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.     

Change in Dysfunctional Beliefs About Sleep in Behavior Therapy,Cognitive Therapy,and Cognitive-Behavioral Therapy for Insomnia

As part of a larger randomized controlled trial, 188 participants were randomized to behavior therapy (BT), cognitive therapy (CT), or cognitive-behavioral therapy (CBT) for insomnia. The aims of this study were threefold: (a) to determine whether change in dysfunctional beliefs about sleep was related to change in sleep, insomnia symptoms, and impairment following treatment; (b) to determine whether BT, CT, and CBT differ in their effects on dysfunctional beliefs; and (c) to determine whether the treatments differ in their effects on particular kinds of dysfunctional beliefs. Beliefs, sleep, insomnia symptoms, and sleep-related psychosocial impairment were assessed at pretreatment, posttreatment, and 6- and 12-month follow-up. Greater change in dysfunctional beliefs occurring over the course of BT, CT, or CBT was associated with greater improvement in insomnia symptoms and impairment at posttreatment and both follow-ups. All groups experienced a significant decrease in dysfunctional beliefs during treatment, which were sustained through 6- and 12-month follow-up. Compared with the BT group, a greater proportion of participants in the CT and/or CBT groups endorsed dysfunctional beliefs below a level considered clinically significant at posttreatment and 12-month follow-up. The results demonstrate the importance of targeting dysfunctional beliefs in insomnia treatment, suggest that beliefs may be significantly modified with BT alone, and indicate that cognitive interventions may be particularly powerful in enhancing belief change.     

The Effect of Support on Internet-Delivered Treatment for Insomnia: Does Baseline Depression Severity Matter?

Internet-delivered cognitive-behavioral treatment is effective for insomnia. However, little is known about the beneficial effects of support. Recently we demonstrated that motivational support moderately improved the effects of Internet-delivered treatment for insomnia. In the present study, we tested whether depressive symptoms at baseline moderate the effect of support on Internet-delivered treatment for insomnia. We performed a multilevel intention-to-treat analysis on 262 participants in a randomized controlled trial. We found that baseline depressive symptoms moderated the effect of support on sleep efficiency, total sleep time, and sleep onset latency (but not on wake after sleep onset, number of nightly awakenings, or the Insomnia Severity Index). This means that for these variables, people with high levels of depressive symptoms benefit from support, whereas people with low levels of depressive symptoms improve regardless of support. The data show that baseline depression severity plays an important role in the way Internet treatments need to be delivered. These findings open up opportunities to personalize the support offered in Internet-delivered treatments.     

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.     

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.     

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.     

Associations Between Psychological Factors and Nighttime/Daytime Symptomatology in Insomnia

Purpose: The aim of this study was to examine psychological factors in insomnia and the association between psychological mechanisms and nighttime and daytime symptoms. Methods: A cross-sectional examination in the general population was used. The study sample consisted of 1890 participants from the general population. The participants completed a survey on nighttime and daytime symptoms, health outcomes, and psychological factors. Results: Relative to poor and normal sleepers, the insomnia group had higher scores on worry, beliefs, physiologic arousal, monitoring/attentional bias, and safety behaviors than the other two groups, and the poor sleepers exhibited a similar pattern relative to the normal sleepers. High total wake time was associated with more worry, physiologic arousal, and safety behaviors (26.3% variance), low sleep restoration with more worry, unhelpful beliefs, and monitoring/attentional bias (28.2% variance), and low sleep quality with higher scores on all the psychological mechanisms (35.8% variance). Elevated daytime symptoms were related to more unhelpful beliefs and monitoring/attentional bias (44.3% variance). Conclusion: The findings indicate that psychological factors are linked to nighttime and daytime symptomatology in insomnia.     

Daytime functioning in older patients suffering from chronic insomnia: treatment outcome in a randomized controlled trial comparing CBT with Zopiclone

The paper presents data from a randomized controlled trial comparing treatment effects of cognitive behavioural therapy (CBT), hypnotic treatment (Zopiclone), and placebo in a sample of insomnia patients. Data from the same trial have already demonstrated that CBT was more efficient in improving sleep than Zopiclone. The novel outcomes that are reported here concern daytime functioning.

Forty-six older patients (age55) qualifying for a diagnosis of primary insomnia were recruited to participate. Assessments were completed at baseline, post-treatment, and at a 6-months follow-up, and measures of worry, anxiety, depression, interpersonal relationships, subjective alertness, vigilance, and quality of life were used.

The participants in both treatment conditions scored within the normal range on the outcome measures at baseline with the exception of reporting less alertness, relative to a group of good sleepers. One interaction effect indicated that subjective alertness improved more in the Zopiclone group than the CBT group from baseline to post-treatment, and another that CBT was more effective than Zopiclone in reducing trait anxiety from baseline to follow-up.

It was concluded that the treatments yielded only minor effects on the measures of daytime functioning, and that none of them was clearly superior to the other.     

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.     

