A test of the bidirectional association between sleep and mood in bipolar disorder and insomnia

The present study investigates sleep, mood, and the proposed bidirectional relationship between the two in psychiatric disorders. Participants with interepisode bipolar disorder (n = 49), insomnia (n = 34), and no psychiatric history (n = 52) completed seven consecutive days of sleep diaries and mood measures. The interepisode bipolar and insomnia participants exhibited greater sleep disturbance than the healthy control individuals. Negative mood was equally heightened in both interepisode bipolar disorder and insomnia, and there were no differences between the three groups in positive mood. Total wake time was associated with next morning negative mood in bipolar disorder, whereas evening negative mood was associated with subsequent total wake time in both bipolar disorder and insomnia. Additionally, positive mood was associated with subsequent total wake time for the insomnia group. Results support the theory that disruptions in nighttime sleep and daytime mood may be mutually maintaining and suggest the potential importance of transdiagnostic or universal processes.     

Intimate Relationships and Psychopathology

Relationship functioning and individual mental health and well-being are strongly associated with one another. In this article, we first review the cross-sectional and longitudinal associations between relationship discord and various types of psychopathology, We then review findings suggesting that relationship discord is associated with poorer outcome for individual-based treatments for psychopathology and that, generally, relationship discord does not improve following individual-based treatments for psychopathology. Finally, we present a model for conceptualizing work with couples in which one partner has a psychiatric disorder and review the efficacy of couple-based interventions in the treatment for psychiatric disorders, with a focus on substance-related, mood, and anxiety disorders.     

Cross-Lagged Analyses of Prolonged Grief and Depression Symptoms With Insomnia Symptoms

Prolonged grief disorder, characterized by severe, persistent and disabling grief, has recently been added to the DSM-5-TR and ICD-11. Treatment for prolonged grief symptoms shows limited effectiveness. It has been suggested that prolonged grief symptoms exacerbate insomnia symptoms, whereas insomnia symptoms, in turn, may fuel prolonged grief symptoms. To help clarify if treating sleep disturbances may be a viable treatment option for prolonged grief disorder, we examined the proposed reciprocal relationship between symptoms of prolonged grief and insomnia. On three time points across 6-month intervals, 343 bereaved adults (88% female) completed questionnaires to assess prolonged grief, depression, and insomnia symptoms. We applied random intercept cross-lagged panel models (RICLPMs) to assess reciprocal within-person effects between prolonged grief and insomnia symptoms and, as a secondary aim, between depression and insomnia symptoms. Changes in insomnia symptoms predicted changes in prolonged grief symptoms but not vice versa. Additionally, changes in depression and insomnia symptoms showed a reciprocal relationship. Our results suggest that targeting insomnia symptoms after bereavement is a viable option for improving current treatments for prolonged grief disorder.     

Psychiatric diagnoses of patients visiting a sleep disorder clinic due to dyssomnias

This study analyzed the demographic characteristics and psychiatric diagnoses of 90 consecutive patients who visited a sleep disorder clinic in Taiwan with complaints of insomnia (difficulty initiating or maintaining sleep, or nonrestorative sleep) or hypersomnia (excessive sleepiness as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily). All subjects were interviewed using a sleep disturbance questionnaire and the structured Mini-International Neuropsychiatric Interview supplemented by the DSM-IV criteria for psychiatric diagnoses. Among 90 patients, 79 were classified as having insomnia and 11 had hypersomnia. 53 patients also had psychiatric diagnoses other than sleep disorders. Patients with insomnia had a significantly higher rate of comorbidities with other psychiatric diagnoses (65.8%) than did subjects with hypersomnia (9.1%). These results emphasize the importance of psychiatric evaluation of patients with complaints of sleep disturbance.     

