Can we modify maladaptive attributions for fatigue?

Research has shown that those with insomnia focus primarily on their sleep as a cause of daytime fatigue rather than the multitude of other possible causes of fatigue. This can create sleep-related anxiety and further perpetuate the sleep disturbance. In order to lessen the increased focus on sleep, the present study investigated whether people could learn to consider other attributions for fatigue via an information-based manipulation. Undergraduate students (N = 88) were randomized to two information groups: They either received information about common factors that could explain daytime fatigue (the fatigue information condition) or received generic sleep-related information (the control condition). Each group was tested pre- and post-intervention. Fatigue information participants were significantly more likely to consider non-sleep-related attributions for fatigue at post-intervention, relative to control participants. These results demonstrate that attributions for fatigue may be amenable to change via an information-based intervention; thus, this research explores a preliminary step toward investigating refinements to insomnia treatments.     

The role of sleep-related beliefs to improvement in early cognitive behavioral therapy for insomnia

The aim of this investigation was to examine whether sleep-related beliefs, and reductions in such beliefs and attitudes, were related to clinical improvements in sleep and daytime symptoms after cognitive behavioral therapy (CBT). In total, 64 patients with a short history of insomnia (3-12 months) who had participated in a randomized controlled trial with a 1-year follow-up and received CBT were included. With stepwise multiple regression analyses, sleep-related beliefs were linked to clinical improvements in sleep (five outcomes) and daytime symptoms (seven outcomes). Results indicated that sleep-related beliefs played a small predictive role in clinical improvements in sleep and daytime symptoms after CBT group treatment. Sleep-related beliefs were predictive of treatment response only with regard to sleep efficiency and sleepiness. Reductions in sleep-related beliefs were, however, differently related to improvements in sleep and daytime symptoms. Reductions in such beliefs were consistently linked to improvements in daytime symptoms (7-14% of the variance) but not to sleep improvements (except for sleep quality). In all, this might suggest that sleep-related beliefs play a slightly different role in insomnia than previously envisioned.     

Sleep-Related Outcomes Following Early Intervention for Childhood Anxiety

A bidirectional relationship between sleep and anxiety is well-established whereby difficulties in one domain predict problems in the other. Interventions for childhood sleep-related problems also share considerable overlap with interventions for anxiety. Although anxious youth report high rates of sleep-related problems, it is relatively unknown whether anxiety-focused interventions for children produce improvements in sleep-related problems. The current study included N = 25 youth ages 7–16 (13 female; mean age 9.92 years ± 2.6) who participated in an early intervention program for anxiety as part of the Arizona Anxiety Resilience Building Project. Child and parent measures of sleep and anxiety symptoms were examined before and after the 12-week cognitive-behavioral intervention program. Statistically significant decreases in total sleep-related problems, bedtime resistance, sleep anxiety, and pre-sleep arousal were observed at post-intervention, though clinically meaningful change was apparent in only a small portion of the sample. Results suggest that purely anxiety-focused interventions may be useful for reducing certain types of sleep-related problems in anxious children, specifically those that occur during the bedtime/pre-sleep period. However, a lack of clinically meaningful change, in addition to post-intervention sleep-related problem scores above the clinical cut-off in a large proportion of the sample, suggest that the sleep-related problems of anxious youth may require direct attention as part of treatment.     

Psychometric properties of an insomnia-specific measure of worry: the Anxiety and Preoccupation about Sleep Questionnaire

The aim of this study was to examine the psychometric properties of the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), with a focus on factorial validity and internal consistency as well as discriminative, convergent, and association with sleep parameters and daytime impairment. Among a randomly selected sample from the general population (N = 5,000), 2,333 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1800 participants who did not fulfill criteria for another sleep disorder than insomnia. A two-factor solution, accounting for 70.7% of the variance, was extracted from the 10 APSQ items. One six-item factor determined worries about the consequences of poor sleep (α = .91); the second factor, with four items, assessed worries about the uncontrollability of sleep (α = .86). The two factors were significantly intercorrelated (ρ = .65) and significantly associated with the total APSQ (ρs = .97 and .76, respectively). The APSQ and the two subscales showed discriminant validity between three sleep status groups (normal sleep, poor sleep, and insomnia disorder; R(2) = .33-.41). The APSQ and the subscales demonstrated convergent validity with measures on cognitive arousal, sleep-related beliefs, anxiety, and depression. They also were significantly correlated with sleep parameters and daytime impairment. The findings suggest that the APSQ is a psychometrically sound instrument for assessing worry in insomnia.     

