Internet interventions have gained popularity and the idea is to use them to increase the availability of psychological treatment. Research suggests that internet interventions are effective for a number of psychological disorders with effect sizes comparable to those found in face-to-face treatment. However, when provided as an add-on to treatment as usual, internet interventions do not seem to provide additional benefit. Furthermore, adherence and dropout rates vary greatly between studies, limiting the generalizability of the findings. This underlines the need to further investigate differences between internet interventions, participating patients, and their usage of interventions. A stronger focus on the processes of change seems necessary to better understand the varying findings regarding outcome, adherence and dropout in internet interventions. Thus, the aim of this dissertation was to investigate change processes in internet interventions and the factors that impact treatment response. This could help to identify important variables that should be considered in research on internet interventions as well as in clinical settings that make use of internet interventions. Study I (Chapter 5) investigated early change patterns in participants of an internet intervention targeting depression. Data from 409 participants were analyzed using Growth Mixture Modeling. Specifically a piecewise model was applied to model change from screening to registration (pretreatment) and early change (registration to week four of treatment). Three early change patterns were identified; two were characterized by improvement and one by deterioration. The patterns were predictive of treatment outcome. The results therefore indicated that early change should be closely monitored in internet interventions, as early change may be an important indicator of treatment outcome. Study II (Chapter 6) picked up on the idea of analyzing change patterns in internet interventions and extended it by using the Muthen-Roy model to identify change-dropout patterns. A sligthly bigger sample of the dataset from Study I was analyzed (N = 483). Four change-dropout patterns emerged; high risk of dropout was associated with rapid improvement and deterioration. These findings indicate that clinicians should consider how dropout may depend on patient characteristics as well as symptom change, as dropout is associated with both deterioration and a good enough dosage of treatment. Study III (Chapter 7) compared adherence and outcome in different participant groups and investigated the impact of adherence to treatment components on treatment outcome in an internet intervention targeting anxiety symptoms. 50 outpatient participants waiting for face- to-face treatment and 37 self-referred participants were compared regarding adherence to treatment components and outcome. In addition, outpatient participants were compared to a matched sample of outpatients, who had no access to the internet intervention during the waiting period. Adherence to treatment components was investigated as a predictor of treatment outcome. Results suggested that especially adherence may vary depending on participant group. Also using specific measures of adherence such as adherence to treatment components may be crucial to detect change mechanisms in internet interventions. Fostering adherence to treatment components in participants may increase the effectiveness of internet interventions. Results of the three studies are discussed and general conclusions are drawn. Implications for future research as well as their utility for clinical practice and decision- making are presented.

The forward testing effect refers to the finding that retrieval practice of previously studied information enhances learning and retention of subsequently studied other information. While most of the previous research on the forward testing effect examined group differences, the present study took an individual differences approach to investigate this effect. Experiment 1 examined whether the forward effect has test-retest reliability between two experimental sessions. Experiment 2 investigated whether the effect is related to participants’ working memory capacity. In both experiments (and each session of Experiment 1), participants studied three lists of items in anticipation of a final cumulative recall test. In the testing condition, participants were tested immediately on lists 1 and 2, whereas in the restudy condition, they restudied lists 1 and 2. In both conditions, participants were tested immediately on list 3. On the group level, the results of both experiments demonstrated a forward testing effect, with interim testing of lists 1 and 2 enhancing immediate recall of list 3. On the individual level, the results of Experiment 1 showed that the forward effect on list 3 recall has moderate test-retest reliability between two experimental sessions. In addition, the results of Experiment 2 showed that the forward effect on list 3 recall does not depend on participants’ working memory capacity. These findings suggest that the forward testing effect is reliable at the individual level and affects learners at a wide range of working memory capacities alike. The theoretical and practical implications of the findings are discussed.

Objective Our study investigated body image representations in female patients with anorexia nervosa and healthy controls using a size estimation with pictures of their own body. We also explored a method to reduce body image distortions through right hemispheric activation. Method Pictures of participants’ own bodies were shown on the left or right visual fields for 130 ms after presentation of neutral, positive, or negative word primes, which could be self-relevant or not, with the task of classifying the picture as “thinner than”, “equal to”, or “fatter than” one’s own body. Subsequently, activation of the left- or right hemispheric through right- or left-hand muscle contractions for 3 min., respectively. Finally, participants completed the size estimation task again. Results The distorted “fatter than” body image was found only in patients and only when a picture of their own body appeared on the right visual field (left hemisphere) and was preceded by negative self-relevant words. This distorted perception of the patients’ body image was reduced after left-hand muscle contractions (right hemispheric activation). Discussion To reduce body image distortions it is advisable to find methods that help anorexia nervosa patients to increase their self-esteem. The body image distortions were ameliorated after right hemispheric activation. A related method to prevent distorted body-image representations in these patients may be Eye Movement Desensitization and Reprocessing (EMDR) therapy.

Salivary alpha-amylase (sAA) influences the perception of taste and texture, features both relevant in acquiring food liking and, with time, food preference. However, no studies have yet investigated the relationship between basal activity levels of sAA and food preference. We collected saliva from 57 volunteers (63% women) who we assessed in terms of their preference for different food items. These items were grouped into four categories according to their nutritional properties: high in starch, high in sugar, high glycaemic index, and high glycaemic load. Anthropometric markers of cardiovascular risk were also calculated. Our findings suggest that sAA influences food preference and body composition in women. Regression analysis showed that basal sAA activity is inversely associated with subjective but not self-reported behavioural preference for foods high in sugar. Additionally, sAA and subjective preference are associated with anthropometric markers of cardiovascular risk. We believe that this pilot study points to this enzyme as an interesting candidate to consider among the physiological factors that modulate eating behaviour.

The forward effect of testing refers to the finding that retrieval practice of previously studied information increases retention of subsequently studied other information. It has recently been hypothesized that the forward effect (partly) reflects the result of a reset-of-encoding (ROE) process. The proposal is that encoding efficacy decreases with an increase in study material, but testing of previously studied information resets the encoding process and makes the encoding of the subsequently studied information as effective as the encoding of the previously studied information. The goal of the present study was to verify the ROE hypothesis on an item level basis. An experiment is reported that examined the effects of testing in comparison to restudy on items’ serial position curves. Participants studied three lists of items in each condition. In the testing condition, participants were tested immediately on non-target lists 1 and 2, whereas in the restudy condition, they restudied lists 1 and 2. In both conditions, participants were tested immediately on target list 3. Influences of condition and items’ serial learning position on list 3 recall were analyzed. The results showed the forward effect of testing and furthermore that this effect varies with items’ serial list position. Early target list items at list primacy positions showed a larger enhancement effect than middle and late target list items at non-primacy positions. The results are consistent with the ROE hypothesis on an item level basis. The generalizability of the ROE hypothesis across different experimental tasks, like the list-method directed-forgetting task, is discussed.