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Hedman-Lagerlöf M, Gasslander N, Ahnlund Hoffmann A, Bragesjö M, Etzell A, Ezra S, Frostell E, Hedman-Lagerlöf E, Ivert C, Liliequist B, Ljótsson B, Hoppe JM, Palmgren J, Spansk E, Sundström F, Särnholm J, Tzavara G, Buhrman M, Axelsson E. Effect of exposure-based vs traditional cognitive behavior therapy for fibromyalgia: a two-site single-blind randomized controlled trial. Pain 2024; 165:1278-1288. [PMID: 38131181 PMCID: PMC11090030 DOI: 10.1097/j.pain.0000000000003128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/13/2023] [Accepted: 10/13/2023] [Indexed: 12/23/2023]
Abstract
ABSTRACT Fibromyalgia is a debilitating pain condition for which treatment effects are typically modest. The most evaluated psychological treatment is traditional cognitive behavior therapy (T-CBT), but promising effects have recently been seen in exposure-based cognitive behavior therapy (Exp-CBT). We investigated whether Exp-CBT was superior to T-CBT in a randomized controlled trial. Self-referred participants with fibromyalgia (N = 274) were randomized (1:1) to 10 weeks of Exp-CBT or T-CBT. Treatments were delivered online and presented as "CBT for fibromyalgia." Participants were assessed at baseline, weekly during treatment, posttreatment, and at 6- and 12-month follow-up. Primary outcome was the difference in reduction in fibromyalgia severity as measured using the Fibromyalgia Impact Questionnaire (FIQ) over 11 assessment points from baseline to posttreatment, modelled within an intention-to-treat framework using linear mixed effects models fitted on multiple imputed data. Approximately 91% of weekly FIQ scores were collected over the main phase. There was no significant difference between Exp-CBT and T-CBT in the mean reduction of fibromyalgia severity from pretreatment to posttreatment (b = 1.3, 95% CI -3.0 to 5.7, P = 0.544, d = -0.10). Minimal clinically important improvement was seen 60% in Exp-CBT vs 59% in T-CBT. Effects were sustained up to 12 months posttreatment. This well-powered randomized trial indicated that Exp-CBT was not superior to T-CBT for fibromyalgia. Both treatments were associated with a marked reduction in fibromyalgia severity, and the online treatment format might be of high clinical utility. T-CBT can still be regarded a reference standard treatment that remains clinically relevant when compared to novel treatment approaches.
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Affiliation(s)
- Maria Hedman-Lagerlöf
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Nils Gasslander
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Alice Ahnlund Hoffmann
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maria Bragesjö
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Amanda Etzell
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Simon Ezra
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Elsa Frostell
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hedman-Lagerlöf
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Gustavsberg Primary Health Care Center, Region Stockholm, Stockholm, Sweden
| | - Caroline Ivert
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Björn Liliequist
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Johanna M. Hoppe
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Josefin Palmgren
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Edward Spansk
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Felicia Sundström
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Josefin Särnholm
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Georgia Tzavara
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Monica Buhrman
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Erland Axelsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Liljeholmen Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
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Liliequist BE, Särnholm J, Skúladóttir H, Ólafsdóttir E, Ljótsson B, Braunschweig F. Cognitive Behavioral Therapy for Symptom Preoccupation Among Patients With Premature Ventricular Contractions: Nonrandomized Pretest-Posttest Study. JMIR Cardio 2024; 8:e53815. [PMID: 38713500 PMCID: PMC11109856 DOI: 10.2196/53815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Premature ventricular contractions (PVCs) are a common cardiac condition often associated with disabling symptoms and impaired quality of life (QoL). Current treatment strategies have limited effectiveness in reducing symptoms and restoring QoL for patients with PVCs. Symptom preoccupation, involving cardiac-related fear, hypervigilance, and avoidance behavior, is associated with disability in other cardiac conditions and can be effectively targeted by cognitive behavioral therapy (CBT). OBJECTIVE The aim of this study was to evaluate the effect of a PVC-specific CBT protocol targeting symptom preoccupation in patients with symptomatic idiopathic PVCs. METHODS Nineteen