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.     

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.     

Higher levels of depression are associated with reduced global bias in visual processing

Sleep-related attentional bias is a well-documented finding in patients with primary insomnia. To address the question of whether attentional preference for sleep-related stimuli is due to sleepiness (as measured by the Stanford Sleepiness Scale; SSS) or sleeplessness (as measured by the Pittsburgh Sleep Quality Index; PSQI) we investigated 105 non-clinical participants with two attentional bias tasks, an emotional Stroop task and a newly introduced mixed-modality task. The emotional Stroop task revealed significant positive linear relationships between sleep-related attentional bias and both poor sleep quality and sleepiness. Additionally, we found a significant negative interaction effect between these two variables on the cognitive bias. This means that attentional bias scores are reduced when poor sleep quality is associated with high sleepiness and high sleep quality is associated with low sleepiness. We did not find any significant result in the mixed-modality task. The results suggest that sleep-related attentional bias can be elicited by both sleepiness and sleeplessness.     

Attempts to control unwanted thoughts in the night: development of the thought control questionnaire-insomnia revised (TCQI-R)

The attempted control of intrusive, uncontrollable thoughts has been implicated in the maintenance of a range of psychological disorders. The current paper describes the refinement of the Thought Control Questionnaire Insomnia (TCQI; Behav. Cogn. Psychoth. 29 (2001)) through its administration to a sample (n=385) including good sleepers and individuals with insomnia. Several items with poor psychometric properties were discarded, resulting in a 35-item revised TCQI. Factor analysis revealed six factors; aggressive suppression, cognitive distraction, reappraisal, social avoidance, behavioural distraction, and worry. The attempted management of unwanted thoughts was compared across individuals with insomnia and good sleepers, and the impact of these strategies on sleep quality, anxiety and depression was investigated. With the exception of cognitive distraction, individuals with insomnia, relative to good sleepers, more frequently used every thought control strategy. The strategies of aggressive suppression and worry, in particular, appeared to be unhelpful, with the use of these strategies predicting sleep impairment, anxiety and depression. The strategy of cognitive distraction appeared to be helpful, with the use of this strategy predicting better sleep quality.     

Only “efficient” emotional stimuli affect the content of working memory during free-recollection from natural scenes

Emotional events are thought to have privileged access to attention and memory, consuming resources needed to encode competing emotionally neutral stimuli. However, it is not clear whether this detrimental effect is automatic or depends on the successful maintenance of the specific emotional object within working memory. Here, participants viewed everyday scenes including an emotional object among other neutral objects followed by a free-recollection task. Results showed that emotional objects—irrespective of their perceptual saliency—were recollected more often than neutral objects. The probability of being recollected increased as a function of the arousal of the emotional objects, specifically for negative objects. Successful recollection of emotional objects (positive or negative) from a scene reduced the overall number of recollected neutral objects from the same scene. This indicates that only emotional stimuli that are efficient in grabbing (and then consuming) available attentional resources play a crucial role during the encoding of competing information, with a subsequent bias in the recollection of neutral representations.     

Effectiveness of Cognitive-Behavioral Insomnia Treatment in a Community Sample of Older Individuals: More Questions than Conclusions

Effectiveness of two modified stimulus control insomnia interventions plus daily sleep self-monitoring for managing insomnia was investigated in a community sample of older adults. Significant post intervention improvement was observed in both interventions as well as in a self-monitoring only control condition. This unexpected finding led us to question the role of self-monitoring as a potential mediator of therapeutic change. Therefore, we compared long-term follow-up data from treated participants to data from similarly poor sleepers who only completed the questionnaire battery at Pre-test and long term follow-up, with no intervening treatment or self-monitoring. Both groups of poor sleepers reduced their reported amount of nocturnal wakefulness. However, only treated participants improved on their perceived frequency of insomnia episodes and insomnia-related distress. Our findings have implications both for the definition and the treatment of insomnia.     

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.     

Emotional and neutral scenes in competition: Orienting,efficiency, and identification

To investigate preferential processing of emotional scenes competing for limited attentional resources with neutral scenes, prime pictures were presented briefly (450 ms), peripherally (5.2° away from fixation), and simultaneously (one emotional and one neutral scene) versus singly. Primes were followed by a mask and a probe for recognition. Hit rate was higher for emotional than for neutral scenes in the dual- but not in the single-prime condition, and A′ sensitivity decreased for neutral but not for emotional scenes in the dual-prime condition. This preferential processing involved both selective orienting and efficient encoding, as revealed, respectively, by a higher probability of first fixation on—and shorter saccade latencies to—emotional scenes and by shorter fixation time needed to accurately identify emotional scenes, in comparison with neutral scenes.     

