratory trial investigated preliminary outcomes, acceptability, feasibility and explored parameters for a full scale randomised control trial. Results: The intervention was acceptable to participants and could be feasibly implemented. No conclusions could be drawn relating to the effectiveness of the intervention. Participants were not affected at baseline for a number of outcomes, which implies that cut off points should be introduced into the inclusion and exclusion criteria of any future studies. Conclusion: The study produced an intervention which is acceptable and feasible to participants, however it is not known if it is effective. A number of recommendations are made for progression to a larger, definitive trial.

Computerised Cognitive Behavioural Therapy (CCBT) has been recommended for patients in the National Health Service (NHS) Primary Care across the United Kingdom for management of mild to moderate anxiety and depression. This approach also promises financial savings, and may fill the gap between demand and supply of face-to-face therapy. Studies have shown that CCBT is feasible and effective. However, dropout rates can be as high as 86%, but the reasons remain unclear and the information available is limited. This thesis explores factors that may impact on the usability and user experience of this computer-mediated therapy. Espousing the “real world” research philosophy and widely used methods in the Human-Computer Interaction (HCI) field for usability evaluations, four studies using a mixed-methods design were conducted. Study I was an online usability survey, which investigated if usability evaluations had been conducted for CCBT applications. Two versions of questionnaires were sent to four CCBT software developers and ten authors of randomised controlled trials. The categories and responses of the questionnaires gathered from five respondents were reviewed and summarised. The findings suggested that usability evaluations for CCBT were still in their infancy when compared to other healthcare interventions to which HCI approaches have been widely applied. Study II was a usability Heuristic Evaluation (HE) conducted with four expert evaluators to assess two different CCBT applications’ interfaces (MoodGYM and Living Life to the Full) against the self-designed usability heuristics for their compliance. The findings revealed numerous usability issues. Major problems related to navigation and inconsistency of the interfaces were identified. These could be rectified to enhance the user experience. Study III focused on other factors besides usability that might have an influence on the effective use of CCBT. Perceptions of service providers who were involved in both decision-making about CCBT availability and supporting its use were gathered. Nine service providers at different NHS organisations were interviewed. The interviews were analysed using techniques from Grounded Theory (GT). The findings suggested that the practitioners’ attitudes towards CCBT might have affected its service delivery. Four categories from the data analysis were identified: (1) shaping behaviour, (2) implementing and delivering, (3) making an appropriate referral, and (4) technology/CCBT packages - advancing with time. A conceptual model was also generated, “building support around CCBT”: a road-map that could address some of these issues. Study IV examined patients’ perceptions and acceptance of a CCBT application (Beating the Blues), its usability and the user experience, and also whether the user characteristics (e.g. computer experience (CE) and computer self-efficacy (CSE)) had any influence on patients’ use of this technology. A mixed-methods approach was utilised with a sample of 33 participants. Face-to-face and email interviews were conducted. Feedback was also gathered from a usability questionnaire and think-aloud protocol with seven participants selected from the sample. The data were analysed using Thematic and Saliency Analysis to uncover themes. Descriptive statistics were used to describe data from questionnaires. Two overarching themes from the interviews were identified: (1) access to CCBT services, and (2) perceptions and attitudes towards CCBT. Both themes revealed issues which might have significantly impacted on patients’ engagement with CCBT. Numerous flaws were also discovered in the application’s design and functionality (e.g. navigation, aesthetics, relevance of content, and inflexibility). However, the results from CE and CSE questionnaires suggested that participants were confident in using this technology. The four studies provided an in-depth understanding of factors that affect the usability and user experience of CCBT and possible reasons for the high attrition rates. The implications of this research point to the need for health policymakers to focus on the current implementation issues and on how best to deploy this treatment therapy to patients. Further development of CCBT is pivotal to its success, in particular, expanding contexts of use and increasing usability evaluations. Keeping users interested and engaged will improve treatment efficiency, completion rates and will achieve better clinical outcomes.

