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.     

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.     

Sleep interventions for performance,mood and sleep outcomes in athletes: A systematic review and meta-analysis

Sleep is fundamental to sports performance and other health outcomes such as mental wellbeing. This systematic review explored the effects of sleep interventions implemented among athletes on performance, sleep, and mood outcomes. Five databases were searched, returning 5996 records for screening. Of these, 27 articles met the inclusion criteria (16 controlled deigns, 11 uncontrolled; athletes n = 617; male n = 432, female n = 93, non-binary/other n = 0 or not reported n = 92). Narrative synthesis of all studies based on intervention type suggested that sleep hygiene, assisted sleep, and sleep extension interventions may be associated with improved sleep, performance, and mood outcomes. Twelve controlled trials were eligible for quantitative meta-analysis, investigating the effect of sleep interventions on athlete sleep, performance, and negative affect, compared to controls post-intervention. Utilizing random-effects meta-analyses, sleep interventions improved subjective sleep quality (g = 0.62, 95% CI [0.21, 1.02]), reduced sleepiness (g = 0.81, 95% CI [0.32, 1.30]) and decreased negative affect (g = 0.63, 95% CI [0.27, 0.98]), but did not appear to influence subjective sleep duration. No effects were identified for objective sleep measures (e.g., actigraphy), or aerobic/anaerobic performance indices. While sleep interventions may offer some benefit to athletes, caution is warranted given limitations of the extant research relating to small, non-representative studies with methodological concerns.     

Combining mindfulness meditation with cognitive-behavior therapy for insomnia: a treatment-development study

This treatment-development study is a Stage I evaluation of an intervention that combines mindfulness meditation with cognitive-behavior therapy for insomnia (CBT-I). Thirty adults who met research diagnostic criteria for Psychophysiological Insomnia (Edinger et al., 2004) participated in a 6-week, multi-component group intervention using mindfulness meditation, sleep restriction, stimulus control, sleep education, and sleep hygiene. Sleep diaries and self-reported pre-sleep arousal were assessed weekly while secondary measures of insomnia severity, arousal, mindfulness skills, and daytime functioning were assessed at pre-treatment and post-treatment. Data collected on recruitment, retention, compliance, and satisfaction indicate that the treatment protocol is feasible to deliver and is acceptable for individuals seeking treatment for insomnia. The overall patterns of change with treatment demonstrated statistically and clinically significant improvements in several nighttime symptoms of insomnia as well as statistically significant reductions in pre-sleep arousal, sleep effort, and dysfunctional sleep-related cognitions. In addition, a significant correlation was found between the number of meditation sessions and changes on a trait measure of arousal. Together, the findings indicate that mindfulness meditation can be combined with CBT-I and this integrated intervention is associated with reductions in both sleep and sleep-related arousal. Further testing of this intervention using randomized controlled trials is warranted to evaluate the efficacy of the intervention for this population and the specific effects of each component on sleep and both psychological and physiological arousal.     

A self-help book is better than sleep hygiene advice for insomnia: a randomized controlled comparative study

The objective was to compare the effects of two types of written material for insomnia in a randomized trial with follow-up after three months. Insomniacs were recruited through newspaper advertisements to a web-based survey with validated questionnaires about sleep, anxiety, depression, and use of sleep medications. A self-help book focusing on cognitive behavioral therapy for insomnia was compared to standard sleep hygiene advice; 77 and 78 participants were randomized to self-help book or sleep hygiene advice, respectively. The response rate was 81.9%. The self-help book gave significantly better scores on the sleep questionnaires compared to sleep hygiene advice. The proportion using sleep medications was reduced in the self-help book group, whereas it was increased in the sleep hygiene group. Compared to pre-treatment, the self-help book improved scores on the sleep (effect sizes 0.61-0.62) and depression (effect size 0.18) scales, whereas the sleep hygiene advice improved scores on some sleep scales (effect sizes 0.24-0.28), but worsened another (effect size -0.36). In addition, sleep hygiene advice increased the number of days per week where they took sleep medications (effect size -0.50). To conclude, in this randomized controlled trial, the self-help book improved sleep and reduced the proportion using sleep medications compared to sleep hygiene advice. The self-help book is an efficient low-threshold intervention, which is cheap and easily available for patients suffering from insomnia. Sleep hygiene advice also improved sleep at follow-up, but increased sleep medication use. Thus, caution is warranted when sleep hygiene advice are given as a single treatment.     