Emotional and neutral scenes in competition: orienting, efficiency, and identification

To investigate preferential processing of emotional scenes competing for limited attentional resources with neutral scenes, prime pictures were presented briefly (450 ms), peripherally (5.2° away from fixation), and simultaneously (one emotional and one neutral scene) versus singly. Primes were followed by a mask and a probe for recognition. Hit rate was higher for emotional than for neutral scenes in the dual- but not in the single-prime condition, and A' sensitivity decreased for neutral but not for emotional scenes in the dual-prime condition. This preferential processing involved both selective orienting and efficient encoding, as revealed, respectively, by a higher probability of first fixation on—and shorter saccade latencies to—emotional scenes and by shorter fixation time needed to accurately identify emotional scenes, in comparison with neutral scenes.     

Disqualified and qualified poor sleepers: subjective and objective variables

Sleep laboratory studies of patients complaining of insomnia have demonstrated discrepancies between subjective reports and electroencephalograph (EEG)-recorded measures. In our research studies on sleeping aids, 60% of the self-described poor sleepers who reported usual sleep latencies of at least 45 min did not meet the laboratory qualification criterion of a 30-min or longer sleep latency. To learn to predict who would qualify for our studies, we compared 30 laboratory-qualified poor sleepers (QPS) with 30 laboratory-disqualified poor sleepers (DPSs) on subjective report, mood, and all-night sleep laboratory variables. QPSs had significantly lower sleep efficiency and total sleep time in the laboratory, but these differences were due to the longer sleep latencies (50.7 +/- 27.8 min vs. 15.2 +/- 6.1 min) of the QPS group. QPSs and DPSs differed significantly in their morning estimates of their laboratory sleep latencies; as a group, QPSs gave an accurate estimate (51.6 +/- 27.8 min), but DPSs were significantly more likely to exaggerate their sleep latencies. Although we did not identify ways of predicting which poor sleepers would show sleep-onset insomnia in the sleep laboratory, we did find that, in this young, healthy population, there are poor sleepers who give an accurate report of a rather severe sleep-onset insomnia.     

Sleep patterns and aging: comparison of older adults with and without insomnia complaints

The nature of geriatric insomnia was studied by comparing older adults with (n = 42) and without (n = 30) insomnia complaints on measures of sleep, mood, life-style, health, and sleep-requirement expectations. Elderly persons with insomnia complaints reported longer sleep latency and more frequent and longer awakenings and used sleeping aids more often than those without insomnia complaints. Nocturnal sleep time was not a reliable discriminator. Poor sleepers showed greater discrepancies between their current sleep patterns and sleep-requirement expectations than did good sleepers. Elderly insomniacs acknowledged greater symptomatology of depression and anxiety than did good sleepers. Daytime napping and physical exercise were equivalent in both groups. Medical disorders, pain conditions, and drug usage (other than sleep aids) did not distinguish the two groups. Clinical implications for the treatment of geriatric insomnia are discussed.     

Guidance of attention to objects and locations by long-term memory of natural scenes

Four flicker change-detection experiments demonstrate that scene-specific long-term memory guides attention to both behaviorally relevant locations and objects within a familiar scene. Participants performed an initial block of change-detection trials, detecting the addition of an object to a natural scene. After a 30-min delay, participants performed an unanticipated 2nd block of trials. When the same scene occurred in the 2nd block, the change within the scene was (a) identical to the original change, (b) a new object appearing in the original change location, (c) the same object appearing in a new location, or (d) a new object appearing in a new location. Results suggest that attention is rapidly allocated to previously relevant locations and then to previously relevant objects. This pattern of locations dominating objects remained when object identity information was made more salient. Eye tracking verified that scene memory results in more direct scan paths to previously relevant locations and objects. This contextual guidance suggests that a high-capacity long-term memory for scenes is used to insure that limited attentional capacity is allocated efficiently rather than being squandered.     

The threat of appearing prejudiced and race-based attentional biases

The current work tested whether external motivation to respond without prejudice toward Blacks is associated with biased patterns of selective attention that reflect a threat response to Black individuals. In a dot-probe attentional bias paradigm, White participants with low and high external motivation to respond without prejudice toward Blacks (i.e., low-EM and high-EM individuals, respectively) were presented with pairs of White and Black male faces that bore either neutral or happy facial expressions; on each trial, the faces were displayed for either 30 ms or 450 ms. The findings were consistent with those of previous research on threat and attention: High-EM participants revealed an attentional bias toward neutral Black faces presented for 30 ms, but an attentional bias away from neutral Black faces presented for 450 ms. These attentional biases were eliminated, however, when the faces displayed happy expressions. These findings suggest that high levels of external motivation to avoid prejudice result in anxious arousal in response to Black individuals, and that this response affects even basic attentional processes.     

Impact of fearful expression on danger processing: The influence of the level of trait anxiety

Threat estimation is crucial for the adaptation of behavior to a dangerous situation. In anxiety, a bias to threat has been described as a core feature. Therefore, the sensitivity for threatening information in anxious individuals may have consequences for danger estimation. In this study, we used the affective priming paradigm to test the assumption that fearful expressions would facilitate danger detection in natural scenes in anxious individuals. Twenty-three high trait anxious individuals and 22 low trait anxious individuals participated in the study. They had to detect the potential threat of a target scene (neutral or threatening) following neutral or fearful face primes. High trait anxious participants detected threat more rapidly than low trait anxious participants, consistent with previous reports of emotional hypervigilance in anxiety. Furthermore, this effect was enhanced when the target scene followed a fearful expression: Only in anxious participants were reaction times shorter to detect danger following a fearful prime than a neutral prime. Our results tend to show that in anxiety, the hypervigilance to threat may be of an important value such as increasing the detection of a subsequent potential danger. Implication of attentional processes and attentional control is discussed.     