A manualised trauma-focused cognitive behavioural therapy (TF-CBT) programme was developed for multiply-abused children diagnosed with posttraumatic stress disorder (PTSD; Feather & Ronan, 2004) referred to the specialist clinic of the statutory child protection agency in New Zealand. The TF-CBT protocol was based on: (1) a review of the history of child abuse (CA) and child protection in New Zealand and internationally, with particular reference to professional developments and the role of psychologists in ameliorating CA; (2) a conceptualisation of the clinical presentation of CA in children; (3) a review of the field of psychotraumatology and theoretical models, including locally developed, relevant to the development of a treatment programme for traumatised abused children in a child protection setting in New Zealand; and (4) a review of evidence-based practice, treatment outcome models, and current empirical research related to developing an effective treatment model in this area. The locally developed TF-CBT programme built on efficacious treatments for child anxiety and PTSD as a result of sexual abuse. It encompasses psychosocial strengthening, coping skills training, gradual exposure using expressive modalities, and special issues relevant to trauma and abuse. A “scientist-practitioner” approach to local clinical research was used to evaluate the programme. A single-case multiple-baseline design demonstrated the controlling effects of the treatment across four studies; each comprising four typically-referred multiply-abused children aged 9-15 years who met diagnostic criteria for PTSD. Parent/caregivers were involved in treatment sessions. Study 1 was a pilot with four Pakeha/New Zealand European children; Study 2 trialled the protocol with two Maori and two Samoan children; Study 3 was an evaluation of the developed protocol with a multicultural group of typically-referred children; and Study 4 was an evaluation with other therapists delivering the manualised programme. Despite some methodological difficulties related to conducting research in a setting of this nature, the overall results indicate a good deal of promise. Across the four studies, for the majority of children treated, PTSD symptoms decreased and child coping increased. Where follow-up data was available, gains generally maintained or improved over 3-, 6-, and 12-month intervals. Recommendations are made about further applications of this TF-CBT programme, including the interweaving of cultural models with TF-CBT, and development and evaluation of the protocol in other settings. Implications of the current research are discussed in terms of recognition of the crucial importance of evidence-based practice in CA/child protection settings, and the contribution psychologists and therapists can make to ensure quality outcomes for this most vulnerable population of children and families.

<p>Under 1990-talet implementerades i Sverige en metod för behandling av aggressivitethos barn och unga, som kallas Aggression Replacement Training (ART). Metoden ärutvecklad i USA av Arnold P. Goldstein och hans kollegor. Metoden har sin teoretiskagrund inom den sociala inlärningsteorin och bygger till stor del på behandlingsprinciperinspirerade av kognitiv beteendeterapi. ART som behandlingsmetod för aggressiva barnoch unga har fått stor spridning i Sverige och en av de kommuner som erbjuder ARTsom öppenvårdsinsats inom socialtjänsten är Västerås. Denna uppsats utgår från ettuppdrag från familjebehandlingen i Västerås Stad, som önskar belysa vilka eventuellaupplevda effekter deras variant av ART har gett. Förutom detta syftar uppsatsen ocksåtill att teoretiskt beskriva ART med avseende på teoretiskt ursprung och praktiskttillämpning. Studien, som har en kvalitativ ansats, utgår från en specifikbehandlingsgrupp om fem barn, vars föräldrar har intervjuats om vilka eventuellaeffekter de upplever att behandlingen gett. Resultaten är inte helt entydiga, då vissaföräldrar väldigt tydligt upplevt stora förbättringar när det gäller ilska och aggressivitethos sitt barn, medan andra föräldrar inte tycker sig se några större förändringar.Genomgående är dock föräldrarna nöjda med metoden och dess genomförande somsådant, men efterfrågar t.ex. intensivare och mer långvariga insatser för att ökamöjligheten för deras barn att ta till sig behandlingen fullt ut.</p> / <p>During the 1990’s a method of treatment for aggression and anger problems in childrenand youth was introduced in Sweden, witch is called Aggression Replacement Training(ART). ART was first developed in the United States, by Arnold P. Goldstein andcolleagues. The method has its theoretical foundation in the social learning theory and isinspired by the treatment principles found in cognitive behavioural therapy. ART as atreatment method for aggressive children and youth has been widely spread in Swedenand one of the cities that offers ART within their social services are Västerås. This essayis a mission from the unit of family treatment in Västerås Stad, who has an interest inelucidate possible treatment outcomes from their work with ART. In addition to that, thepurpose of this essay is to describe the theoretical foundations and practical appliancesof ART. This study, which has a qualitative approach, emanate from a specific treatmentgroup of five children, whose parents has been interviewed about what, if any, outcomethey experience that the treatment has resulted in. The results are not really univocal.Some of the parents experience very significant improvements in their child’sexpression of anger and aggressiveness, whereas some other parents don’t experienceany improvement at all. Consistently though, all of the parents are very pleased with themethod itself and its implementation, but some of them ask for more intensive and farreachinginterventions, to increase the possibilities for their children to fully ingest thetreatment.Key</p>