Internet-delivered or mailed self-help treatment for insomnia? A randomized waiting-list controlled trial

Cognitive Behavioral Therapy (CBT) is effective in reducing insomnia complaints, but the effects of self-help CBT have been inconsistent. The aim of this study was to determine the effectiveness of self-help for insomnia delivered in either electronic or paper-and-pencil format compared to a waiting-list. Participants kept a diary and filled out questionnaires before they were randomized into electronic (n = 216), paper-and-pencil (n = 205), or waiting-list (n = 202) groups. The intervention consisted of 6 weeks of unsupported self-help CBT, and post-tests were 4, 18, and 48 weeks after intervention. At 4-week follow-up, electronic and paper-and-pencil conditions were superior (p < .01) compared to the waiting-list condition on most daily sleep measures (Δd = 0.29–0.64), global insomnia symptoms (Δd = 0.90–1.00), depression (Δd = 0.36–0.41), and anxiety symptoms (Δd = 0.33–0.40). The electronic and paper-and-pencil groups demonstrated equal effectiveness 4 weeks after treatment (Δd = 0.00–0.22; p > .05). Effects were sustained at 48-week follow-up. This large-scale unsupported self-help study shows moderate to large effects on sleep measures that were still present after 48 weeks. Unsupported self-help CBT for insomnia therefore appears to be a promising first option in a stepped care approach.     

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.     

Exploring Socioeconomic Differences in Bedtime Behaviours and Sleep Duration in English Preschool Children

Children's sleep is critical for optimal health and development; yet sleep duration has decreased in recent decades, and many children do not have adequate sleep. Certain sleep behaviours (‘sleep hygiene’) are commonly recommended, and there is some evidence that they are associated with longer nighttime sleep. Parents of 84 British 3‐year‐old children were interviewed about their children's sleep and completed five‐night/four‐day sleep diaries documenting their children's sleep, from which daily sleep duration was estimated. Diaries were validated by actigraphy in a subgroup of children. Sleep hygiene behaviours (regular bedtime, reading at bedtime, falling asleep in bed) were associated with each other, and were more common in the high socioeconomic status compared to the low socioeconomic status group. Parents' reasons for not practicing sleep hygiene included difficulty, inability or inconvenience. Sleep hygiene behaviours were associated with significantly longer child sleep at night but not over 24 h. Longer daytime napping compensated for shorter nighttime sleep in children whose parents did not implement sleep hygiene behaviours. Parents may need to be advised that certain behaviours are associated with longer nighttime sleep and given practical advice on how to implement these behaviours. © 2014 The Authors. Infant and Child Development published by John Wiley & Sons, Ltd.     

Individual differences in the obligatory activation of addition facts

In two experiments, we found evidence for individual differences in the obligatory activation of addition facts. Subjects were required to verify the presence of a target digit (e. g., 4) in a previously presented pair (e. g., 5 + 4). Subjects rejected targets that formed the sum of the initial pair (e. g., 5+4 and 9) more slowly than they rejected unrelated targets (e. g., 5+4 and 7). This interference of the sum was largest for subjects who were relatively skilled at multidigit arithmetic. Less skilled subjects did not show statistically significant effects of obligatory activation. In comparison with less skilled subjects, skilled subjects showed differential interference on plus-one (e. g., 34 1) and standard (e. g, 2+3) problems when the plus sign was presented, and on ties (e. g., 22) when the plus sign was omitted. These results suggest that network models of arithmetic fact retrieval are appropriate for skilled subjects, but that alternative models need to be considered for less skilled individuals.     

An evaluation of group therapy for adolescents using social skills training

The present study investigated the hypothesis that social skills training is more effective in increasing socially acceptable behaviour in adolescents than is a generalized or non-specific form of group therapy. Forty-two subjects were selected to participate in the study from among adolescents referred for group therapy at two youth guidance clinics in Brisbane, Australia. The 23 males and 19 females were randomly assigned to one of three treatment conditions: a social skills training group, a non-specific therapy group and a waiting-list-for-therapy (control) condition. All subjects were assessed before and after treatment on five measures of social skills. Subjects in the social skills training group showed significant improvements on three of these measures while the non-specific therapy and waiting-list control groups showed no specific changes on any of the measures.     

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.     

Napping promotes inter-session habituation to emotional stimuli

The effects of a daytime nap on inter-session habituation to aversive visual stimuli were investigated. Healthy young adult volunteers viewed repeated presentations of highly negative and emotionally neutral (but equally arousing) International Affective Picture System (IAPS) photographs during two afternoon sessions separated by 2.5h. Half of the photographs were shown at both sessions (Repeated Sets) and half differed between sessions (Novel Sets). For each stimulus presentation, evoked skin conductance response (SCR), heart-rate deceleration (HRD) and corrugator supercilii EMG response (EMG), were computed and range corrected using respective maximum session-1 responses. Following each presentation, subjects rated each photograph on dimensions of pleasantness and arousability. During the inter-session interval, Nap subjects had a 120-min polysomnographically monitored sleep opportunity, whereas Wake subjects watched a non-stimulating video. Nap and Wake subjects did not differ in their subjective ratings of photographs. However, for Repeated-Set photographs, Nap subjects demonstrated greater inter-session habituation in SCR and EMG but a trend toward lesser inter-session habituation in HRD. These group differences were absent for Novel-Set photographs. Group differences across all measures were greater for negative stimuli. Occurrence of SWS during the nap was associated with greater inter-session habituation of EMG whereas occurrence of REM was associated with lesser inter-session habituation of SCR to negative stimuli. Sleep may therefore promote emotional adjustment at the level of somatic responses. Physiological but not subjective inter-session habituation to aversive images was enhanced by a daytime nap.     

