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  • From bedside back to bench? A commentary on: "The future of cognitive behavioral therapy for insomnia: What important research remains to be done?"

    24 October 2018

    In this month's issue of the Journal of Clinical Psychology, Vitiello and colleagues articulate an important research agenda that will help advance cognitive-behavioral therapy for insomnia (CBT-I) research and clinical practice. In addition to this ambitious agenda, we also propose that pursuing a parallel research program, focusing on treatment mechanisms and process will help move the CBT-I field forward and optimize therapeutic dissemination and uptake. © 2013 Wiley Periodicals, Inc.

  • Use of the internet and mobile media for delivery of cognitive behavioral insomnia therapy

    24 October 2018

    Cognitive behavioral therapy (CBT) is an effective treatment of insomnia disorder. CBT has traditionally been delivered by a therapist in a clinic; however, the ubiquitous nature of the Internet and increasing penetration of mobile devices offers new possibilities. Moreover, there are limitations to face-to-face therapy, particularly in relation to between-session home implementation. This article, therefore, presents the opportunity afforded by technological development, not only to meet the need and demand for CBT but also to improve insomnia care both at the level of the individual patient and at population level. © 2013 Elsevier Inc.

  • Who is predisposed to insomnia: a review of familial aggregation, stress-reactivity, personality and coping style

    24 October 2018

    Copyright © 2013 Elsevier Ltd. All rights reserved. Insomnia is a common health complaint world-wide. Insomnia is a risk factor in the development of other psychological and physiological disorders. Therefore understanding the mechanisms which predispose an individual to developing insomnia has great transdiagnostic value. However, whilst it is largely accepted that a vulnerable phenotype exists there is a lack of research which aims to systematically assess the make-up of this phenotype. This review outlines the research to-date, considering familial aggregation and the genetics and psychology of stress-reactivity. A model will be presented in which negative affect (neuroticism) and genetics (5HTTLPR) are argued to lead to disrupted sleep via an increase in stress-reactivity, and further that the interaction of these variables leads to an increase in learned negative associations, which further increase the likelihood of poor sleep and the development of insomnia.

  • The Glasgow Sleep Impact Index (GSII): a novel patient-centred measure for assessing sleep-related quality of life impairment in Insomnia Disorder.

    24 October 2018

    Daytime dysfunction and quality of life impairment are important and salient consequences of poor sleep in those with insomnia. Existing measurement approaches to functional impact tend to rely on non-specific generic tools, non-validated scales, or ad hoc single scale items. Here we report the development and validation of the Glasgow Sleep Impact Index (GSII), a novel self-report measure which asks patients to generate, and assess, three domains of impairment unique to their own individual context. These three patient-generated areas of impairment are ranked in order of concern (1-3; i.e. 1=the most concerning impairment), and then rated on a visual analogue scale with respect to impact in the past two weeks. Patients re-rate these specified areas of impairment, post-intervention, permitting both individual and group-level analyses. One-hundred and eight patients (71% female; Mean age=45 yrs) meeting Research Diagnostic Criteria for Insomnia Disorder completed the GSII, resulting in the generation of 324 areas (ranks) of sleep-related daytime and quality of life impairment. Fifty-five patients also completed the GSII pre- and post-sleep restriction therapy. The following psychometric properties were assessed: content validity of generated domains; relationship between ranks of impairment; and sensitivity to change post-behavioural intervention. Content analysis of generated domains support recent DSM-5 proposals for specification of daytime consequences of insomnia; with the most commonly cited areas reflecting impairments in energy/motivation, work performance, cognitive functioning, emotional regulation, health/well-being, social functioning and relationship/family functioning. Preliminary results with 108 patients indicate the GSII to have excellent face and construct validity. The GSII was found to be sensitive to change, post-behavioural treatment (p<0.001; Cohen's d≥0.85 for all three ranks of impairment), and improvements were associated with reductions in insomnia severity in both correlational (range of r=0.28-0.56) and responder versus non-responder analyses (all p<0.05). The development of the GSII represents a novel attempt to capture and measure sleep-related quality of life impairment in a valid and meaningful way. Further psychometric and clinical evaluation is suggested. Copyright © 2012 Elsevier B.V. All rights reserved.