patients diagnosed with symptomatic idiopathic PVCs and symptom preoccupation underwent PVC-specific CBT over 10 weeks. The treatment was delivered by a licensed psychologist via videoconference in conjunction with online text-based information and homework assignments. The main components of the treatment were exposure to cardiac-related symptoms and reducing cardiac-related avoidance and control behavior. Self-rated measures were collected at baseline, post treatment, and at 3- and 6-month follow-ups. The primary outcome was PVC-specific QoL at posttreatment assessment measured with a PVC-adapted version of the Atrial Fibrillation Effects on Quality of Life questionnaire. Secondary measures included symptom preoccupation measured with the Cardiac Anxiety Questionnaire. PVC burden was evaluated with 5-day continuous electrocardiogram recordings at baseline, post treatment, and 6-month follow-up. RESULTS We observed large improvements in PVC-specific QoL (Cohen d=1.62, P<.001) and symptom preoccupation (Cohen d=1.73, P<.001) post treatment. These results were sustained at the 3- and 6-month follow-ups. PVC burden, as measured with 5-day continuous electrocardiogram, remained unchanged throughout follow-up. However, self-reported PVC symptoms were significantly lower at posttreatment assessment and at both the 3- and 6-month follow-ups. Reduction in symptom preoccupation had a statistically significant mediating effect of the intervention on PVC-specific QoL in an explorative mediation analysis. CONCLUSIONS This uncontrolled pilot study shows preliminary promising results for PVC-specific CBT as a potentially effective treatment approach for patients with symptomatic idiopathic PVCs and symptom preoccupation. The substantial improvements in PVC-specific QoL and symptom preoccupation, along with the decreased self-reported PVC-related symptoms warrant further investigation in a larger randomized controlled trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05087238; https://clinicaltrials.gov/study/NCT05087238.
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Affiliation(s)
- Björn E Liliequist
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Helga Skúladóttir
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Ólafsdóttir
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Särnholm J, Kronish IM. Psychological Distress and Hypertension Diagnostic Testing: Is There Anything to Worry About? Am J Hypertens 2024; 37:18-20. [PMID: 37798140 PMCID: PMC10724523 DOI: 10.1093/ajh/hpad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/07/2023] Open
Affiliation(s)
- Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Ian M Kronish
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA
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Axelsson E, Santoft F, Särnholm J, Ljótsson B. Brief scales for the measurement of target variables and processes of change in cognitive behaviour therapy for major depression, panic disorder and social anxiety disorder. Behav Cogn Psychother 2023:1-18. [PMID: 37986585 DOI: 10.1017/s1352465823000541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND The measurement of process variables derived from cognitive behavioural theory can aid treatment development and support the clinician in following treatment progress. Self-report process measures are ideally brief, which reduces the burden on patients and facilitates the implementation of repeated measurements. AIMS To develop 13 brief versions (3-6 items) of existing cognitive behavioural process scales for three common mental disorders: major depression, panic disorder, and social anxiety disorder. METHOD Using data from a real-world teaching clinic offering internet-delivered cognitive behavior therapy (n=370), we drafted brief process scales and then validated these scales in later cohorts (n=293). RESULTS In the validation data, change in the brief process scales significantly mediated change in the corresponding domain outcomes, with standardized coefficient point estimates in the range of -0.53 to -0.21. Correlations with the original process scales were substantial (r=.83-.96), internal consistency was mostly adequate (α=0.65-0.86), and change scores were moderate to large (|d|=0.51-1.18). For depression, the brief Behavioral Activation for Depression Scale-Activation subscale was especially promising. For panic disorder, the brief Agoraphobic Cognitions Questionnaire-Physical Consequences subscale was especially promising. For social anxiety disorder, the Social Cognitions Questionnaire, the Social Probability and Cost Questionnaire, and the Social Behavior Questionnaire-Avoidance and Impression Management subscales were all promising. CONCLUSIONS Several brief process scales showed promise as measures of treatment processes in cognitive behaviour therapy. There is a need for replication and further evaluation using experimental designs, in other clinical settings, and preferably in larger samples.
