We’ve been very busy at AI-Therapy over the past few months. In this post we will summarize some of the new developments.

Icelandic TV Appearance

I was interviewed for the evening news in Iceland a few weeks ago:

During the interview I gave a demonstration of AI-Therapy’s social anxiety treatment program, and announced our new program in development called Overcome Fertility Related Stress (see below).

Fertility Survey

I have started working on a new treatment program for people who are struggling with the emotional aspects of conception and fertility problems. I’ve created a survey, and the information I gather will be used to ensure that the program is helpful for a wide range of people:

http://www.ai-therapy.com/treatments/fertility/

Those who participate in the survey will be given the opportunity to be beta testers for the program when it is ready.

AI-Therapy Site License for Clinics, Therapists and Other Organizations

Site licenses are now available for our social anxiety treatment program. More information can be found here:

http://www.ai-therapy.com/therapist-and-clinic-site-license

Overcome OCD

Ross Menzies and I are developing a treatment program for people who have Obsessive Compulsive Disorder. If you would like to be kept up to date on this project, please register your interest here:

http://www.ai-therapy.com/treatments/ocd/

Fjola Helgadottir, PhD, MClinPsych, is a clinical psychologist, a senior research clinician at the University of Oxford, and is a co-creator of AI-Therapy.com, an online CBT treatment program for overcoming social anxiety

Quality of life is worse if you have social anxiety

Quality of life measures provide clinicians with information about their client’s “real life”. What do I mean by mean by “real life”? This includes topics like health, self-esteem, goals and values, money, work, hobbies, learning, creativity, love, friends, family, community, etc. People are asked to subjectively assess how satisfied they are with these various categories. Study after study has shown that living with an anxiety disorder can have a significant negative impact in all of these areas. It is important for effective therapy to consider the broader implications of a disorder, rather than focus purely on the specific symptoms.

The World Congress of CBT

At the 7th World Congress of CBT I attended a symposium called “Quality of Life and Anxiety Disorders”. The presenters included leading authorities in CBT, such as Lars-Göran Öst (Sweden), Lisa Liberman (Chile) Ron Rapee (Australia) and Thomas Ollendick (Virginia, USA). I was very impressed with the talks. Several of these researchers are investigating complex topics. As we all know, life is chaotic and complicated, and when we have a better understanding of the intricacies of anxiety disorders we will be be able to devise better treatments.

Quality of life and anxiety disorders at the 7th world congress of CBT: Discussant Thomas Ollendick

The cultural component of social anxiety

As a social anxiety researcher, one study that I found particularly interesting was conducted by Professor Öst of Stockholm University. He compared a group of social anxious individuals from the USA with a similar group from Sweden. He found that social anxiety interfered more with people’s real lives in America.

I asked Professor Öst to speculate on why he thought this might be the case. He hypothesized that it is likely cultural. Being an introvert is perhaps more consistent with Swedish culture. On the other hand, American culture may place a higher value on outgoing personality types. This is not to say that socially anxious individuals do not suffer in Sweden; it is simply saying that there is a cultural component to anxiety disorders that we should consider. Professor Rapee added that similar findings have been found in studies comparing Asian cultures with Western cultures.

The good news for Americans with social anxiety is that there are effective treatments, and these treatments are known to improve overall quality of life. Perhaps this why we are seeing such a strong interest from the US in seeking online treatment with AI-Therapy’s social anxiety program.

Last month I attended the 7th World Congress for CBT in Lima, Peru. Conferences are a great way to get up to speed on the latest developments in a field, and this conference was no exception. Overall, the presentations made me very optimistic about the future of online therapy. There is a lot of exciting and encouraging research being conducted.

As part of a symposium on internet-based treatment, I presented some of the latest results from AI-Therapy’s Overcome Social Anxiety program:

Fjola presenting at the CBT world congress — Dr Fjola Helgadottir presenting AI-Therapy overcoming social anxiety at the CBT World Congress 2013

Investigation into real world treatment data

My presentation was somewhat unusual for an academic conference in that it was based on real world data. Typically, talks are based on carefully controlled trials. There is an important reason for this – one goal of a trial is to make the results reproducible by other researchers. This is a key aspect of scientific research. However, there is an important question that is often ignored: will the results translate into the real world? The real world is chaotic, users are not screened, users are not monitored, there is less control over the equipment used, etc. In the past it has been found that treatments that work well in a laboratory environment cease to have the same impact when they are released to the general population. One goal of my talk was to present data from a commercially available treatment program, and contrast this with the latest results from academic systems.