Under 1990-talet implementerades i Sverige en metod för behandling av aggressivitethos barn och unga, som kallas Aggression Replacement Training (ART). Metoden ärutvecklad i USA av Arnold P. Goldstein och hans kollegor. Metoden har sin teoretiskagrund inom den sociala inlärningsteorin och bygger till stor del på behandlingsprinciperinspirerade av kognitiv beteendeterapi. ART som behandlingsmetod för aggressiva barnoch unga har fått stor spridning i Sverige och en av de kommuner som erbjuder ARTsom öppenvårdsinsats inom socialtjänsten är Västerås. Denna uppsats utgår från ettuppdrag från familjebehandlingen i Västerås Stad, som önskar belysa vilka eventuellaupplevda effekter deras variant av ART har gett. Förutom detta syftar uppsatsen ocksåtill att teoretiskt beskriva ART med avseende på teoretiskt ursprung och praktiskttillämpning. Studien, som har en kvalitativ ansats, utgår från en specifikbehandlingsgrupp om fem barn, vars föräldrar har intervjuats om vilka eventuellaeffekter de upplever att behandlingen gett. Resultaten är inte helt entydiga, då vissaföräldrar väldigt tydligt upplevt stora förbättringar när det gäller ilska och aggressivitethos sitt barn, medan andra föräldrar inte tycker sig se några större förändringar.Genomgående är dock föräldrarna nöjda med metoden och dess genomförande somsådant, men efterfrågar t.ex. intensivare och mer långvariga insatser för att ökamöjligheten för deras barn att ta till sig behandlingen fullt ut. / During the 1990’s a method of treatment for aggression and anger problems in childrenand youth was introduced in Sweden, witch is called Aggression Replacement Training(ART). ART was first developed in the United States, by Arnold P. Goldstein andcolleagues. The method has its theoretical foundation in the social learning theory and isinspired by the treatment principles found in cognitive behavioural therapy. ART as atreatment method for aggressive children and youth has been widely spread in Swedenand one of the cities that offers ART within their social services are Västerås. This essayis a mission from the unit of family treatment in Västerås Stad, who has an interest inelucidate possible treatment outcomes from their work with ART. In addition to that, thepurpose of this essay is to describe the theoretical foundations and practical appliancesof ART. This study, which has a qualitative approach, emanate from a specific treatmentgroup of five children, whose parents has been interviewed about what, if any, outcomethey experience that the treatment has resulted in. The results are not really univocal.Some of the parents experience very significant improvements in their child’sexpression of anger and aggressiveness, whereas some other parents don’t experienceany improvement at all. Consistently though, all of the parents are very pleased with themethod itself and its implementation, but some of them ask for more intensive and farreachinginterventions, to increase the possibilities for their children to fully ingest thetreatment.Key

Background & objective Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) have been the treatment of choice for problem or pathological gambling in the field in Western countries, and their efficacy has been supported by a considerable empirical research. Alternative treatments are little known; and such treatments for minority ethnic populations have been scarce. This study adopted Kazdin‘s procedures for assessing the acceptability of treatments (Kazdin, 1980a, 1980b, 1981) to test alternative treatments of problem or pathological gambling as a part of the broadening of treatment choices. This thesis presented 2009 survey results from counselling service providers in New Zealand on the acceptability of alternative treatments to problem or pathological gambling. The thesis, therefore, reports the responses of counsellors to counselling vignette case examples, not the views of actual clients viewing counselling. Methods The survey pack was distributed to counselling service providers in New Zealand. The survey included descriptions of sixteen vignettes of case examples of counselling treatments. Categories of clients in the vignette case examples included two genders (male, female) and three ethnicities (Pakeha, Maori, and Asian). Four counselling treatment conditions were selected from Solution-Focused Brief Counselling (SFBC), SFBC+Multicultural Counselling (SFBC+MC), Cognitive-Behavioural Therapy (CBT), and Motivational Interviewing (MI). CBT and MI were only administered to Pakeha clients for the purpose of comparison of the alternatives. Two measurements were used. The first a modified Problem Gambling Treatment Evaluation Inventory (TEI) was used to measure the acceptability levels of the alternative treatments for problem or pathological gambling. The Cross-Cultural Counselling Inventory-Revised (CCCI-R) was used for measuring the perceived cross-cultural competency of counsellors depicted in the vignette case examples. Findings Counsellors‘ ratings of the vignette case examples revealed the following findings: Measurement 1: Problem Gambling Treatment Evaluation Inventory (TEI). Overall, 1) The survey results of TEI questionnaires showed significant main effects across the four treatment conditions and the three client ethnicities, and there was no difference according to client genders. 