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Affiliation(s)
- Erland Axelsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Liljeholmen University Primary Health Care Center, Region Stockholm, Stockholm, Sweden
- Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
| | - Fredrik Santoft
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Josefin Särnholm
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Särnholm J, Ljótsson B, Braunschweig F. Reply: Targeting Symptom Preoccupation in Atrial Fibrillation: A Promising Treatment Approach and Avenue for Future Research. J Am Coll Cardiol 2023; 82:e183-e184. [PMID: 37914521 DOI: 10.1016/j.jacc.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 11/03/2023]
Affiliation(s)
| | | | - Frieder Braunschweig
- Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden
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Pachankis JE, Soulliard ZA, Layland EK, Behari K, Seager van Dyk I, Eisenstadt BE, Chiaramonte D, Ljótsson B, Särnholm J, Bjureberg J. Guided LGBTQ-affirmative internet cognitive-behavioral therapy for sexual minority youth's mental health: A randomized controlled trial of a minority stress treatment approach. Behav Res Ther 2023; 169:104403. [PMID: 37716019 PMCID: PMC10601985 DOI: 10.1016/j.brat.2023.104403] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/16/2023] [Accepted: 09/04/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE LGBTQ-affirmative cognitive-behavioral therapy (CBT) addresses the adverse impacts of minority stress. However, this treatment has rarely been tested in randomized controlled trials with LGBTQ youth and never using an asynchronous online platform for broad reach. This study examined the feasibility, acceptability, preliminary efficacy, and multi-level stigma moderators of LGBTQ-affirmative internet-based CBT (ICBT). METHOD Participants were 120 LGBTQ youth (ages 16-25; 37.5% transgender or non-binary; 75.8% assigned female at birth; 49.2% non-Latino White) living across 38 U.S. states and reporting depression and/or anxiety symptoms. Participants were randomized to receive 10 sessions of LGBTQ-affirmative ICBT or only complete 10 weekly assessments of mental and behavioral health and minority stress; all completed measures of psychological distress, depression, anxiety, suicidal thoughts, alcohol use, and HIV-transmission-risk behavior at baseline and 4 and 8 months post-baseline; 20 LGBTQ-affirmative ICBT participants completed a qualitative interview regarding intervention acceptability. RESULTS Participants randomized to LGBTQ-affirmative ICBT completed, on average, 6.08 (SD = 3.80) sessions. Participants reported that LGBTQ-affirmative ICBT was helpful and engaging and provided suggestions for enhancing engagement. Although most outcomes decreased over time, between-group comparisons were small and non-significant. LGBTQ-affirmative ICBT was more efficacious in reducing psychological distress than assessment-only for participants in counties high in anti-LGBTQ bias (b = -1.73, p = 0.001, 95% CI [-2.75, -0.70]). Session dosage also significantly predicted reduced depression and anxiety symptoms. CONCLUSIONS LGBTQ-affirmative ICBT represents a feasible and acceptable treatment. Future research can identify more efficacious approaches and modalities for engaging LGBTQ youth, especially those living under stigmatizing conditions, who might benefit most.
