The sleep patterns and problems of clinically anxious children

Childhood sleep problems have been associated with a range of adverse cognitive and academic outcomes, as well as increased impulsivity and emotional disorders such as anxiety and depression. The aim of the study was to examine subjective reports of sleep-related problems in children with anxiety disorders during school and weekend nights. Thirty-seven children with clinically-diagnosed anxiety disorders and 26 non-clinical children aged 7-12 years completed an on-line sleep diary to track sleep patterns across school nights and weekend nights. Anxious children reported going to bed significantly later (p = 0.03) and had significantly less sleep (p = 0.006) on school nights compared to non-anxious children. No significant differences in sleep onset latency, number of awakenings or time awake during the night, daytime sleepiness, or fatigue were found between the two groups. On the weekends, anxious children fell asleep quicker and were less awake during the night than on weeknights. School-aged anxiety disordered children showed a sleep pattern that differs from their non-anxious peers. Although the mean 30 min less sleep experienced by anxious children may initially seem small, the potential consequences on daytime performance from an accumulation of such a sleep deficit may be significant, and further investigation is warranted.     

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.     

Book Reviews

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.     

Sleep Hygiene Practices of Good and Poor Sleepers in the United States: An Internet-Based Study

This Internet-based investigation assessed the frequency of multiple sleep hygiene practices in 128 good sleepers and 92 poor sleepers (mean age = 41.6, SD = 12.8, 61.8% women). The Pittsburgh Sleep Quality Index was used to measure sleep quality (< 5 = good sleep, > 7 = poor sleep). Although sleep hygiene practices were generally good, poor sleepers showed increased cognitive activity in the bed, even after controlling for global indices of depression and anxiety. Poor sleepers also reported statistically significant increases in excessive noise in the bedroom, uncomfortable nighttime temperature, and activities that were exciting, emotional, or demanded high concentration near bedtime. Future studies should further investigate the prevalence of these variables and their potential impact on sleep quality.     

Associations Between Sleep Hygiene and Insomnia Severity in College Students: Cross-Sectional and Prospective Analyses

Although a small number of studies characterized cross-sectional associations between sleep hygiene and insomnia severity, no prior study has examined their relationships prospectively. Further, the relationship between sleep hygiene and insomnia severity among college students has rarely been examined. This study examined the prevalence of diverse sleep hygiene behaviors and their associations with insomnia severity in two independent samples of college students from a cross-sectional (N = 548; mean age = 19; 59% female; 71% White) and a two-wave short-term prospective (N = 157; mean age = 19; 71% female; 76% White) study. A total of 12% to 13% of students reported clinically significant insomnia. On average, students reported frequent engagement in inconsistent sleep-wake schedules and lounging and worrying/thinking about important matters in the bed. Improper sleep scheduling, behaviors that promote arousal near bedtime, and uncomfortable sleeping environments were positively associated with cross-sectional insomnia severity. After controlling for other well-established risk factors, only improper sleep scheduling remained significant. Prospectively, baseline improper sleep scheduling predicted insomnia severity at a 2-month follow-up after controlling for baseline insomnia severity and other well-established risk factors. Together, findings suggest a potential unique role of improper sleep scheduling in insomnia among college students.     

Associations between multiple health risk behaviors and mental health among Chinese college students

Although there is substantial evidence that health risk behaviors increase risks of premature morbidity and mortality, little is known about the multiple health risk behaviors in Chinese college students. Here, we investigated the prevalence of multiple health risk behaviors and its relation to mental health among Chinese college students. A cross-sectional study was conducted in Wuhan, China from May to June 2012. The students reported their health risk behaviors using self-administered questionnaires. Depression and anxiety were assessed using the self-rating depression scale and self-rating anxiety scale, respectively. A total of 2422 college students (1433 males) aged 19.7 ± 1.2 years were participated in the study. The prevalence of physical inactivity, sleep disturbance, poor dietary behavior, Internet addiction disorder (IAD), frequent alcohol use and current smoking was 62.0, 42.6, 29.8, 22.3, 11.6 and 9.3%, respectively. Significantly increased risks for depression and anxiety were found among students with frequent alcohol use, sleep disturbance, poor dietary behavior and IAD. Two-step cluster analysis identified two different clusters. Participants in the cluster with more unhealthy behaviors showed significantly increased risk for depression (odds ratio (OR): 2.21; 95% confidence interval (CI): 1.83, 2.67) and anxiety (OR: 2.32; 95%CI: 1.85, 2.92). This study indicates that a relatively high prevalence of multiple health risk behaviors was found among Chinese college students. Furthermore, the clustering of health risk behaviors was significantly associated with increased risks for depression and anxiety.     

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.     