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: A pathway linking personality to mortality risk

Personality and sleep predict longevity; however, no investigation has tested whether sleep mediates this association. Thus, we tested this effect across a 20-year follow-up (N = 3759) in the Midlife Development in the United States cohort (baseline M_age = 47.15) using proportional hazards in a structural equation modeling framework. Lower conscientiousness predicted increased death risk via the direct, indirect, and total effect of quadratic sleep duration. Although there were no other direct personality-mortality effects, higher neuroticism and agreeableness and lower conscientiousness predicted increased death risk via the joint indirect effects of quadratic sleep duration and higher daytime dysfunction. Lower extraversion predicted increased mortality risk via the indirect effect of daytime dysfunction. Our findings have implications for personality-based health interventions.     

Diurnal time courses in psychomotor performance and waking EEG frequencies

The present study examined the similarities between the diurnal time courses in the waking EEG activity and the psychomotor performance. The aim was to verify if some ongoing changes in the excitability of the cortical nerve cells across the daytime could facilitate the sensorimotor processing. EEG recordings and performance results for the Four Choice Reaction Time Test (FCRTT) were obtained every two hours, from morning to late evening period, in 8 young normal subjects (21.3 +/- 0.5 years). ANOVAs were used to verify the presence of diurnal variations in the two measures. Nonparametric correlations were obtained to test the similarity between the changes across the day in the two measures. Three EEG frequency bands (delta, sigma, and beta1) and the reaction time measures varied across the daytime. The changes in the sigma (12.00-13.75 Hz) and the beta1 (14.00-19.75 Hz) bands were similar to the diurnal variations in the reaction time measures. It is suggested that the changes in the sigma and the beta1 bands may facilitate the processing of the sensorimotor treatment.     

Stimulant Drug Effects on Performance and Behavior After Prolonged Sleep Deprivation: A Comparison of Amphetamine,Nicotine, and Deprenyl

Normal male subjects (N = 102) underwent total sleep deprivation in a laboratory environment for 48 hr. In separate dose-response, double-blind, placebo-controlled experiments, 36 subjects received single doses of d- amphetamine, 35 received intravenous nicotine, and 31 received l-deprenyl. All were deprived of sleep for an additional 12 hr. Amphetamine reversed the effects of sleep loss in a dose-related way, but the pattern and persistence of the reversal varied across measures. Neither nicotine nor I-deprenyl produced substantial persistent reversal of sleep deprivation effects. We conclude that these latter two agents are unlikely to be useful for the acute remediation of the effects of severe sleep loss. Although amphetamine is acutely effective, its usefulness in the treatment or prophylaxis of sleep loss requires further study.     

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.     

Exercise, changes in aerobic capacity, and changes in self-perceptions: An experimental investigation

Subjects in an exercise training condition participated in a 10-week aerobic exercise class, whereas subjects in waiting-list control and independent control conditions did not. The results indicated that subjects in the training condition evidenced reliably greater improvements in physical fitness (aerobic capacity) and reported reliably greater improvements in their abilities and confidence in both the physical area (e.g., ability to run distances) and nonphysical area (e.g., frustration tolerance) than did subjects in the control conditions. On the other hand, improvements in physical fitness were not related to reported improvements in abilities and confidence. These findings are of interest because they indicate that some of the important personal changes that are associated with physical fitness training are not due to changes in fitness, but appear to be due to other factors (e.g., group participation and expectancies).     

A comparison of stress-reduction behavioral counseling and contingent nocturnal EMG feedback for the treatment of bruxism

This study compared the efficacy of two treatment modalities (stress-reduction behavioral counseling and contingent nocturnal EMG biofeedback) on night-time bruxism. The 16 subjects (Ss) were assigned sequentially to one of four treatment groups: (1) stress-reduction behavioral counseling: (2) nocturnal biofeedback; (3) stress-reduction behavioral counseling and nocturnal biofeedback; and (4) waiting-list control group. A portable EMG unit was used to record the nightly total of electrical activity (?20 μV) from the masseter muscle 10 days before and after treatment. The three treatment procedures were found to be significantly superior to no-treatment control group. The outcome of the two treatments which made use of stress-reduction behavioral counseling, although better than the treatment which solely used nocturnal biofeedback, was not significantly better. This study demonstrates that stress-reduction skills learned while awake can have a generalized effect on stress-induced muscle activity during sleep. Implications for further research are discussed.