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Affiliation(s)
| | | | | | | | | | | | | | - Brjánn Ljótsson
- Division for Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Josefin Särnholm
- Division for Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Johan Bjureberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
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Bragesjö M, Arnberg FK, Olofsdotter Lauri K, Aspvall K, Särnholm J, Andersson E. Condensed Internet-delivered prolonged exposure provided soon after trauma: a randomised trial - Corrigendum. Psychol Med 2023; 53:5888. [PMID: 37492022 PMCID: PMC10482714 DOI: 10.1017/s0033291723002027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Maria Bragesjö
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Filip K Arnberg
- Department of Neuroscience, Psychiatry, National Centre for Disaster Psychiatry, 751 24 Uppsala, Sweden
- Stress Research Institute, Stockholm University, 106 91 Stockholm, Sweden
| | - Klara Olofsdotter Lauri
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Kristina Aspvall
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, 171 77 Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
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Särnholm J, Skúladóttir H, Rück C, Axelsson E, Bonnert M, Bragesjö M, Venkateshvaran A, Ólafsdóttir E, Pedersen SS, Ljótsson B, Braunschweig F. Cognitive Behavioral Therapy Improves Quality of Life in Patients With Symptomatic Paroxysmal Atrial Fibrillation. J Am Coll Cardiol 2023; 82:46-56. [PMID: 37380303 DOI: 10.1016/j.jacc.2023.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is often associated with troubling symptoms leading to impaired quality of life (QoL) and high health care use. Symptom preoccupation, that is, fear of cardiac-related symptoms and avoidance behavior, potentially contributes to disability in AF but is not targeted by current interventions. OBJECTIVES We sought to evaluate the effect of online cognitive behavior therapy (AF-CBT) on QoL in patients with symptomatic paroxysmal AF. METHODS Patients with symptomatic paroxysmal AF (n = 127) were randomly assigned to receive AF-CBT (n = 65) or standardized AF education (n = 62). Online AF-CBT lasted 10 weeks and was therapist guided. The main components were exposure to cardiac-related symptoms and reduction of AF-related avoidance behavior. Patients were evaluated at baseline, posttreatment, and at the 3-month follow-up. Primary outcome was AF-specific QoL as assessed by the Atrial Fibrillation Effect on Quality of Life summary score (range: 0-100) at the 3-month follow-up. Secondary outcomes included AF-specific health care consumption and AF burden assessed by 5-day continuous electrocardiogram recording. The AF-CBT group was followed for 12 months. RESULTS AF-CBT led to large improvements in AF-specific QoL (Atrial Fibrillation Effect on Quality of Life summary score) by 15.0 points (95% CI: 10.1-19.8; P < 0.001). Furthermore, AF-CBT reduced health care consumption by 56% (95% CI: 22-90; P = 0.025). The AF burden remained unchanged. Results on self-assessed outcomes were sustained 12 months after treatment. CONCLUSIONS In patients with symptomatic paroxysmal AF, online CBT led to large improvements in AF-specific QoL and reduced health care use. If these results are replicated, online CBT may constitute an important addition to AF management. (Internet-Delivered Cognitive Behavior Therapy for Atrial Fibrillation; NCT03378349).
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Affiliation(s)
- Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
| | - Helga Skúladóttir
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm, Sweden
| | - Erland Axelsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Liljeholmen Primary Health Care Center, Region Stockholm, Stockholm, Sweden; Academic Primary Health Care Center, Region Stockholm, Stockholm, Sweden
| | - Marianne Bonnert
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Maria Bragesjö
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Ashwin Venkateshvaran
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Eva Ólafsdóttir
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Odense, Denmark; Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
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Bragesjö M, Arnberg FK, Olofsdotter Lauri K, Aspvall K, Särnholm J, Andersson E. Condensed Internet-delivered prolonged exposure provided soon after trauma: a randomised trial. Psychol Med 2023; 53:1989-1998. [PMID: 37310324 PMCID: PMC10106292 DOI: 10.1017/s0033291721003706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/06/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Exposure to trauma is common and can have a profoundly negative impact on mental health. Interventions based on trauma-focused cognitive behavioural therapy have shown promising results to facilitate recovery. The current trial evaluated whether a novel, scalable and digital early version of the intervention, Condensed Internet-Delivered Prolonged Exposure (CIPE), is effective in reducing post-traumatic stress symptoms. METHOD A single-site randomised controlled trial with self-referred adults (N = 102) exposed to trauma within the last 2 months. The participants were randomised to 3 weeks of CIPE or a waiting list (WL) for 7 weeks. Assessments were conducted at baseline, week 1-3 (primary endpoint), week 4-7 (secondary endpoint) and at 6-month follow-up. The primary outcome measure was PTSD Checklist for DSM-5 (PCL-5). RESULTS The main analysis according to the intention-to-treat principle indicated statistically significant reductions in symptoms of post-traumatic stress in the CIPE group as compared to the WL group. The between-group effect size was moderate at week 3 (bootstrapped d = 0.70; 95% CI 0.33-1.06) and large at week 7 (bootstrapped d = 0.83; 95% CI 0.46-1.19). Results in the intervention group were maintained at the 6-month follow-up. No severe adverse events were found. CONCLUSIONS CIPE is a scalable intervention that may confer early benefits on post-traumatic stress symptoms in survivors of trauma. The next step is to compare this intervention to an active control group and also investigate its effects when implemented in regular care.