Misperception of sleep can adversely affect daytime functioning in insomnia

This experiment was designed to investigate the relationship between subjective perception of sleep and daytime processes in primary insomnia. Twenty-two individuals with primary insomnia received positive or negative feedback about their sleep, immediately on waking, on three consecutive mornings. The positive feedback was that last night's sleep was good quality. The negative feedback was that last night's sleep was poor quality. Objective sleep on each of the three nights was estimated by actigraphy and did not differ across the three nights or the two feedback conditions. Negative feedback (based on 32 nights of data) was associated with more negative thoughts, sleepiness, monitoring for sleep-related threat, and safety behaviours during the day, relative to positive feedback (based on 34 nights of data). These results indicate that the impaired daytime functioning reported by insomnia patients is maintained, at least in part, by subjective perception of sleep.     

Effects of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study

OBJECTIVE: Sleep disturbances are a core feature of post-traumatic stress disorder (PTSD), and are often resistant to first-line pharmacological and psychological PTSD interventions. The goal of this pilot study was to explore the effects of a very brief intervention for PTSD-related nightmares and insomnia in victims of violent crimes with PTSD. METHODS: Seven adult victims of violent crimes with a current diagnosis of PTSD received a single, 90-min intervention session that used cognitive-behavioral techniques aimed at reducing post-traumatic nightmares and insomnia. Sleep diary measures, and measures of sleep quality, PTSD severity, anxiety, and depression were completed at baseline and 6 weeks post-intervention. RESULTS: Improvements in self-report and sleep diary measures of sleep quality and dream frequency were observed post-intervention. Clinically meaningful reductions in daytime PTSD symptom severity were also observed. CONCLUSIONS: A very brief behavioral intervention targeting post-traumatic nightmares and insomnia was associated with significant improvements in sleep and daytime PTSD symptom severity. Brief sleep-focused intervention may be helpful adjuncts to first-line PTSD treatments.     

A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility,Acceptability, and Potential Efficacy

Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28–55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = −0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = −1.1, p = .001), sleep onset latency (d = −0.6, p = .021), global sleep quality (d = −0.9, p = .002), and depression symptoms (d = −0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.     

Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia?

Dysfunctional beliefs and attitudes about sleep are presumed to play an important mediating role in perpetuating insomnia. The present study evaluated the impact of cognitive-behavioral and pharmacological treatments for insomnia on sleep-related beliefs and attitudes and the relationship between those changes and sleep improvements. The participants were older adults with chronic and primary insomnia. They received cognitive-behavior therapy (CBT), pharmacotherapy (PCT), combined CBT+PCT (COMB), or a medication placebo (PLA). In addition to daily sleep diaries and sleep laboratory measures, the participants completed the dysfunctional beliefs and attitudes about sleep scale (DBAS) at baseline and posttreatment, and at 3-, 12- and 24-month follow-up assessments. The results showed that CBT and COMB treatments produced greater improvements of beliefs and attitudes about sleep at posttreatment than PCT and PLA. Reductions of DBAS scores were significantly correlated with improvements of sleep efficiency as measured by daily sleep diaries and by polysomnography. In addition, more adaptive beliefs and attitudes about sleep at posttreatment were associated with better maintenance of sleep improvements at follow-ups. These findings highlight the importance of targeting sleep-related beliefs and attitudes in the treatment of insomnia.     

Psychometric properties of the Insomnia Catastrophizing Scale (ICS) in a large community sample

ABSTRACT

The purpose was to investigate the psychometric properties of the Insomnia Catastrophizing Scale (ICS) including factorial validity and internal consistency as well as discriminative and convergent validity. Associations with sleep parameters and daytime impairment are also examined. Drawn from a randomly selected sample of the general population, 1615 participants completed a survey on insomnia-related nighttime and daytime symptoms, health outcomes and psychological processes, including the ICS. A one-factor solution was supported for both the nighttime catastrophizing (11 items) and daytime catastrophizing (6 items) subscales. Both subscales displayed high internal consistencies (α > 0.90) and accounted for 59.1–70.1% of the variance. The insomnia disorder group had significantly higher scores than participants without insomnia on the two subscales and on the individual items. Cutoffs were established for both subscales with acceptable sensitivity and specificity. Both subscales displayed adequate convergent validity with measures indexing worry, cognitive pre-sleep arousal and anxiety. The two subscales were also significantly associated with nighttime and daytime insomnia symptoms. The ICS is a reliable and valid scale for the assessment of insomnia-related catastrophizing. Future research is needed to examine the test-retest reliability and treatment sensitivity of the ICS.     