  • Ecological momentary assessment of daytime symptoms during sleep restriction therapy for insomnia

    24 October 2018

    This study profiles changes in self-reported daytime functioning during sleep restriction therapy (SRT) for insomnia. Ecological momentary assessment (EMA) captured point-in-time symptomatology to map the time-course of symptoms. We hypothesized a deterioration (week 1) followed by improvements at week 3 of therapy relative to baseline. Nine patients with psychophysiological insomnia completed the Daytime Insomnia Symptom Scale (DISS) at rise-time, 12:00 hours, 18:00 hours and bedtime for 1 week before and 3 weeks during SRT. Four validated factors from the DISS were analyzed (alert cognition, positive mood, negative mood and sleepiness/fatigue) across 28 days yielding 17 170 data points. Factors evaluated week (baseline versus weeks 1 and 3) and time of day symptomatology. Insomnia Severity Index scores decreased significantly pre-to-post treatment (mean 18 versus 7). Reflecting acute effects of SRT, significant differences were found for all factors, except negative mood, between baseline and week 1 of SRT, suggesting adverse effects. By week 3, sleepiness/fatigue and negative mood decreased significantly compared to baseline, and positive mood showed a trend towards improvement (P = 0.06). Sleepiness/fatigue displayed a significant week × time of day interaction, explained by a reduction in sleepiness/fatigue at every daytime assessment point (except bedtime, which remained high). A significant interaction for alert cognition was associated with reduction in alertness at bedtime by week 3 and an increase in alertness at rise-time, suggesting that SRT not only improves sleep, but moderates alertness and sleepiness in therapeutic ways. Initial SRT is associated with an increase in sleepiness/fatigue and a decrease in alert cognition. © 2013 European Sleep Research Society.

  • Integrating psychology and medicine in CPAP adherence - New concepts?

    24 October 2018

    To date, continuous positive airway pressure (CPAP) is the most effective intervention in the treatment of obstructive sleep apnoea, but adherence to this treatment is often less than optimal. A variety of factors and interventions that influence and improve CPAP use have been examined. There is increasing recognition of the multifaceted nature of CPAP adherence: the patient's psychological profile and social environment have been recognised, in addition to the more extensively researched patient's treatment and physiological profile. Understanding how these multiple factors impact on CPAP use in an integrative fashion might provide us with a useful holistic model of CPAP adherence. This concept of integration - a biopsychosocial (BPS) approach to health and illness - has previously been described to understand care provision for various chronic health disorders. This paper proposes an adherence framework, whereby variables integrally affect CPAP use. The BPS model has been considered for nearly 35 years; the presence of poor CPAP adherence was acknowledged in the early 1990s - it is timely to incorporate this approach into our care pathway of CPAP users. © 2013 Elsevier Ltd.

  • The evidence base of sleep restriction therapy for treating insomnia disorder

    24 October 2018

    © 2014 Elsevier Ltd. Sleep restriction therapy is routinely used within cognitive behavioral therapy to treat chronic insomnia. However, the efficacy for sleep restriction therapy as a standalone intervention has yet to be comprehensively reviewed. This review evaluates the evidence for the use of sleep restriction therapy in the treatment of chronic insomnia. The literature was searched using web-based databases, finding 1344 studies. Twenty-one were accessed in full (1323 were deemed irrelevant to this review). Nine were considered relevant and evaluated in relation to study design using a standardized study checklist and levels of evidence. Four trials met adequate methodological strength to examine the efficacy of therapy for chronic insomnia. Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement. Standalone sleep restriction therapy is efficacious for the treatment of chronic insomnia for sleep diary continuity variables. Studies are insufficient to evaluate the full impact on objective sleep variables. Measures of daytime functioning in response to therapy are lacking. Variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy. A future research agenda is outlined.

