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Introduction:

Idiographic network analysis, where associations between multiple nodes are estimated, can potentially guide choice of interventions in psychological treatment. In this single case experiment using ecological momentary assessment data to estimate continuous time network models, we aimed to test the so-called centrality hypothesis. We did so by comparing effects of interventions guided by the most central node to those guided by the least central node. We used the composite level psychological inflexibility processes lack of openness, lack of awareness, and lack of engagement, alongside an interference outcome, as network nodes. Effects on pain interference, motivation, and pain intensity were examined.

Method:

We employed a multiple baseline design across six participants. Therapists and participants were blinded to participants' treatment conditions. Baseline length and order of treatment phases were randomized.

Results:

Four participants had an overall treatment effect on pain interference, but it was generally not possible to discern that one particular phase was more beneficial than another. For three participants, the picture was somewhat clearer, indicating one of the treatment phases as more beneficial, although the results for these participants were not consistently in line with hypotheses. Retrospectively examining other potential guidance methods for these three participants, we saw a potential in discrete time contemporaneous network models.

Discussion:

Current results are not in line with previous assumptions or research on idiographic network models for treatment personalization, although the previous research in this area is scarce. Future research should investigate alternative network models or estimation choices to determine the potential utility of data driven idiographic networks.

Background: Non-traumatic stress-related illnesses are associated with considerable functional impairment and costs for both individuals and societies. In Sweden, the national diagnose Exhaustion disorder (ED) is one of the most frequently diagnosed disorders in this category. Despite the major negative consequences of illnesses such as ED, there is no clear evidence on successful treatments or effective interventions to enhance return to work outcomes for this population. Therefore, the aim of this study was to explore how individuals who had returned to work after sick leave due to ED experienced the process of returning to work, including facilitating factors, significant challenges and needs of further support.

Methods: Participants were recruited from three clinics in Stockholm specialized in rehabilitation for Exhaustion Disorder. Semi-structured interviews were conducted with 15 participants and the transcribed interviews were analyzed using qualitative content analysis.

Results: The results yielded three themes - Struggling to adapt sustainably to change, Being supported or hindered by the context and Being part of a larger societal system. The first theme revolves around individual processes of change, such as gaining insight in one's own behavior, and rethinking one's perceived identity. The second theme focuses on how practical and emotional support, or lack thereof, affect the experience of returning to work. The third theme addresses hindering or facilitating factors on a more societal level, such as social norms or conditions of the social welfare system.

Conclusions: The results indicate the relevance of further and prolonged support for individuals returning to work after sick leave due to ED. The workplace and overall organization plays an important role in providing this support. In a clinical individual context, the support given may include programs designed to facilitate behavioral maintenance, sustainable psychological flexibility and renegotiation of values. However, further research is needed on how such programs should be best designed and delivered.

Background

Chronic pain (CP) is a leading cause of disability worldwide and is associated with substantial psychological, functional, and social burden. Acceptance and Commitment Therapy (ACT) has demonstrated efficacy in improving pain acceptance and functioning; however, access to psychological care remains limited. Internet-based interventions (IBIs) may help bridge this gap. To date, no ACT internet-based intervention has been developed and tested for individuals with CP in Italy. The present pilot randomized controlled trial (RCT) evaluated feasibility, acceptability, usability, and exploratory changes in pain acceptance of MobACT, a guided internet-based ACT intervention translated and adapted for the Italian context.

Methods

A two-arm pilot RCT with parallel groups (1:1 allocation) was conducted. Forty adults with CP were randomized to either the MobACT intervention (n = 20) or a waitlist control group (n = 20). The seven-week guided intervention was delivered via the Iterapi platform. Feasibility outcomes included recruitment, retention, usability, satisfaction, intervention experience, and participant feedback. The primary exploratory clinical outcome was pain acceptance, measured using the Chronic Pain Acceptance Questionnaire (CPAQ-20) at baseline (T0) and post-intervention (T1). Feasibility, usability, and participant experiences were explored through post-intervention questionnaires and semi-structured interviews analyzed using thematic analysis.