Visitors to the AI-Therapy website

Before continuing, I should mention that all AI-Therapy users are anonymous, and their results are kept strictly confidential. The only data I presented are aggregated, showing average scores across groups of users.

As can be seen in the slide above, we have had almost 20,000 unique visitors to the website since our launch about a year ago. The top 5 countries for visitors are:

USA
UK
Iceland
Australia
Canada

These results are roughly what I would expect. The US is our largest market, but a significant margin. The reason Iceland has made the top 3 is due to some media coverage we have received there.

Effective social anxiety treatment

In order to assess the efficacy of the Overcome Social Anxiety program, I determined its pre-post effect size. When using the program, users fill out a series of questionnaires before starting, and the same questionnaires after completion. The effect size is a standardized measures of the reduction in symptoms over this period (see this page for information about effect sizes, and effect size calculators).

The effect size for the first 19 people who completed all sections of the program was 1.7. An effect size of 0.2 is considered small, an effect size of 0.5 is considered medium, and effect size of 0.8 is considered large. Therefore, an effect size of 1.7 is very large. (It is important to note that this value has been calculated based on people who completed the whole program, and does not include people who started the program, but did not reach the end. We intend to write up a more detailed analysis, and release it as a white paper on this site. Please watch this space.) The primary conclusion is that online treatment programs for social anxiety can be an effective treatment strategy for real world patients.

I am already looking forward to the 8th CBT World Congress, which will be held in Melbourne Australia in 2016. I look forward to seeing the advances that will be made in the online therapy field over the next three years!

A recent study says “yes”!

Online therapy is an active and growing area of research in clinical psychology. In fact, there was a symposium devoted to the subject at the recent World Congress of CBT in Lima, Peru (which I was honoured to be a part of – to be covered in a future blog). Perhaps the most important question that researchers are trying to answer is: “Does online work as well as face to face therapy?”

This is a difficult question to answer since there are so many hidden variables. In fact, there is no universal answer, since it depends on the particular online system being examined, and the skill level of the therapists involved in the study. A better questions is “Can online therapy work as well as face to face therapy?” In other words, are there any online systems that can match the results of live therapists for a specific problem? According to a recent publication, the answer is “yes”!

A team of researchers from the University of Zurich published the following paper:

Birgit Wagner, Andrea B. Horn, Andreas Maercker. Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal of Affective Disorders. July 23, 2013. (see this link for more information)

The authors conducted a study involving 62 people with moderate depression. Half of the patients were treated using traditional CBT in-person techniques, and the other half were treated online. The authors found that at a three month follow up, the patients who were treated online had fewer symptoms of depression than the control group. In other words, the online treatment program actually performed better than the face to face therapy.

Advantages of online therapy

I have discussed some of the advantages of online therapy on this blog and in my publications. These include:

Clients can progress at their own pace
Clients have a complete record of their treatment, which they can revisit at any time
“Therapist drift” is a known phenomenon, where therapists move away from the best practices of a particular treatment over time. With online treatments, it is easier to enforce a consistent treatment, with the correct “dose” of clinical content delivered during each session.

Of course, online therapies have challenges of their own. In particular, it is more difficult to adapt the treatment towards the individual symptoms and needs of the users without therapist involvement. In fact, it is this problem of individual personalization that AI-Therapy’s social anxiety program attempts to address.

More studies are needed to fully investigate the strengths and weaknesses of online therapy. However, the study above adds to a growing body of evidence that online therapy has tremendous potential, and will play an important role in the future of mental health treatment.

Earlier this year I presented the Overcome Social Anxiety treatment program to my colleagues in the Department of Psychiatry at the University of Oxford. One of the questions from the audience was: How do you diagnose social anxiety in order to treat individuals? My answer: I don’t.

In the last blog I discussed the controversy around the new DSM-5. The goal of the DSM is to define the criteria for a formal diagnosis. In other words, it helps a practitioner determine whether or not person X has condition Y. I pointed out the shortcomings of this approach. In particular, the severity of a mental disorder is best measured using a continuous scale, rather than a binary classification.

A DSM diagnosis is important in a situation where a patient may be prescribed medication (recall that the DSM is published by the American Psychiatric Association). Most drugs have negative side effects, and they carry the risk of addiction. Therefore, taking medication for mild or moderate cases may not be a good idea. In this case, the DSM plays a vital role in determining who receives treatment. The DSM also plays a crucial role for clinical psychologists, as it guides the diagnosis and treatment of patients.

