Daytime functioning in primary insomnia: does attentional focus contribute to real or perceived impairment?

A study was conducted to test the proposal that self-focused attention or monitoring exacerbates the perception of poor daytime functioning in the absence of objective deficits among individuals with insomnia. Fifty-one participants meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for primary insomnia were randomly assigned to a self-focus group (viewing themselves on a TV monitor), a monitoring group (instructed to focus on their thoughts, body sensations, mood, and performance), or a no instruction group while completing a battery of neuropsychological tests. The results indicated that all participants performed within published normative ranges on all tests. The groups did not differ on their objective test performance, but the self-focus group perceived their performance on the tests as significantly worse than the no instruction group. These findings suggest that self-focused attention may contribute to perceived impairment in daytime functioning in primary insomnia.

Misperception of sleep can adversely affect daytime functioning in insomnia.

This experiment was designed to investigate the relationship between subjective perception of sleep and daytime processes in primary insomnia. Twenty-two individuals with primary insomnia received positive or negative feedback about their sleep, immediately on waking, on three consecutive mornings. The positive feedback was that last night's sleep was good quality. The negative feedback was that last night's sleep was poor quality. Objective sleep on each of the three nights was estimated by actigraphy and did not differ across the three nights or the two feedback conditions. Negative feedback (based on 32 nights of data) was associated with more negative thoughts, sleepiness, monitoring for sleep-related threat, and safety behaviours during the day, relative to positive feedback (based on 34 nights of data). These results indicate that the impaired daytime functioning reported by insomnia patients is maintained, at least in part, by subjective perception of sleep.

Sleep-related functioning in euthymic patients with bipolar disorder, patients with insomnia, and subjects without sleep problems.

OBJECTIVE: The authors investigated sleep-related functioning in euthymic patients with bipolar disorder. METHOD: Euthymic patients with bipolar disorder (N=20), patients with insomnia (N=20), and subjects with good sleep (N=20) were compared on data from interviews and questionnaires and on findings from eight consecutive days and nights of sleep diary keeping (subjective sleep estimate) and actigraphy (objective sleep estimate). RESULTS: Seventy percent of the euthymic patients with bipolar disorder exhibited a clinically significant sleep disturbance. Compared with the other groups, the bipolar disorder group exhibited impaired sleep efficiency, higher levels of anxiety and fear about poor sleep, lower daytime activity levels, and a tendency to misperceive sleep. The bipolar disorder group held a level of dysfunctional beliefs about sleep that was comparable to that in the insomnia group and significantly higher than that in the good sleeper group. CONCLUSIONS: Insomnia is a significant problem among euthymic patients with bipolar disorder. Components of cognitive behavior therapy for insomnia, especially stimulus control and cognitive therapy, may be a helpful adjunct to treatment for patients with bipolar disorder.

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.

Monitoring for sleep-related threat: a pilot study of the Sleep Associated Monitoring Index (SAMI).

OBJECTIVE: The aims of this pilot study were: 1) to establish the reliability and validity of a new self-report instrument designed to index monitoring for sleep-related threat; 2) to determine the presence of ten monitoring types proposed in a recent cognitive model of insomnia and to examine the relationship between monitoring for sleep-related threat and severity of sleep disturbance; and 3) to explore the association between monitoring and the established constructs of amplification and self-focus. METHODS: Participants (N = 400) completed the Sleep Associated Monitoring Index (SAMI) and the Pittsburgh Sleep Quality Index (PSQI) (1). Based on the PSQI score, the sample was split into two groups to compare normal sleepers (NS) and individuals with a clinically significant sleep disturbance (CSSD). A subset of the sample completed the SAMI and a battery of questionnaires to examine convergent validity between monitoring, amplification, and self-focus. RESULTS: Individuals in the CSSD group had higher SAMI scores than the NS group and the SAMI correlated positively with severity of sleep disturbance as indexed by the PSQI. A principal components analysis extracted 8 components accounting for 69% of the variance. The 30-item SAMI demonstrated high validity, consistency, and reliability. Scores on the SAMI were moderately positively correlated with scores on measures of amplification and self-focus. CONCLUSIONS: Preliminary evidence suggests that the SAMI offers a valid and reliable instrument to index monitoring before and after treatment for sleep disturbance. The implications for the presence of monitoring for sleep-related threat in chronic insomnia are discussed.