睡眠问题在创伤后应激障碍各症状间的独特作用：基于交叉滞后网络分析模型

借助交叉滞后网络的分析方法, 探讨睡眠问题在创伤后应激障碍(PTSD)的症状系统中与其他症状的格兰杰因果关系。以经历舟曲泥石流的1460名儿童青少年为研究对象, 在灾后3, 15和27个月对其PTSD症状进行测量。交叉滞后网络分析结果显示：3到15个月时的睡眠问题的发出预期影响最高; 而15到27个月时与他人疏离和线索引发生理反应的发出预期影响最高。结果表明了睡眠问题对PTSD症状影响的时间特异性, 并为儿童青少年的PTSD干预方案和诊断模式提供了启示。     

Phenotypes of sleeplessness: stressing the need for psychodiagnostics in the assessment of insomnia

Insomnia is a too general term for various subtypes that might have different etiologies and therefore require different types of treatment. In this explorative study we used cluster analysis to distinguish different phenotypes in 218 patients with insomnia, taking into account several factors including sleep variables and characteristics related to personality and psychiatric comorbidity. Three clusters emerged from the analysis. The ‘moderate insomnia with low psychopathology’-cluster was characterized by relatively normal personality traits, as well as normal levels of anxiety and depressive symptoms in the presence of moderate insomnia severity. The ‘severe insomnia with moderate psychopathology’-cluster showed relatively high scores on the Insomnia Severity Index and scores on the sleep log that were indicative for severe insomnia. Anxiety and depressive symptoms were slightly above the cut-off and they were characterized by below average self-sufficiency and less goal-directed behavior. The ‘early onset insomnia with high psychopathology’-cluster showed a much younger age and earlier insomnia onset than the other two groups. Anxiety and depressive symptoms were well above the cut-off score and the group consisted of a higher percentage of subjects with comorbid psychiatric disorders. This cluster showed a ‘typical psychiatric’ personality profile. Our findings stress the need for psychodiagnostic procedures next to a sleep-related diagnostic approach, especially in the younger insomnia patients. Specific treatment suggestions are given based on the three phenotypes.     

Sleep disturbances in treatment‐seeking OCD‐patients: Changes after concentrated exposure treatment

Research indicates that patients with Obsessive Compulsive Disorder (OCD) frequently suffer from comorbid sleep difficulties, and that these difficulties often are not clinically recognized and diagnosed. There has been limited research investigating if comorbid sleep difficulties impair treatment outcome for OCD and if the sleep difficulties change following OCD‐treatment. Thirty‐six patients with obsessive compulsive disorder underwent concentrated exposure treatment delivered in a group over four consecutive days and were assessed with measures of OCD, depressive symptoms and sleep disturbance at three different time points (pre, post and 6 months follow‐up). The sample was characterized by a high degree of comorbidity with other psychiatric disorders. At pre‐treatment nearly 70% of the patients reported sleep difficulties indicative of primary insomnia. The results showed that patients had large reductions of OCD‐symptoms as well as significant improvements in sleep disturbance assessed after treatment, and that these improvements were maintained at follow‐up. Sleep disturbance did not impair treatment outcome, on the contrary patients with higher degree of sleep disturbance at pre‐treatment had better outcome on OCD‐symptoms after treatment. The results indicated that the majority of the OCD sample suffered from sleep disturbances and that these sleep disturbances were significantly reduced following adequate treatment of OCD without specific sleep interventions. However, a proportion of the patients suffered from residual symptoms of insomnia after treatment.     

Sleep disturbances in depressed pregnant women and their newborns

Pregnant women (N=253) were recruited during their second trimester of pregnancy (M=22.3 weeks gestation) and assigned to depressed (N=83) and non-depressed groups based on a SCID diagnosis of depression. They were then given self-report measures on sleep disturbance, depression, anxiety and anger, and their urine was assayed for norepinephrine and cortisol. These measures were repeated during their third trimester (M=32.4 weeks). Their newborns were then observed during sleep. During both the second and third trimesters, the depressed women had more sleep disturbances and higher depression, anxiety and anger scores. They also had higher norepinephrine and cortisol levels. The newborns of the depressed mothers also had more sleep disturbances including less time in deep sleep and more time in indeterminate (disorganized) sleep, and they were more active and cried/fussed more.     