The situation for online self-help is different. For example, consider our Overcome Social Anxiety program. At the start of the program each user completes a series of standardized questionnaires (e.g. the “Fear of Negative Evaluation Scale” and the “Depression, Stress and Anxiety Scale”). The goal of this assessment is not a diagnosis. Rather, the goal is to determine where the user falls on the social anxiety spectrum prior to treatment. After the user completes the treatment program, they fill out the same questionnaires. The results are compared to the user’s pre-treatment results to see if their symptoms have improved.

We don’t require a diagnosis to use the program since people from along the whole social anxiety spectrum, from mild to severe, can benefit from treatment. The program uses online cognitive behavior therapy (CBT), which is known to be helpful in a wide range of cases. CBT involves revisiting thinking styles and behaviors. Unlike drugs, there are no negative side effects of CBT. Therefore, it can help everyone make better choices in their day to day life. This typically leads to an overall improvement in happiness and confidence, regardless of a DSM diagnosis.

How are social anxiety and depression related?

Social anxiety and depression often occur together, and research has shown that targeting social anxiety can lead to an overall increase in mood and happiness. In this blog we look at an example of how the two can be connected.

A thought pattern that can be a contributing factor to depression is rumination. Let’s consider the following scenario: you’ve been to an evening party, and the first thought that pops into your head the next morning is “Oh no, did I really say that? I wish I hadn’t – I may have offended someone.” You continue to dwell on the thought, and over time your feelings of anxiety amplify. Eventually, you convince yourself that it was a terrible scene, and you become angry and upset.

Rumination following social situations is a common symptom of social anxiety. The social anxiety is leading you to (a) set unrealistic expectations for yourself, and (b) over-analyze the event after the fact. By targeting social anxiety, you will be less likely to ruminate, and therefore spend less time being self-critical.

As a side note, this is consistent with the results that we are observing with our social anxiety program. In particular, there is a (statistically significant) decrease in symptoms of low mood for those who complete the program. Dealing with social anxiety can have follow-on effects that lead to a happier, more fulfilling life.

There is a well known 2011 study that looks at the brains of London taxi drivers. The map of London is complex, and taxi drivers are required to memorize the complete layout and pass a difficult exam before being given their taxi license. The study found that the hippocampus region of the brain, which plays an important role in memory, actually grows (in a physical sense) while the prospective drivers are studying for the exam. This is an interesting result since it clearly shows that our actions can make real, measurable changes to our brains.

Can you change your brain with therapy?

In short, yes.

Some people view psychological treatments as “softer” than using medication, since drugs can directly target neurochemical aspects of the brain. However, this view is unjustified, since there is mounting evidence that therapy can make very real structural changes to the brain. A great example is CBT.

Cognitive behavior therapy (CBT) is an evidence-based approach to tackling mental health problems, such as anxiety or depression. CBT has been subject to countless clinical trials, and has even been shown to be more effective than medication in some long-term studies. CBT works by targeting the thoughts and behaviours that are maintaining the problem (more information about CBT, and how it can be administered online, can be found here). For example, consider someone who has social anxiety and would like to ask their boss for a raise or promotion. This would be extremely stressful situation for them, and they would likely put it off indefinitely. CBT treatment would examine the thoughts that are leading to this avoidance, and would challenge them through a series of exercises. In much the same way that physical exercise changes the body, these mental exercises can make changes to the structure of your brain!

How does CBT change the brain?

The fact that CBT changes the brain is not a particularly new result. However, neuroscience journals tend to announce findings with headlines like “The neurobiological role of the dorsolateral prefrontal cortex in…”. The details are complex, but the general idea is understandable in surprisingly basic terms.

The brain is divided into different regions or modules, each of which is specialized to perform a certain type of task. For example, the visual cortex is the region of the brain that processes the sensory input from the eyes. There are some brain structures that deal with emotions such as stress and fear, and collectively these are sometimes known as the “emotional brain”. These are very “old” areas of the brain, in the sense that we share them with our distant ancestors. When a socially anxious person is nervous when thinking about asking for a raise, it is the emotional brain that is becoming active.

There are higher order brain structures that deal with planning, logic and reasoning. These are sometimes known as the “logical brain”. These brain areas, such as the prefrontal cortex, are “newer” in the sense that they are much larger in primates than in other species. There are two key points:

The logical brain is able to override the emotional brain. For example, our socially anxious person can take a rational look at the situation, and realize that he or she is exaggerating the potential risks. He or she might come to the conclusion “the worst case scenario is that the boss says no – that’s not the end of the world!” This thought will help them calm down, and build the confidence to actually ask for the raise.
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Every time the logical brain overrides the emotional brain, the logical brain “muscle” becomes stronger and stronger. In other words, through CBT training the brain actually reinforces the neural pathways, so it becomes easier and easier to deal with future stressful situations.