An investigation of monitoring for sleep-related threat in primary insomnia

In Study 1, individuals with primary insomnia (n=32) and good sleepers (n=38), recruited from a university population, completed a semi-structured interview. The interview assessed monitoring for sleep-related threat, negative thoughts and safety behaviours, at night and during the day. Compared to good sleepers, individuals with insomnia reported more frequent monitoring at night and during the day, more negative thoughts associated with monitoring at night and during the day, and the use of more safety behaviours associated with monitoring at night. A path analysis showed that the total monitoring frequency was significantly positively related to the score for total negative thoughts, which in turn, was significantly positively related to the total number of safety behaviours used. Study 2 aimed to test the generalisability of these findings in a clinical sample of individuals with primary insomnia (n=23). The results indicated that the clinical sample also engaged in monitoring for sleep-related threat, experienced negative thoughts and used safety behaviours. Further, more severe insomnia was associated with more negative thoughts and the use of more safety behaviours associated with monitoring at night. Together, these results are consistent with the proposal that monitoring for sleep-related threat functions to maintain insomnia by triggering negative thoughts and the use of safety behaviours. Future research is required to verify the proposed causal status of monitoring, using prospective designs and experimental manipulations.     

Early mechanism of negativity bias: An attentional blink study1

Abstract: The negativity bias is the perceptual phenomena whereby an emotionally negative stimulus is processed faster than a positive or neutral stimulus. We used the attentional blink paradigm to investigate whether attentional resources are required to obtain the negativity bias. Positive, negative or neutral words were used as a preceding target (T1) and/or a subsequent target (T2). Experiment 1 showed that the negativity bias occurred, because the attentional blink was reduced by a negative T2, but not by a positive or neutral T2. Experiment 2 indicated that a negative T1 grabbed attentional resources, interfering with the identification of a neutral T2. Experiment 3 demonstrated that the report of a negative T2 deteriorated when T1 was also negative. We conclude that attentional resources were required for the occurrence of the negativity bias.     

The impact of anxiety on visual attention to central and peripheral events

Recent reports in the literature suggest that anxious individuals show an attentional bias to mood-congruent information. Various investigators have hypothesized that such anxiety-based coding biases contribute to the maintenance of mood disorders. The present study sought to determine if attentional biases in anxious subjects extends to the perception of neutral, as opposed to affect-laden, stimuli. A procedure used to determine the locus of attention to foveal and peripheral visual events was used in combination with two inter-stimulus intervals, fixed and variable, to examine anxious and non-anxious subjects' attentional biases. Mood states were established by a well-validated musical induction procedure. The results revealed an attentional bias to foveal visual events in non-anxious subjects and an attenuated or reversed (peripheral) bias in anxious subjects. The clinical implications of these findings are discussed.     

Attentional bias affects change detection

Thirty smokers and 30 nonsmokers participated in aflicker study in which the role of attentional bias in change detection was examined. The participants observed picture pairs of everyday objects flicker on a computer screen until they detected the one object that had changed. In half of the pictures, a smoking-related object (e.g., a lighter) was included among smoking-unrelated objects (e.g., a spoon). Half of the smokers and half of the nonsmokers were aware of the experiment’s focus, and the other half were not. The smokers exhibited shorter detection latencies than did the nonsmokers when a smoking object changed and longer detection latencies when a nonsmoking object changed while a smoking object was present, and they exhibited detection latencies similar to those of the nonsmokers when smoking objects were not present. Interestingly, the nonsmokers displayed the same attentional bias as the smokers when they were aware of the experiment’s smoking focus, but they did not display any attentional bias when they were unaware. Thus, these findings provide evidence for long-term context-independent, as well as for short-term context-dependent, attentional bias.     

An open trial of cognitive therapy for chronic insomnia

We describe the development of a cognitive therapy intervention for chronic insomnia. The therapy is based on a cognitive model which suggests that the processes that maintain insomnia include: (1) worry and rumination, (2) attentional bias and monitoring for sleep-related threat, (3) unhelpful beliefs about sleep, (4) misperception of sleep and daytime deficits and (5) the use of safety behaviors that maintain unhelpful beliefs. The aim of cognitive therapy for insomnia is to reverse all five maintaining processes during both the night and the day. In an open trial 19 patients meeting diagnostic criteria for primary insomnia were treated with cognitive therapy for insomnia. Assessments were completed pretreatment, posttreatment and at 3-, 6- and 12-month followup. The significant improvement in both nighttime and daytime impairment evident at the posttreatment assessment was retained up to the 12 month followup.