Published: 28-04-2020 13:51 | Updated: 28-04-2020 14:22

Online CBT is effective for excessive worry

Researchers at Karolinska Institutet, Sweden have developed an online Cognitive Behavioural Therapy (CBT) program for people who struggle with excessive worry.

In one of the largest comparative studies for worriers conducted to date researchers at the Department of Clincial Neuroscience, Karolinska Institutet randomized 311 individuals with excessive worry to either online CBT, stress-management training or a waiting-list. In addition to being highly cost effective, the online CBT was superior to both stress-management and the wait-list, with 63% of the participants in the online CBT group experiencing large reductions in the frequency of worry.

Närporträtt av Erik Andersson utanför Aula Medica.

Treating  excessive worry via the Internet

A large number of trials have shown that psychological treatments delivered via the internet are as effective as traditional face-to-face approaches. Patients access the treatment via a secure internet platform which includes a messaging system for maintaining contact with a psychologist throughout the treatment.

- This has the potential to increase scalability and reach individuals who would not otherwise receive care. Due to the Covid-19 crisis, many individuals experience excessive worry but are unable to meet with a therapist right now. At least for some people, this treatment may be a viable option says first author Erik Andersson, researcher and clinical psychologist at the Department of Clinical Neuroscience, Karolinska Institutet,

Why worry?

Worry is often described as intrusive thoughts and images about possible future events.

- Worry can serve a very valuable function for us as worrisome thoughts about potential future threats  can motivate us to take precautionary measures to either prevent or minimize the impact of any possible future threats. However, when an individual gets stuck in this cognitive process they experience high levels of distress and their ability to function can suffer Dr. Andersson explains.

Less focus on psychiatric diagnoses

As excessive worry is a central feature of many psychiatric conditions, and is experienced by people without a disorder, the target population for this trial was individuals with excessive worry rather than a particular disorder(s). Individuals with a wide range of comorbid conditions were included in the trial, and about one-fourth of the participants did not fulfil criteria for any psychiatric disorders but experienced excessive worry only.

- If you only recruit people who meet criteria for one or more psychiatric disorders, you are going to miss a lot of the excessive worriers. We know that many different psychiatric and physical disorders that people don’t usually associate with excessive worry, have worry as a central or associated feature. So while individuals with anxiety disorders, OCD, and PTSD are known to suffer from bouts of excessive worry, so do individuals with various forms of depression, with insomnia, psychosis and neurodevelopmental disorders, and with chronic pain and other physical conditions and diseases. However, one of the largest group of excessive worriers are individuals with no psychiatric disorders. Although the content of worrisome thoughts may differ across disorders and individuals, the function of worry is often the same, and we can help reduce the frequency and distress associated with these worries says Dr. Andersson.

Worry seen as an endless tennis game

The treatment used in the trial was based on a self-help book, where excessive worry is described as an interplay between two types of cognitions; catastrophic thoughts and comforting thoughts. Catastrophic thoughts are intrusive and anxiety provoking thoughts about uncertain past or future events, while comforting thoughts are thoughts with the primary function of relieving the discomfort evoked by the catastrophic thoughts. While comforting thoughts can provide some relief from the catastrophic thoughts and feelings of distress, this relief is short-lived and the individual gets stuck in a cycle of catastrophic and comforting thoughts.

In the online CBT treatment used in the current study, participants were instructed to break the cycle of catastrophic and comforting thoughts that underpin excessive worrying through exposure exercises.

As Dr Andersson explains, - When your imagination serves up a catastrophic thought, our natural instinct is to respond immediately, usually with some comforting thought. To break this endless cognitive tennis game, it’s best not to return the serve.

The study was financed with support from the Fredrik and Ingrid Thuring Foundation.


The paper was recently published in Psychological Medicine.


Erik Andersson Assistant Senior Lecturer