Results

Pain acceptance significantly improved over time across participants (p < .001), but the time & times; group interaction was not significant (p = .978), indicating no evidence of a differential change between MobACT and waitlist during the pilot period. Reliability of the CPAQ-20 was good at both time points (alpha = 0.802-0.842). Qualitative findings indicated high usability, satisfaction, and perceived applicability of ACT strategies. Participants reported increased awareness, reduced rumination, improved emotional regulation, and greater engagement in valued activities, despite limited changes in pain intensity.

Conclusions

Findings support the feasibility, acceptability, and usability of MobACT as a culturally adapted internet-based ACT intervention for CP in Italy. Exploratory outcome findings should not be interpreted as evidence of efficacy; rather, they support further evaluation in a larger, fully powered RCT with more comprehensive engagement monitoring and longer follow-up.

Background: The COVID-19 pandemic left many people with persistent health problems following a COVID-19 infection. Research on the condition better known as Post-Covid Condition (PCC) is still inconclusive, and few evidence-based treatments are currently available, although several studies report promising results. There are however people in need of treatment and support.

Methods: To better understand what such help might entail, we conducted an online-based survey (n = 629, 82.6% women) to examine the impact of PCC in Sweden and explore relationships among various variables using correlation analysis. Swedish-speaking adults with at least one persisting health problem after COVID-19 were included in the study. The survey included demographic and psychosocial variables, historic COVID-19 data, other clinical measures of psychological distress, satisfaction with life, and daily functioning impairment.

Results: Results indicate a substantial and heterogeneous impact of PCC in this sample. Participants reported an average of 10.70 (SD = 5.62) symptoms with the most frequently reported being fatigue (90.9%, n = 507) and cognitive deficits (73.3%, n = 409). The highest average symptom burden scores were reported for post-exertional malaise (PEM; M = 8.37, SD = 1.70) and fatigue (M = 8.22, SD = 1.77). Medication, self-help advice, and physiotherapy were the most frequently reported treatment modalities. Most participants reported their problems being unchanged or improved after treatment, but there were reports of worsening as well. Regarding psychological distress, participants reported mild anxiety, moderate depression, and subclinical but notable levels of sleeping problems. On average, daily functioning was substantially impaired by PCC and participants reported being "somewhat dissatisfied with life". The correlational analyses revealed several significant correlations (|r| = 0.11-0.93, p < .01), with strongest relationships between the clinical variables.

Conclusions: While this study aimed to measure impacts of PCC in many different areas of life, it holds some limitations, and there are many questions remaining. We present several recommendations for methodology and future research topics. Identifying modifiable variables that can be used in developing a treatment is naturally a next step. Based on empiric evidence from similar conditions, psychological flexibility (PF) may be a promising one.

Introduction: Idiographic network analysis, assessing associations between a system of variables of interest, also called nodes, is a proposed method for personalizing psychological treatment. The aim of this study was to test the centrality hypothesis that a treatment condition delivering interventions guided by the most central network node will yield better outcomes compared to a treatment condition delivering interventions guided by the least central node. We tested this using perceived causal networks (PECAN) and focusing on psychological inflexibility processes. Effects were examined in terms of pain interference, motivation, and pain intensity.

Method: We used a single case design with multiple baselines across six participants. Therapists were blind to treatment conditions. While participants were not blind to the responses that they provided for creating the PECAN, they were blind to the resulting network and the treatment conditions. Randomization was applied to baseline length and to whether the most central node or the least central node intervention came first.

Results: All participants had at least one outcome changing in beneficial directions in line with hypotheses. However, two participants also had one outcome each that changed in contradiction to the hypotheses.

Discussion: Adapting psychological treatment by matching interventions to the most central node in a perceived causal network looks promising. However, it is unlikely that this method will always be the best matching method. We need to keep exploring additional personalization methods and under which circumstances they are efficient.