Childhood diagnoses and later risk for multiple suicide attempts

The relationship between childhood diagnosis, personality psychopathology and suicidal behavior in young adulthood was explored in a sample of 327 suicide ideators, single attempters, and multiple attempters. Of the total sample, 174 received at least one childhood diagnosis; the 153 without a diagnosis provided a comparison group. Results suggest that a childhood history of an anxiety disorder or major depression predispose a person to both later multiple suicide attempts and personality psychopathology. Gender was found to play a significant role, with females being predisposed to multiple attempts in young adulthood but only as a function of childhood anxiety, not major depression. Additionally, childhood anxiety disorders were found to predispose to multiple attempts as a function of personality psychopathology, with distinctly different paths for males and females. Implications are discussed in terms of etiology, prevention, and treatment.     

Transdiagnostic processes in emotional disorders and insomnia: results from a sample of adult outpatients with anxiety and mood disorders

Conceptual similarities between recent models of insomnia and emotional disorders suggest there may be common factors that underlie or maintain these difficulties. Maladaptive cognitive and behavioral processes similar to those described in connection with emotional disorders have been cited as key mechanisms in the maintenance of primary insomnia. Unfortunately, research on this potential overlap is lacking. The present study examined the relationship among anxiety sensitivity (AS), dysfunctional beliefs, fatigue, safety behaviors, and insomnia severity in 59 outpatients with anxiety and mood disorders. Key insomnia processes (dysfunctional beliefs, fatigue, safety behaviors) were all related to insomnia severity in the comorbid sample, although AS was not. However, as hypothesized, AS did moderate the relationship of both dysfunctional beliefs and fatigue with insomnia severity. The relationships between key insomnia processes and insomnia severity was strongest among individuals high in AS. Results support the hypothesis that common mechanisms are involved for insomnia and emotional disorders. AS might function as a mechanism for the maintenance of sleep disturbance in the context of anxiety and mood disorders, suggesting a promising avenue for future research.     

Repetitive Thought and Self-Reported Sleep Disturbance

Repetitive thought has been focused upon as a transdiagnostic risk factor for depression, anxiety, and poor physical health. Among the forms of repetitive thought, rumination and worry are considered to play important roles in the onset and maintenance of insomnia. However, there have been few attempts to clarify the similarities, differences, and interaction between the functions of rumination and worry in sleep problems. Furthermore, no study has investigated the prospective relationships between these two forms of repetitive thought and sleep disturbance. In the present study, we examined the prospective associations between repetitive thought and subjective sleep quality, measured by a self-report questionnaire. A total of 208 undergraduates participated in a 2-wave longitudinal survey with an interval of 3 weeks between assessments. Hierarchical multiple regression analyses showed that baseline rumination predicted reduction in the follow-up assessment of subjective sleep quality, controlling for levels of depressive and anxious symptoms. This main effect of rumination was qualified by the levels of worry; for individuals with higher levels of worry, rumination was associated with greater reduction in subjective sleep quality. These results suggest that both rumination and worry have unique associations with sleep and that their interaction is especially important in sleep problems.     

Psychological well-being of patients with insomnia and its relationship with anxiety and depression

The aims of the present study are to evaluate the impact of insomnia on psychological well-being and to examine the associations of insomnia and psychological well-being with anxiety and depression. Forty-one patients attending our hospital-based Centre for sleep medicine were administered scales for the evaluation of insomnia (ISI), anxiety (STAI-Y), depression (BDI-II) and psychological well-being (PWB). The scores were compared to those of a control group of 68 subjects attending the hospital for routine examinations or as accompanying persons. Significant differences between patients and controls were detected for anxiety and depression, as well as for psychological well-being. Even if subclinical on average, anxiety and depression symptoms were significantly related to poor psychological well-being, whereas insomnia per se was not. These findings suggest that patients with insomnia report a relevant impact on their psychological well-being, and that such an impact seems to be strongly associated with concomitant subthreshold symptoms of anxiety and depression. The implications for diagnosis and treatment are discussed.     