The utility of the Pittsburgh Sleep Quality Index in US military personnel

Sleep disturbances are endemic in military personnel with nonclinical populations averaging 6 hours of sleep. The Pittsburgh Sleep Quality Index (PSQI), however, has not been validated in this population. It is thus unknown if the PSQI can differentiate clinically significant sleep disorders from sleep disturbances resulting from military duties with restricted sleep periods. After a clinical evaluation and polysomnogram, participants (N = 148) were classified as having insomnia only, obstructive sleep apnea (OSA) only, comorbid insomnia and OSA (CIO), service-related illnesses only (SRI–; pain, depression, posttraumatic stress disorder, traumatic brain injury), and controls. Military personnel in the insomnia only, and the CIO groups had higher PSQI scores (13.5 ± 2.8 and 14.7 ± 3.5, respectively) compared to the controls (8.9 ± 3.9). A cut-off score of ≥10 was optimal (90% sensitivity and 69% specificity) for determining clinically significant insomnia (≥12 for CIO; 84% sensitivity, 77% specificity). In military personnel, a PSQI score >5 is not necessarily indicative of a clinically significant sleep disorder. The use of elevated cut-off PSQI scores are likely better suited to differentiate military personnel who require further clinical evaluation versus a more conservative sleep improvement protocol.     

Psychological mechanisms in the maintenance of insomnia: arousal, distress, and sleep-related beliefs

The purpose of this study was to examine whether arousal, distress, and sleep-related beliefs are related to the maintenance of insomnia. From a randomly selected sample from the general population (n=3600), 1936 participants filled out a baseline and 1-year follow-up survey. Logistic regressions were used to investigate whether arousal, distress, and beliefs were related to sleep status (insomnia: n=116; poor sleep: n=222; normal sleep: n=529; good sleep: n=234) over 1 year. Cluster analysis was employed to assess whether it was possible to classify the participants based on their profiles of psychological functioning. The results showed that beliefs in the long-term negative consequences of insomnia, anxiety, depression, and arousal were significantly related to the maintenance of insomnia (18-72% of the variance). Of the individuals with persistent insomnia, 91% belonged to a cluster characterized by high scores on sleep-related beliefs, anxiety, depression, and arousal, and 9% to a cluster defined by low scores on the mechanisms. This study shows that sleep-related beliefs, anxiety, depression, and arousal are related to the maintenance of persistent insomnia, but also that these mechanisms often co-occur in individuals with insomnia.     

A cognitive model of insomnia

Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.     

Rethinking safety behaviors in insomnia: examining the perceived utility of sleep-related safety behaviors

Harvey's cognitive model of insomnia (2002a) proposes that sleep-related safety behaviors play a central role in the maintenance of insomnia because such maladaptive coping strategies are thought to reinforce threat-based appraisals of the likelihood and consequences of poor sleep. Research to date has assessed the frequency of safety behavior use in those with insomnia only; however, in addition to the frequency of occurrence, the function of safety behaviors (i.e., a belief that they will prevent a feared outcome from occurring), may be an important consideration. The purpose of this study was to examine sleep-related safety behaviors based on an expanded theoretical understanding of such behaviors across psychological disorders; that is, by examining both their frequency and perceived utility. Undergraduate students (N = 376) completed an online survey about their sleep, mood, and use of sleep-related safety behaviors. Insomnia severity was associated with a greater perceived need to use safety behaviors (i.e., utility) but not with frequency of safety behavior use. Higher perceived utility of safety behaviors was also associated with unhelpful beliefs about sleep, fear and avoidance of fatigue, and both general and sleep-specific helplessness. These results suggest that these behaviors and the associated underlying maladaptive beliefs may be important targets in cognitive behavioral therapy for insomnia. The current study extends the existing literature and refines the concept of safety behaviors in insomnia to include both the function and frequency of these behaviors.     