Background: Guided Internet-based Cognitive Behavioral Therapy (iCBT) typically involves text correspondence with a clinician who provides feedback and answers questions during the course of the treatment. Previous research indicates that therapist guidance can improve outcomes. A few studies show that therapists' type of feedback, and possibly participant's choice of questions, are associated with treatment adherence and outcome. While a small number of studies have been published on this topic, few has reported on both therapist and patient correspondence in the same study, and to our knowledge no studies have been published on correspondence in iCBT for patients with chronic pain. Aims: The aim of the current study was to characterize therapist-participant correspondence and to examine whether specific behaviors correlate with treatment adherence and/or clinical outcomes in a guided, individually tailored iCBT for individuals with chronic pain and psychological distress. Methods: Data were obtained from a previously published randomized controlled trial (Gasslander et al., 2022). The study included 1240 therapist messages and 609 participant messages, which were coded using two separate coding schemes. Proportions of coded behaviors were analyzed through correlations to explore associations between therapist-participant communication patterns, treatment adherence (defined as the number of completed treatment steps), and treatment outcomes (pre-to post treatment change scores). Results: Participant and therapist behaviors were identified and comparisons with previous studies revealed notable similarities and differences. Correlational analyses showed associations both between and within therapist and participant behaviors. No significant associations were observed between specific behaviors and outcome. However, several observed behaviors demonstrated significant correlations with treatment adherence. Conclusions: Distinct therapist and participant behaviors can be identified in guided iCBT for individuals with chronic pain. While the relationship with treatment outcome is unclear, adherence to treatment seems to be related to the specific types of behaviors exhibited in the text-based correspondence.

This study investigates whether data from people with endometriosis (n = 58) and fibromyalgia (n = 58) exhibit what is called "ergodicity," meaning that results from analyses of aggregated group data can be used to support conclusions about the individuals within the groups. The variables studied here are commonly investigated in chronic pain: pain intensity, pain interference, depressive symptoms, psychological flexibility, and pain catastrophizing. Data were collected twice daily for 42 days from each participant and analyzed in 2 ways: as separate cross-sectional group studies using the timepoints as the separate data sets (between-person) and as individual longitudinal studies using each person's time series data (within person). To confirm ergodicity, the results from the 2 analyses should agree. However, this is not what was observed in several respects. The between-person data showed substantially less variability compared with within-person data. This was evident in both the summary statistics involving single variables and in the correlational analyses. Overall, between-person correlations were relatively restricted in range, while within-person correlations varied widely. These findings have potentially profound implications for the field of chronic pain research. Because ergodicity was not found, this raises doubts around the assumption that aggregated data collected from groups can accurately represent the range of individual experiences in chronic pain. These results advocate for a shift toward inclusion of more individual person-focused approaches as an addition to group-based approaches. This shift could lead to more personalized and effective treatments by better capturing and then clarifying the heterogeneous nature of chronic pain, including the processes that underlie it.

BackgroundThe Multidimensional Psychological Flexibility Inventory (MPFI) is a measure of all facets of psychological flexibility and inflexibility, potentially important processes of change in psychological treatment for chronic pain. In some contexts, it can be considered too long. The aim of this study was, therefore, to validate a short form MPFI (MPFI-24P) in a chronic pain sample.MethodsAdults with chronic pain were recruited online (N = 404) for a cross-sectional survey study. They first completed pain background questions and the MPFI. For examining convergent construct validity and explained variance in pain-related outcomes, participants also completed the Brief Pain Inventory (BPI) Pain Interference Scale, the Work and Social Adjustment Scale (WSAS) and the Patient Health Questionnaire (PHQ-9), a depression measure. Data were collected on two occasions, 2 weeks apart. Item response theory (IRT) and confirmatory factor analysis (CFA) were used for selecting the best-performing items.ResultsIRT parameters were overall adequate, and hierarchical CFA demonstrated a good model fit. Network analysis of the MPFI items indicated that, in general, items intended to measure the same facets were substantially interconnected, more so for the inflexibility items. Temporal stability was adequate, and internal consistency was good. The MPFI-24P correlated with pain interference, work and social adjustment and depression, with the inflexibility scale better predicting these outcomes. The MPFI-24P correlated strongly with the full-length MPFI.ConclusionsThe MPFI-24P for chronic pain is generally valid and reliable, especially the inflexibility scale. It performs similarly to the full-length MPFI.SignificanceThis paper contributes with a measure that is both feasible to use in clinical practice and research, while being able to measure all facets of psychological flexibility and inflexibility-psychological processes of change that are important to evaluate in psychological treatment of chronic pain in order to better individualize treatment.