Motivational support provided via email improves the effectiveness of internet-delivered self-help treatment for insomnia: A randomized trial

Internet-delivered treatment is effective for insomnia, but little is known about the beneficial effects of support. The aim of the current study was to investigate the additional effects of low-intensity support to an internet-delivered treatment for insomnia. Two hundred and sixty-two participants were randomized to an internet-delivered intervention for insomnia with (n = 129) or without support (n = 133). All participants received an internet-delivered cognitive behavioral treatment for insomnia. In addition, the participants in the support condition received weekly emails. Assessments were at baseline, post-treatment, and 6-month follow-up. Both groups effectively ameliorated insomnia complaints. Adding support led to significantly higher effects on most sleep measures (d = 0.3–0.5; p < 0.05), self-reported insomnia severity (d = 0.4; p < 0.001), anxiety, and depressive symptoms (d = 0.4; p < 0.01). At the 6-month follow-up, these effects remained significant for sleep efficiency, sleep onset latency, insomnia symptoms, and depressive symptoms (d = 0.3–0.5; p < 0.05). Providing support significantly enhances the benefits of internet-delivered treatment for insomnia on several variables. It appears that motivational feedback increases the effect of the intervention and encourages more participants to complete the intervention, which in turn improves its effectiveness.     

Sleep locus of control and computerized cognitive-behavioral therapy (cCBT)

This study investigated the relationship between sleep locus of control and sleep in a secondary data analysis. Participants were 100 adults with chronic insomnia previously involved in a randomized controlled trial of 5 weeks of computerized cognitive-behavioral therapy (cCBT). Additionally, a sample of 46 completers of an in-person group for insomnia were utilized as a comparison group. At pre-treatment, participants completed the Sleep Locus of Control Scale, the Insomnia Severity Index, the Pre-Sleep Arousal Scale, 7 days of sleep diaries, and participated in structured interviews to assess for psychiatric and medical conditions. Measures were re-administered at post-treatment and at a 4 week follow-up. Results showed that sleep locus of control mediated the impact of cCBT on insomnia severity at follow-up. cCBT more than waiting list control or a convenience sample of individuals treated with in-person CBT, enhanced an internal sleep locus of control. Implications are that sleep locus of control may be an important variable to assess in the internet context and that internet programs for insomnia may want to consider amplifying or giving priority to interventions which enhance an internal sleep locus.     

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.     

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent–child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study’s limitations, and future directions for research are further discussed.     

Pre-experimental sleep effects on directed forgetting

A directed forgetting (DF) paradigm was used to compare the remembering and forgetting of participants with good sleep quality to those with poor sleep quality and the presence of insomnia symptoms. This study implemented a point system in place of remember and forget instructions in a DF task with the goal of computing DF costs and benefits. Relations among memory, sleep, and working memory capacity (WMC) were also examined. DF benefits were observed in both groups, with negative costs found for participants without the presence of insomnia symptoms. WMC was found to be related to memory for positive point items only, and did not differ based on sleep quality. These results suggest that the presence of self-reported insomnia symptoms does not affect performance on a DF task.     

Relaxation therapy for insomnia: nighttime and day time effects

We compared day time functioning in college students with and without insomnia and explored changes in day time functioning after progressive relaxation (PR) treatment for insomnia. Students with insomnia (SWI; n = 57) were compared to a control group of students not complaining of insomnia (SNI; n = 61) on self-reported sleep variables and five questionnaires: Insomnia Impact Scale (IIS), Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS), Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), and Penn State Worry Questionnaire (PSWQ). SWI demonstrated significant impairment on all day time functioning and sleep measures compared to SNI. To investigate treatment effects on day time functioning, 28 SWI were randomly assigned to PR. Treated SWI were compared to untreated SWI and SNI at posttreatment. Treated participants improved sleep in comparison to untreated SWI, but failed to show significant improvements in day time functioning. Insomnia treatments focused on improving sleep may not improve day time functioning, or day time gains may emerge more slowly than sleep gains. This study documents the wide range of day time functioning complaints in young adults with insomnia and suggests that the goal of insomnia treatment should be to not only improve sleep but also to improve the subjective experience of day time functioning.     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals.     

Psychological treatment of hypnotic-dependent insomnia in a primarily older adult sample

Objective

This study tested cognitive behavior therapy (CBT) in hypnotic-dependent, late middle-age and older adults with insomnia.

Method

Seventy volunteers age 50 and older were randomized to CBT plus drug withdrawal, placebo biofeedback (PL) plus drug withdrawal, or drug withdrawal (MED) only. The CBT and PL groups received eight, 45 min weekly treatment sessions. The drug withdrawal protocol comprised slow tapering monitored with about six biweekly, 30 min sessions. Assessment including polysomnography (PSG), sleep diaries, hypnotic consumption, daytime functioning questionnaires, and drug screens collected at baseline, posttreatment, and 1-year follow-up.

Results

Only the CBT group showed significant sleep diary improvement, sleep onset latency significantly decreased at posttreatment. For all sleep diary measures for all groups, including MED, sleep trended to improvement from baseline to follow-up. Most PSG sleep variables did not significantly change. There were no significant between group differences in medication reduction. Compared to baseline, the three groups decreased hypnotic use at posttreatment, down 84%, and follow-up, down 66%. There was no evidence of withdrawal side-effects. Daytime functioning, including anxiety and depression, improved by posttreatment. Rigorous methodological features, including documentation of strong treatment implementation and the presence of a credible placebo, elevated the confidence due these findings.

Conclusions

Gradual drug withdrawal was associated with substantial hypnotic reduction at posttreatment and follow-up, and withdrawal side-effects were absent. When supplemented with CBT, participants accrued incremental self-reported, but not PSG, sleep benefits.     

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.     

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.