1.1) SFBC+MC and SFBC were slightly more acceptable than CBT, and much more acceptable than MI. 1.2) The TEI scores for Pakeha clients were much higher than for Maori clients, and the scores for the Asian clients were in between. 2) There was a significant interaction effect between the four treatments and the three client ethnicities. 2.1) For Maori clients: SFBC+MC was much more acceptable than SFBC; for Pakeha clients: SFBC+MC was the most acceptable, closely followed by SFBC, CBT, then MI; and for Asian clients: SFBC was more acceptable than SFBC+MC. 2.2) SFBC+MC was most acceptable to Maori clients across all treatments and ethnic groups. 2.3) The variation in acceptability ratings for SFBC was larger than for SFBC+MC in Maori and Asian clients, and less variable in Pakeha. 2.4) Maori clients had the largest mean variation between SFBC and SFBC+MC, and Pakeha clients had the smallest mean variation. Measurement 2: Cross-Cultural Counselling Inventory-Revised (CCCI-R). The survey results of the CCCI-R showed significant main effects across the four treatment conditions and the three ethnicities. 1) The counsellors depicted in the vignette case examples under the SFBC+MC treatment condition were rated with the highest mean competence score and least variability across all the treatments and the ethnicities, the MI treatment condition were rated with the lowest mean score, CBT and SFBC were in between. 2) The counsellors described in the vignette case examples were rated more culturally competent with Pakeha clients and Maori clients than with Asian clients in the vignette case examples, the rating levels for both Pakeha and Maori were similar. 3) The Maori client in the vignette case examples had the largest mean gap between SFBC and SFBC+MC, and Pakeha client in the vignette case examples had the smallest mean gap. Clinical implications The tests of the acceptability of alternative treatment for problem or pathological gambling could provide useful information about 1) whether the above alternatives would be recommended or selected by the counselling service providers in their clinical practice, 2) which treatment would be more/less preferred by which ethnic group, 3) whether it would work or be worth the efforts to introduce or promote the above alternatives to the counselling service providers, 4) what needs to be explored for increasing levels of the acceptability of alternative treatment to problem or pathological gambling, 5) adding training in the techniques to counsellors training programme and curricula. The limitation of this study was discussed and future research was suggested.

Erythrophobie wird als klinische Bezeichnung für die Angst zu erröten verwendet, wenn das Einzelsymptom Erröten im Vordergrund einer Angstproblematik steht. Die vorliegende Übersicht beruht auf einer umfangreichen Literaturrecherche und wird ergänzt durch eigene klinische Beobachtungen aus einer Pilotstudie zur kognitiv-behavioralen Gruppentherapie der Errötungsangst. Wir referieren den aktuellen Kenntnisstand zu Erythrophobie in Bezug auf die differentialdiagnostische Einordnung, auf ätiologische und pathogenetische Konzepte sowie auf die Verhaltenstherapie der Störung. Insgesamt zeigt die Übersicht, dass Erythrophobie am sinnvollsten als Subsyndrom der Sozialen Phobie beschrieben werden kann. Patienten mit Errötungsangst als Hauptbeschwerde unterscheiden sich jedoch von anderen Patienten mit Sozialer Phobie im Hinblick auf Behandlungsanliegen, Inanspruchnahmeverhalten, Behandlungserwartung und Therapieziele sowie durch spezifische aufrechterhaltende Mechanismen der Störung, insbesondere durch eine übertriebene und inflexible Aufmerksamkeitsfokussierung auf körperliche Symptome. Der Einsatz eines Aufmerksamkeitstrainings als spezifisches Behandlungsmodul bei Errötungsangst ist vielversprechend und sollte in bekannte Ansätze zur Therapie der Sozialen Phobie integriert werden. Abschließend werden Impulse für weiterführende Forschungsaktivitäten skizziert. / Erythrophobia is the pathological form of fear of blushing. This review is based upon an extensive literature research and supplemented by clinical observations from a pilot study of a cognitive-behavioural group therapy for fear of blushing. Current knowledge about fear of blushing is reported regarding diagnostic considerations, aetiologic and pathogenetic mechanisms, and cognitive-behavioural therapy. In conclusion, this review indicates that fear of blushing should be classified as a sub-syndrome of social phobia. Patients suffering from fear of blushing as predominant complaint differ from other patients with social phobia in health-care utilisation, treatment expectation and treatment goals. However, the most prominent difference lies in the exaggerated and inflexible self-focused attention these patients direct to their arousal and bodily symptoms. Therefore, attention training as a specific treatment unit is promising and should be integrated in standard treatment approaches for social phobia. Finally, options for further research are outlined. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.