Fibromyalgia (FM) is associated with significant economic costs. Given the limited availability of effective and accessible treatments, it is crucial to develop and assess the cost-effectiveness of new interventions. This study aimed to evaluate the cost-effectiveness of online exposure therapy (EXP-CBT) versus online traditional CBT (TCBT) for FM. We analyzed health economic data from a randomized controlled trial in which 274 participants with FM were assigned to either EXP-CBT or T-CBT. The time horizon was 15 months, and treatment effectiveness relative to costs was evaluated from both a societal perspective (direct and indirect costs) and a health care perspective (direct medical costs only). Bootstrapped net benefit regression analyses were conducted to compare cost and effect differences between EXP-CBT and T-CBT under various willingness-to-pay scenarios. The results showed that the incremental cost-effectiveness ratio was -1477/0.09 = -$16,884 from the societal perspective, indicating that EXP-CBT was cost-effective. Each additional successfully treated case (treatment responder) in EXP-CBT compared to T-CBT was associated with lower costs and there was a 69% probability of EXP-CBT being cost-effective even at a willingness-to-pay threshold of $0. The cost-utility analysis resulted in an estimate of -1477/0.05 = -$28,763, also here with an 69% probability of EXP-CBT being cost-effective at a willingness-to-pay threshold of $0. There were no significant differences in total costs or effectiveness between EXP-CBT and T-CBT. In conclusion, online exposure therapy may be a cost-effective alternative to online traditional CBT, but there appears to be no marked cost- or effect differences between the two treatments. Perspective: This article presents a cost-effectiveness evaluation of online exposure therapy compared to online traditional CBT for fibromyalgia. Results indicate that online exposure therapy may be cost-effective compared to online traditional CBT. However, as there were no marked cost- or effect differences between the treatments, results should be interpreted with caution.

Introduction. Premenstrual dysphoric disorder (PMDD) is a cyclic mood disorder affecting around 2%–5% of women of reproductive age. Pharmacological interventions exist, but many patients with PMDD experience residual symptoms, discontinue medications or refrain from them due to side effects. Thus, non-pharmacological treatments are needed as an alternative or additive treatment strategy. Evidence indicates that cognitive behavioural therapy (CBT) is a promising candidate. However, further research is required to establish its efficacy and identify ways to improve the treatment. Specifically, incorporating components targeting emotional and interpersonal dysregulation could theoretically enhance its effects. Furthermore, increasing the generally low accessibility of CBT for PMDD necessitates scalable and cost-effective ways to deliver treatment. The current study aims to evaluate the effects and cost-effectiveness of an internet-delivered CBT (ICBT) intervention for PMDD incorporating skills training in emotion regulation and interpersonal effectiveness.

Methods and analysis. The study is a parallel two-group randomised controlled trial with 1:1 allocation to 8 weeks of therapist-guided ICBT or a waitlist control condition. Following recruitment and inclusion, 164 individuals aged 18–45 years who fulfil the Diagnostic Manual of Mental Disorders-5 criteria for PMDD will be randomly assigned to the two groups. Primary outcomes are pretreatment to post-treatment group differences in premenstrual symptoms and their impact on everyday life, as well as psychological and functional impairment during the premenstrual phase. Secondary outcomes include treatment effects on quality of life and difficulties in emotion regulation. Long-term treatment effects will be assessed 6 and 12 months postintervention. Data will be analysed using latent Gaussian process modelling and linear mixed models. The economic evaluation will analyse individual-level societal costs and outcomes between trial arms. Recruitment is expected to begin in February 2025, with study completion anticipated by February 2028.

Ethics and dissemination. The study has been approved by the Swedish Ethical Review Authority (2023-00655-01). Results will be disseminated via presentations and publications in international journals and national outlets for clinicians and patients with PMDD.