Cognitive-behavioral therapy for insomnia in alcohol dependent patients: a randomized controlled pilot trial

In a randomized controlled trial, we evaluated the efficacy of cognitive-behavioral treatment for insomnia to improve sleep and daytime symptoms, and to reduce relapse in recovering alcohol dependent (AD) participants. Seventeen abstinent AD patients with insomnia (6 women, mean age 46.2 ± 10.1 years) were randomized to 8 sessions of cognitive-behavioral treatment for insomnia for AD (CBTI-AD, n = 9) or to a behavioral placebo treatment (BPT, n = 8). Subjective measures of sleep, daytime consequences of insomnia and AD, alcohol use, and treatment fidelity were collected at baseline and post-treatment. Diary-rated sleep efficiency and wake after sleep onset, and daytime ratings of General Fatigue on the Multidimensional Fatigue Inventory improved more in the CBTI-AD compared to the BPT group. In addition, more subjects were classified as treatment responders following CBTI-AD. No group differences were found in the number of participants who relapsed to any drinking or who relapsed to heavy drinking. The findings suggest that cognitive-behavioral insomnia therapy benefits subjective sleep and daytime symptoms in recovering AD participants with insomnia more than placebo. The benefits of treating insomnia on drinking outcomes are less apparent.     

Cognitive-behavioural Analysis and 1 reatment ot Insomnia

Abstract

Insomnia is a condition characterized by subjective complaints of insufficient sleep and poor daytime functioning. Objective measures of sleep and daytime functioning, however, seldom show evidence of a similar degree of dysfunction. Most insomniacs, for example, do not suffer from sleep deprivation or daytime sleepiness. This discrepancy between subjective and objective measures of sleep and daytime functioning suggests that cognitive factors may play a central role in persistent insomnia. In particular, it is argued that fears about insufficient sleep and its adverse daytime consequences tend to interfere with sleep, thereby causing a vicious cycle which serves to maintain the insomnia. It is also argued that perfectionist standards and other dysfunctional beliefs may predispose people to these kinds of fears. Finally, existing models for cognitive-behavioural treatment of insomnia are criticized for being almost exclusively focused on the night-time aspects of insomnia. If insomnia is maintained by various kinds of vicious cycles involving fears, beliefs, and standards with regard to daytime functioning, these daytime aspects of insomnia should receive more attention in cognitive-behavioural treatment.     

Epidemiology of Insomnia in College Students: Relationship With Mental Health,Quality of Life,and Substance Use Difficulties

The purpose of this study was to evaluate the prevalence and correlates of insomnia using rigorous diagnostic criteria and a comprehensive assessment battery. In a large sample (N = 1,074) of college students (mean age 20.39 years), participants were asked to complete a week-long sleep diary and comprehensive questionnaire packet assessing recommended daytime functioning domains (i.e., fatigue, quality of life, depression, anxiety, stress, academic performance, substance use) during the academic year. A significant portion of this sample of college students met proposed DSM-5 criteria for chronic insomnia (9.5%). The chronic insomnia group reported significantly worse sleep, fatigue, depression, anxiety, stress, and quality of life, and greater hypnotic and stimulant use for sleep problems. There were no differences between groups on excessive daytime sleepiness, academic performance, or substance use. This was a rigorous and comprehensive assessment of the prevalence and psychosocial correlates of insomnia. Insomnia is a significant problem in college students and should be regularly assessed. More research is also needed to guide treatment in this population.     

Assessing the effect of a Cognitive Behaviour Therapy (CBT)-based workshop on work-related rumination,fatigue, and sleep

This quasi-experimental longitudinal study assessed the effect of a one-day Cognitive Behaviour Therapy (CBT)-based workshop on work-related rumination, chronic fatigue, and sleep quality. We hypothesized that participants who attended the workshop would report lower levels of affective work-related rumination, chronic fatigue, and improved sleep quality, at follow-up, 6 months after workshop completion. Two hundred and twenty-seven participants took part in the study, with 102 participants attending a one-day workshop delivered in their workplace. Participants completed an online questionnaire at two time-points, with follow-up occurring 6 months after initial survey completion. Results showed that participants who took part in the CBT workshop reported significantly lower levels of affective rumination (p = .03) and chronic fatigue (p = .003), at follow-up in comparison with individuals who did not attend the workshop; however, there were no significant differences between the groups in self-reported sleep quality (p = .06). A combination of more effective recovery both at work and outside of work may explain the reductions in both affective rumination and fatigue over time. This study adds to the recovery from work literature by providing initial support for a one-day CBT-based workshop delivered in the workplace.     