Dispositional mindfulness,insomnia, sleep quality and dysfunctional sleep beliefs in post-treatment cancer patients

Dispositional mindfulness, or the tendency to be more mindful in daily life, has been associated with better psychological functioning and reduced overall distress. This study investigated the degree to which dispositional mindfulness was associated with sleep disturbances in cancer patients with insomnia. Further, we examined whether levels of mindfulness moderated the relationship between stress levels, mood disturbance, insomnia severity, sleep quality and dysfunctional sleep beliefs. Participants (N = 111) were adults who had been previously treated for cancer and currently met diagnostic criteria for insomnia. Higher levels of acting with awareness, non-judging and non-reacting were associated with better sleep and psychological outcomes. Despite these significant associations, mindfulness facets did not significantly moderate the relationship between stress, mood and sleep outcomes. This negative finding raises the possibility that increased mindfulness may not act directly to improve psychological outcomes, but rather through a series of other cognitive and affective changes. Our results emphasize the importance of addressing mood symptoms and stress appraisals as predictors of sleep disturbance in cancer patients.     

The clock as a focus of selective attention in those with primary insomnia: An experimental study using a modified Posner paradigm

Espie and colleagues [(2006). The attention-intention-effort pathway in the development of psychophysiological insomnia: a theoretical review. Sleep Medicine Reviews, 10, 215-245] propose a route into psychophysiological insomnia along the attention-intention-effort pathway which focuses on the inhibition of sleep-wake automaticity. A contributing factor to this is selective attention to sleep (alongside explicit intention to sleep and effort in the sleep engagement process). Following on from previous work on selective attention to sleep [Marchetti, L. M., Biello, S. M., Broomfield, N. M., MacMahon, K. M. A., & Espie, C. A. (2006). Who is pre-occupied with sleep?. A comparison of attention bias in people with psychphysiological insomnia, delayed sleep phase syndrome and good sleepers using the induced change blindness paradigm. Journal of Sleep Research, 15, 212-221; MacMahon, K., Broomfield, N., Macphee, L., & Espie, C. A. (2006). Attention bias for sleep related stimuli in primary insomnia and delayed sleep phase syndrome using the dot-probe task. Sleep, 29, 11] and considering the importance of monitoring both internal and external cues in the maintenance of insomnia, as highlighted in the cognitive model of insomnia [Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869-893], a cognitive probe task was employed to investigate further the role of the clock as a focus of selective attention in those with primary insomnia.A 2 × 2 between participants design comparing reaction time of individuals with primary insomnia (n = 22) and normal sleepers (n = 22) on a modified Posner paradigm. Responses obtained from a computer task presenting times which fall within a normal sleep period were analysed.Individuals with primary insomnia demonstrated delayed disengagement to the clock (F(1,84) = 6.9, p < 0.05) which is taken as further support for previous research demonstrating that individuals with primary insomnia exhibit an attentional bias to sleep related stimuli.These results lend support to the attention-intention-effort model (Espie et al., 2006) and the cognitive model (Harvey, 2002) both of which recognise the importance of selective attention towards salient stimuli in the maintenance of insomnia. Possible clinical implications of attentional bias to sleep as a marker of psychopathology progression and treatment efficacy are discussed.     

2010~2020中国内地大学生心理健康问题检出率的元分析

估计我国大学生心理健康问题的检出率, 能够为心理健康政策完善和教育活动开展提供证据支持。对2010~2020年我国大学生主要心理健康问题检出率及影响因素进行元分析, 结果表明, 睡眠问题、抑郁、自我伤害在大学生中较为突出; 近10年, 大学生焦虑、抑郁、睡眠问题和自杀未遂的检出率显著上升, 自我伤害的检出率显著下降; 测量工具、检出标准和检出时间是导致检出率大小不一的关键因素; 整体而言, 东北和中部地区大学生的心理健康情况优于西部和东部大学生; 性别、生源地、独生与否对大学生心理健康问题检出率的影响均不显著。未来应重视研制适合我国大学生的心理健康测评工具并确定检出标准, 同时据此积极开展心理行为问题的筛查与控制。     

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.     

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.     

Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: A pilot randomised controlled trial

ObjectiveInsomnia is a debilitating comorbidity of chronic pain. This pilot trial tested the utility of a hybrid treatment that simultaneously targets insomnia and pain-related interference.MethodsChronic pain patients with clinical insomnia were randomly allocated to receive 4 weekly 2-h sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). Participants were assessed at the beginning and end of this 4-week period. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were fatigue, anxiety, depression and pain intensity. Ancillary information about the hybrid treatment's effect on psychological processes and sleep (as measured with sleep diary and actigraphy) are also presented, alongside data demonstrating the treatment's clinical significance, acceptability and durability after one and six months. Data from all participants (n = 20) were combined for this purpose.ResultsCompared to symptom monitoring, the hybrid intervention was associated with greater improvement in sleep (as measured with the Insomnia Severity Index and sleep diary) at post-treatment. Although pain intensity did not change, the Hybrid Group reported greater reductions in pain interference, fatigue and depression than the Monitoring Group. Overall, changes associated with the hybrid intervention were clinically significant and durable at 1- and 6-month follow-ups. Participants also rated highly on treatment acceptability.ConclusionThe hybrid intervention appeared to be an effective treatment for chronic pain patients with insomnia. It may be a treatment approach more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.     