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Affiliation(s)
- Maria Bragesjö
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Filip K. Arnberg
- Department of Neuroscience, Psychiatry, National Centre for Disaster Psychiatry, 751 24 Uppsala, Sweden
- Stress Research Institute, Stockholm University, 106 91 Stockholm, Sweden
| | - Klara Olofsdotter Lauri
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Kristina Aspvall
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, 171 77 Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
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Bjureberg J, Ojala O, Berg A, Edvardsson E, Kolbeinsson Ö, Molander O, Morin E, Nordgren L, Palme K, Särnholm J, Wedin L, Rück C, Gross JJ, Hesser H. Targeting maladaptive anger with brief therapist-supported internet-delivered emotion regulation treatments: A randomized controlled trial. J Consult Clin Psychol 2022; 91:254-266. [PMID: 36409100 DOI: 10.1037/ccp0000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Bonnert M, Särnholm J, Andersson E, Bergström SE, Lalouni M, Lundholm C, Serlachius E, Almqvist C. Targeting excessive avoidance behavior to reduce anxiety related to asthma: A feasibility study of an exposure-based treatment delivered online. Internet Interv 2021; 25:100415. [PMID: 34401374 PMCID: PMC8350602 DOI: 10.1016/j.invent.2021.100415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/13/2021] [Accepted: 06/11/2021] [Indexed: 12/11/2022] Open
Abstract
There is an established relationship between anxiety and asthma, which is associated with poor health outcomes. Most previous cognitive behavior therapies (CBT) have focused on comorbid panic disorder whereas anxiety related to asthma may rather be illness-specific. The feasibility of an online CBT targeting avoidance behavior in anxiety related to asthma was evaluated, using a pretest-posttest design. Thirty participants with self-reported anxiety related to asthma were offered an eight-week treatment with therapist support. Mean adherence was good (80% of content), and most participants (89%) reported adequate relief after treatment. Catastrophizing about asthma (CAS), assessed at 2 months after treatment, improved significantly with a large effect size (Cohen's d = 1.52). All secondary outcomes, including asthma control, avoidance behavior, fear of asthma symptoms and quality of life, improved significantly with moderate to large effect sizes (d: 0.40-1.44). All improvements were stable at 4 months follow up. Weekly ratings showed that a decrease in avoidance behavior predicted a decrease in CAS the following week throughout the treatment period. We conclude that CBT targeting avoidance behavior is a feasible treatment for anxiety related to asthma. The results justify investigation of efficacy and mechanisms of change in a randomized controlled trial. ClinicalTrials.gov, ID: NCT03486756.