Correlates of general quality of life are different in patients with primary insomnia as compared to patients with insomnia and psychiatric comorbidity

Chronic insomnia is known to have a negative influence on quality of life (QOL). To date, most studies on chronic insomnia have focused on health-related aspects of QOL. General QOL, which is a different construct, has not been studied in detail. Moreover, it is not known which factors are associated with general QOL in insomnia, and whether the presence of mental disorders, a condition known as comorbid insomnia, affects these variables. The present study focused on identifying sleep and psychosocial variables that might be associated with general QOL in primary and comorbid insomnia. Personality traits, coping variables, anxiety and depressive symptoms, fatigue and subjective sleep variables were assessed in 218 consecutive well-characterized patients with primary and comorbid insomnia, referred to a third line centre for sleep medicine. In primary insomnia, higher extraversion and lower discrepancies in social support were associated with higher QOL. Surprisingly, insomnia severity was not significantly associated with QOL in this group. However, lower fatigue, which can be seen as an important daytime consequence of insomnia was correlated with higher QOL in patients with primary insomnia. In both insomnia groups, low anxiety and depressive symptoms and low fatigue were associated with higher general QOL. In contrast with the primary insomnia group, lower insomnia severity was correlated with higher QOL in patients with comorbid insomnia. These results stress the importance of assessing and treating daytime fatigue in insomnia. In primary insomnia, improving social support might be an important treatment goal. Furthermore, this study supports the concept that treatment of insomnia should not be neglected in patients with comorbid insomnia. Indeed, both insomnia and indices of psychiatric disease are strongly associated with general QOL in this condition.     

Cognitive-behavioral therapy of insomnia: A clinical case series study of patients with co-morbid disorders and using hypnotic medications

Cognitive-behavioral therapy for insomnia (CBTi) has demonstrated considerable efficacy within randomized clinical trials and case-series designs. This case-series study in a community sleep medicine clinic assessed the effectiveness of an eight-session CBTi protocol chronic insomnia patients who were allowed to continue their use of hypnotics (intent-to-treat n = 48), administered by a clinical psychology doctoral student receiving training and supervision in CBTi by a behavioral sleep medicine certified clinician. Outcome measures included daily sleep diaries, self-report measures on insomnia severity, dysfunctional beliefs and attitudes about sleep, daytime sleepiness, as well as medication usage. Patients showed significant improvements in sleep onset latency, wake time after sleep onset, sleep efficiency, insomnia severity, and dysfunctional sleep beliefs from pre- to post-treatment. No changes were seen in daytime sleepiness - patients were not excessively sleepy either before or after treatment. Use of sleep medication declined significantly from 87.5% pre-treatment to 54% post-treatment, despite no active efforts to encourage patients to withdraw. Results demonstrate that a CBTi conducted in a community sleep medicine clinic with patients not required to discontinue sleep-related medications can have similar effects as therapy delivered among those not on medication.     

Group Cognitive-Behavioral Therapy for Insomnia in a VA Mental Health Clinic

Effective cognitive-behavioral therapies for insomnia have been developed over the past 2 decades, but they have not been systematically evaluated in some clinical settings. While insomnia is common among veterans with mental health problems, the availability of effective treatments is limited. We report on the group application of a cognitive-behavioral therapy for chronic insomnia in a veteran population with significant comorbidity for both psychiatric problems and chronic medical conditions. Outcome measures were obtained for both sleep (via sleep diaries) and daytime functioning. Substantial posttreatment improvements were evident for measures of sleep consolidation, total sleep time, depression, anxiety, and fatigue. The unique suitability of the group therapy approach with this population is discussed. Controlled evaluations of the group cognitive-behavioral treatment for comorbid insomnia in this and other ambulatory settings are warranted.