Applying the social cognitive model of career self-management to career exploration and decision-making

We present two studies applying the social cognitive model of career self-management (Lent & Brown, 2013) to career exploration and decision-making outcomes in college students. In the first study (N = 180 college students), we developed a new, brief measure of career exploration and decision-making self-efficacy for use in subsequent model testing. The measure yielded two factors, decisional self-efficacy and coping efficacy, with adequate internal consistency reliability estimates. The decisional self-efficacy factor related strongly to an established measure of career decision self-efficacy and produced theory consistent relations with measures of outcome expectations, social support, conscientiousness, exploration goals, prior engagement in career exploration, decisional anxiety, and level of career decidedness. In the second study (N = 215 college students), we re-examined the factor structure of the new self-efficacy measure and used it to assess the tenability of the self-management model in a path analysis predicting exploration goals, decisional anxiety, and career decidedness. The model fit the data well overall, though certain predictors were linked to the criterion variables only indirectly via mediated pathways. Implications of the findings for the social cognitive model as well as for future research and practice are considered.     

Relationships between health behaviors,posttraumatic stress disorder,and comorbid general anxiety and depression

Poor health outcomes associated with posttraumatic stress disorder (PTSD) may reflect engagement in unhealthy behaviors that increase morbidity risk and disengagement in healthy behaviors that decrease morbidity risk. Although research supports this pattern, findings are not definitive, particularly for healthy behaviors. Many studies have not controlled for effects of concurrent generalized anxiety and depression, which might explain conflicting findings. To address this limitation, we used an online cross-sectional research design and multivariate multilevel modelling to evaluate associations between a multitude of health behaviors (i.e. sedentary behavior, sleep quality, physical activity, eating habits, alcohol use and substance use) and PTSD, while adjusting for comorbid generalized anxiety and depression, in a sample of trauma-exposed individuals (N = 246). Our results indicate that PTSD and comorbid generalized anxiety and depression symptoms were differentially associated with specific health constructs. Specifically, sedentary behavior and poor sleep quality were associated with PTSD, whereas low physical activity, poor sleep quality, and unhealthy eating habits were associated with depression. Both increased alcohol and substance use were associated with generalized anxiety. Results from our study highlight the need to conceptualize associations between health behaviors and specific psychological symptoms in a comprehensive manner as part of clinical presentations of PTSD.     

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.     

Integrating Sleep Management into Clinical Practice

Although the basic function of sleep remains a mystery, insufficient sleep is associated with mood disturbance, fatigue and daytime lethargy, cognitive impairments, daytime behavior problems, academic problems, use of stimulants, work absenteeism, lost work production and an increase in healthcare utilization. The International Classification of Sleep Disorders distinguishes 90 different disorders, many of which can be effectively treated, but when left untreated can be costly in terms of quality of life, health and healthcare cost. Over the past 50 years we have become more effective in measuring sleep and have honed our treatments to better address the sleep disorders that most impact us. This article will focus on the three sleep disorders for which patients most frequently seek care, including insomnia, obstructive sleep apnea syndrome and restless leg syndrome.     

慢性腰背痛患者和抑郁症患者的情绪、睡眠及疼痛症状

本研究对慢性腰背痛患者、抑郁症患者和对照人群的疼痛、抑郁水平、焦虑水平和睡眠质量进行测评,发现慢性腰背痛患者的抑郁、焦虑程度增高,失眠较常见;抑郁症患者的焦虑和失眠现象严重,疼痛是其常见症状。结果提示临床上对慢性疼痛患者和抑郁症患者的疼痛、情绪和睡眠问题予以评定和治疗具有重要意义。     

Cognitive-Behavioral Therapy for Insomnia Co-Morbid with Hearing Impairment: A Randomized Controlled Trial

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.     

The Association Between Female College Students' Reports of Depression and Their Perceptions of Parental Attitudes Regarding Gender

This study related female college students' ( n = 377) reports of symptomatology to their reports of parental attitudes suggesting limitations inherent in being female. Young women completed a scale measuring their perceptions that their fathers would have been prouder of them if they were male, and a scale measuring their distress over the limitations experienced by their mothers. Respondents who scored high on either scale exhibited much higher prevalence than other respondents of self-reported depression accompanied by anxiety, somatic symptoms including headaches, insomnia, dyspnea, fatigue, disordered eating, and poor body image/preference for thinness (labeled anxious somatic depression ). Compared to men ( n = 191), women exhibited much higher prevalence of anxious somatic depression, but not higher prevalence of depression unaccompanied by the other symptoms.