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.     

Assessment of psychopathology across and within cultures: issues and findings

Research based information on the impact of culture on psychopathology is reviewed, with particular reference to depression, somatization, schizophrenia, anxiety, and dissociation. A number of worldwide constants in the incidence and mode of expression of psychological disorders are identified, especially in relation to schizophrenia and depression. The scope of variation of psychopathological manifestations across cultures is impressive. Two tasks for future investigations involve the determination of the generic relationship between psychological disturbance and culture and the specification of links between cultural characteristics and psychopathology. To this end, hypotheses are advanced pertaining to the cultural dimensions investigated by Hofstede and their possible reflection in psychiatric symptomatology. It is concluded that the interrelationship of culture and psychopathology should be studied in context and that observer, institution, and community variables should be investigated together with the person's experience of distress and disability.     

Psychological treatment of secondary insomnia

Psychological treatment of insomnia has focused on primary insomnia (i.e., having a psychological origin). Secondary insomnia, sleep disturbance caused by a psychiatric or medical disorder, although it is more common than primary insomnia, has received very little attention as a result of the belief that it would be refractory to treatment. The present study randomly assigned older adults with secondary insomnia to a treatment group, 4 sessions composed of relaxation and stimulus control, or a no-treatment control group. Self-report assessments conducted at pretreatment, posttreatment, and a 3-month follow-up revealed that treated participants showed significantly greater improvement on wake time during the night, sleep efficiency percentage, and sleep quality rating. The authors hypothesize that treatment success was probably due in part to difficulty in diagnostic discrimination between primary and secondary insomnia.     

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.     

Test-Retest Reliability of Maternal Reports of Lifetime Mental Disorders in Their Children

This study examined the test-retest reliability of maternal reports of lifetime psychopathology using DSM-III-R criteria in nonreferred offspring. Sixty-three mothers reported on 79 children, ages 6 to 18 years. Retest intervals were between one and 12 months. The results indicated acceptable reliability for all supraordinate categories (any disorder, any anxiety disorder, any disruptive disorder, externalizing disorders, internalizing disorders) as well as for most individual diagnoses (separation anxiety disorder, simple phobias, oppositional defiant disorder, attention deficit disorder with and without hyperactivity, simple phobias, and adjustment disorder). Maternal reports for any diagnosis were significantly better for intervals under 6 months than for longer retest intervals. Reliability of maternal reports was not significantly affected by child's age or gender. This study supports the expectation that a history of psychiatric disturbance in children can be obtained reliably from mothers.     

Caring for the Caregivers: An Investigation of Factors Related to Well-Being Among Parents Caring for a Child with Smith-Magenis Syndrome

Smith-Magenis syndrome (SMS) is a complex disorder characterized by numerous challenges, including intellectual disability, speech delay, decreased pain sensitivity, sleep disturbances, hyperactivity, mood instability, and self-injury. Caregivers must readily adapt to the ever-changing needs of the child. Due to these demands, caregivers may encounter difficulties maintaining their own level of well-being. Thus, a total of 112 primary caregivers (i.e., parents) of individuals diagnosed with SMS responded to online questionnaires to assess demographic and psychosocial factors, such as perceptions of child health vulnerability, benefit finding, sleep behaviors, anxiety and depression symptomatology, and caregiver satisfaction and self-efficacy, which may be related to caregiver well-being. Results show that, among mothers, caregiver well-being was directly related to perceived child health vulnerability, caregiver satisfaction, and benefit finding, and a significant moderating effect was observed for depression/anxiety counseling after beginning the caregiver role on the relationship between anxiety symptomatology and caregiver well-being. Results further suggest that maternal caregivers who report high levels of anxiety but do not seek counseling fair the worst in terms of well-being. Among fathers, lower depression symptoms and greater benefit finding were related to higher levels of caregiver well-being. These data show that many factors play roles in influencing coping and well-being among SMS caregivers. Investigating these variables and relationships may reveal additional resources and interventions to assist primary caregivers.     

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.