  • Attribution, cognition and psychopathology in persistent insomnia disorder: Outcome and mediation analysis from a randomized placebo-controlled trial of online cognitive behavioural therapy

    24 October 2018

    Objectives: Insomnia patients complain that mental events keep them awake. This study investigates how cognitive behavioural therapy (CBT) affects such events and considers how attributional, cognitive and psychopathological symptoms may mediate sleep improvement. Method: A pragmatic, parallel-group randomized controlled trial of 164 adults (120 F: (mean 49. years (18-78. years)) meeting Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for insomnia disorder, assigned to CBT (n=55; 40 F), imagery relief therapy (IRT placebo; n=55; 42 F), or treatment as usual (TAU; n=54; 38 F), was conducted. CBT/IRT comprised six online sessions delivered by an animated therapist, with automated web/e-mail support. CBT users had access to a moderated community. TAU comprised 'usual care'. Participants completed the Sleep Disturbance Questionnaire (SDQ), Glasgow Content of Thoughts Inventory (GCTI), Depression Anxiety and Stress Scales (DASS) and Sleep Condition Indicator (SCI) at baseline, post treatment and 8-week follow-up. Results: The sample was characterised by mental arousal, notably 'trying too hard' to sleep (SDQ), and by 'sleep and sleeplessness' and 'rehearsal and planning' thoughts (GCTI). Treatment effects were observed for all SDQ domains (e.g., CBT vs. IRT: d=0.76 for 'trying too hard'). CBT was also superior to IRT on the GCTI (e.g., 'rehearsal and planning', d=0.62; 'sleep and sleeplessness', d=0.74). CBT vs. TAU comparisons yielded larger effects, whereas placebo effects (IRT vs. TAU) were small to moderate. Hierarchical regression demonstrated partial mediation of SCI improvement by attributional and cognitive factors (R2=21-27%) following CBT. Improvement in sleep efficiency appears to be independent of such factors. Conclusion: Online CBT modifies sleep-related attributions, night-time thought content and psychopathology. This process partly mediates improvement in DSM-5-defined insomnia. © 2014 Elsevier B.V.

  • Metacognitive beliefs relate specifically to sleep quality in primary insomnia: A pilot study

    24 October 2018

    Objective: To identify whether metacognitive aspects are a specific mental pattern of primary insomnia (PI) or an aspecific correlate of sleep alterations. Methods: Sleep quality (Pittsburgh Sleep Quality Index: PSQI), anxiety (Self-rating Anxiety State: SAS), depression (Beck Depression Inventory: BDI) and metacognition (Metacognitions Questionnaire - Insomnia: MCQ-I) were evaluated in 24 PI patients, 13 snorers and 17 healthy controls. Rank-transformed PSQI, BDI, SAS and MCQ-I scores were submitted to one-way analysis of variance with group as a between-factor. PSQI was submitted to three-way analysis of covariance (ANCOVA) with MCQ-I, BDI or SAS as covariate and group as a between-factor. Post-hoc analyses were conducted using pairwise comparisons with Sidak correction. Results: As expected, PSQI scores significantly differentiated the three groups, one from another: PI had highest scores followed by snorers and healthy controls. PI subjects had MCQ-I scores significantly higher than those of snorers and healthy controls; no difference between the latter groups was found. The ANCOVA on PSQI with MCQ-I as a covariate abolished the difference in sleep quality between PI and snorers, whereas covarying for BDI or SAS left the differences in sleep quality between the groups unchanged. Conclusion: These preliminary results lead to two main conclusions: (i) metacognitive aspects are more prominent in PI when compared to snorers and healthy controls; (ii) MCQI shows higher sensitivity in defining PI patients, with respect to PSQI. If these findings are confirmed and expanded by further studies, the development of a specific metacognitive model of primary insomnia may be warranted. © 2014 Elsevier B.V.