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Affiliation(s)
- Marianne Bonnert
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 77 Stockholm, Sweden,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden, Norra Stationsgatan 69, 113 64 Stockholm, Sweden,Corresponding author at: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 65 Stockholm, Sweden.
| | - Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden, Nobels väg 9, 171 65 Stockholm, Sweden
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Sweden, Nobels väg 9, 171 65 Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Gävlegatan 22, SE-113 30 Stockholm, Sweden
| | - Sten-Erik Bergström
- Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Lalouni
- Department of Clinical Neuroscience, Division of Neuro, Karolinska Institutet, Sweden, Nobels väg 9, 171 65 Stockholm, Sweden
| | - Cecilia Lundholm
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 77 Stockholm, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Sweden, Norra Stationsgatan 69, 113 64 Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Gävlegatan 22, SE-113 30 Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Sweden, Nobels väg 12, 171 77 Stockholm, Sweden,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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12
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Bragesjö M, Arnberg FK, Jelbring A, Nolkrantz J, Särnholm J, Olofsdotter Lauri K, von Below C, Andersson E. Demanding and effective: participants' experiences of internet-delivered prolonged exposure provided within two months after exposure to trauma. Eur J Psychotraumatol 2021; 12:1885193. [PMID: 33968320 PMCID: PMC8075080 DOI: 10.1080/20008198.2021.1885193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants' experiences in receiving this type of intervention remotely. Objective: Investigate participants' experiences of receiving CIPE early after trauma. Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim. Results: One overarching theme labelled as 'demanding and effective' was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure. Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.
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Affiliation(s)
- Maria Bragesjö
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Filip K Arnberg
- National Centre for Disaster Psychiatry, Department of Neuroscience, Uppsala University, Uppsala, Sweden.,Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Anna Jelbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | | | - Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Klara Olofsdotter Lauri
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | | | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
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13
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Särnholm J, Skúladóttir H, Rück C, Klavebäck S, Ólafsdóttir E, Pedersen SS, Braunschweig F, Ljótsson B. Internet-Delivered Exposure-Based Therapy for Symptom Preoccupation in Atrial Fibrillation: Uncontrolled Pilot Trial. JMIR Cardio 2021; 5:e24524. [PMID: 33650972 PMCID: PMC8411432 DOI: 10.2196/24524] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/20/2020] [Accepted: 01/18/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. AF is associated with a poor quality of life (QoL) and, in many patients, current medical treatments are inadequate in alleviating AF symptoms (eg, palpitations). Patients often present with symptom preoccupation in terms of symptom fear, avoidance, and control behaviors. Internet-delivered cognitive behavior therapy is effective for treating other somatic disorders but has never been evaluated in patients with AF. OBJECTIVE The aim of this study is to evaluate the efficacy and feasibility of AF-specific internet-delivered cognitive behavior therapy. METHODS We conducted an uncontrolled pilot study in which 19 patients with symptomatic paroxysmal AF underwent internet-delivered cognitive behavior therapy. Participants completed self-assessments at pretreatment, posttreatment, and at a 6-month follow-up along with handheld electrocardiogram measurements with symptom registration. The treatment lasted 10 weeks and included exposure to physical sensations, reduction in avoidance behavior, and behavioral activation. RESULTS We observed large within-group improvements in the primary outcome, AF-specific QoL (Cohen d=0.80; P<.001), and in symptom preoccupation (Cohen d=1.24; P<.001) at posttreatment; the results were maintained at the 6-month follow-up. Treatment satisfaction and adherence rates were also high. We observed an increased AF burden, measured by electrocardiogram, at the 6-month follow-up, but a significant decrease was observed in the overestimation of AF symptoms at posttreatment and 6-month follow-up. Exploratory mediation analysis showed that a reduction in symptom preoccupation mediated the effects of internet-delivered cognitive behavior therapy on AF-specific QoL. CONCLUSIONS This study presents preliminary evidence for the potential efficacy and feasibility of a novel approach in treating patients with symptomatic AF with internet-delivered cognitive behavior therapy. TRIAL REGISTRATION ClinicalTrials.gov NCT02694276; https://clinicaltrials.gov/ct2/show/NCT02694276.
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Affiliation(s)
- Josefin Särnholm
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Helga Skúladóttir
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Christian Rück
- Department of Clinical Neuroscience, Karolinska Institutet, Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Sofia Klavebäck
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Ólafsdóttir
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Frieder Braunschweig
- Department of Medicine, Cardiology Unit, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
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14
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Bonnert M, Olén O, Lalouni M, Hedman-Lagerlöf E, Särnholm J, Serlachius E, Ljótsson B. Internet-Delivered Exposure-Based Cognitive-Behavioral Therapy for Adolescents With Functional Abdominal Pain or Functional Dyspepsia: A Feasibility Study. Behav Ther 2019; 50:177-188. [PMID: 30661558 DOI: 10.1016/j.beth.2018.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 05/06/2018] [Accepted: 05/12/2018] [Indexed: 12/18/2022]
Abstract
Functional abdominal pain (FAP) and functional dyspepsia (FD) are common in adolescents and associated with low quality of life. Exposure-based cognitive-behavioral therapy (CBT) is efficient for adult and adolescent irritable bowel syndrome (IBS), but has never been evaluated for adolescent FAP/FD. The aim of this study was to evaluate the feasibility and potential efficacy of a novel disorder-specific Internet-delivered CBT (Internet-CBT) for adolescents with FAP or FD, using an uncontrolled open pilot including 31 adolescents. The Internet-CBT consisted of 10 weekly online modules, which focused mainly on exposure to abdominal symptoms. Parents received modules to help them reduce unhelpful parental behaviors. Participants reported the treatment to be credible, and an overall satisfaction with the treatment. Data attrition rate was low (7%) and adherence to treatment was acceptable. We saw a significant and large effect on the primary outcome, pain intensity, at posttreatment (d = 1.20, p < .001) that was further improved after 6 months (d = 1.69, p < .001). Participants also made significant and large improvements on gastrointestinal symptoms (d = 0.84, p < .001) and quality of life (d = 0.84, p < .001) that were sustained or further improved at follow-up 6 months after treatment. This study demonstrated that exposure-based Internet-CBT, tailored for adolescents with FAP or FD, is a feasible treatment that potentially improves pain intensity, gastrointestinal symptoms, and quality of life.
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Affiliation(s)
- Marianne Bonnert
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council.
| | - Ola Olén
- Karolinska Institutet; Karolinska University Hospital; Sachs' Children's Hospital
| | - Maria Lalouni
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council
| | | | | | - Eva Serlachius
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council
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15
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Särnholm J, Skúladóttir H, Rück C, Pedersen SS, Braunschweig F, Ljótsson B. Exposure-Based Therapy for Symptom Preoccupation in Atrial Fibrillation: An Uncontrolled Pilot Study. Behav Ther 2017; 48:808-819. [PMID: 29029677 DOI: 10.1016/j.beth.2017.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 04/24/2017] [Accepted: 06/01/2017] [Indexed: 01/23/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia. Patients often experience a range of symptoms resulting in a markedly reduced quality of life, and commonly show symptom preoccupation in terms of avoidance and control behaviors. Cognitive behavior therapy (CBT) has been shown to improve symptom burden and quality of life in other somatic disorders, but has never been evaluated in patients with AF. The purpose of this study was to evaluate the potential efficacy and feasibility of an AF-specific CBT protocol in an uncontrolled pilot study. The study included 19 patients with symptomatic paroxysmal (intermittent) atrial fibrillation who were assessed pre- and posttreatment and at 6-month follow-up. The CBT lasted 10 weeks and included exposure to physical sensations similar to AF symptoms, exposure to avoided situations or activities, and behavioral activation. We observed large within-group improvements on the primary outcome AF-specific quality of life measurement AFEQT posttreatment (Cohen's d = 1.54; p < . 001) and at 6-month follow-up (d = 1.15; p < . 001). We also observed improvements in self-reported frequency and severity of AF symptoms. All participants completed the treatment and treatment satisfaction was high. This study demonstrates the potential efficacy and feasibility of a novel CBT approach to reduce symptoms and increase quality of life in AF patients.
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Affiliation(s)
| | | | - Christian Rück
- Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council
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