Investigating the efficacy of digital cognitive behavioural therapy in comparison to a sleep-monitoring application via integrated diary and actigraphy: A randomised-controlled trial.

Dissemination of digital cognitive behavioural therapy is a promising approach for treating insomnia in the broad population. Current evidence supports the effectiveness of the digital format, but clinical findings are often limited by the choice of control group and lack of in-depth therapeutic measures. This study was designed to investigate the specific effects of digital cognitive behavioural therapy in comparison to a self-monitoring application. Participants meeting criteria for insomnia were randomly allocated (1:1) to 8 weeks of digital cognitive behavioural therapy or 8 weeks of digital sleep monitoring (control application). The primary outcome, insomnia severity, was assessed at baseline, 8- and 16-weeks post-randomisation. Secondary outcomes included the assessment of sleep via application-integrated sleep diaries and actigraphy. Linear-mixed models were fitted to assess between-group differences. Fifty-six participants (48 females, mean age: M = 45.55 ± 13.70 years) were randomised to either digital cognitive behavioural therapy (n = 29) or digital sleep monitoring (n = 27). At 8- and 16-weeks post-randomisation, large treatment effects (d = 0.87-1.08) indicated robust reductions (-3.70 and -2.97, respectively; p ≤ 0.003) in insomnia severity in the digital cognitive behavioural therapy arm, relative to digital sleep monitoring. Treatment effects in favour of digital cognitive behavioural therapy were also found for self-reported and actigraphy-derived sleep continuity variables, indicating that sleep improved throughout the 8-week intervention period. Our study reinforces the role of digital cognitive behavioural therapy in achieving clinical improvements for patients with insomnia, affirming previous findings and supporting the specific effects of cognitive behavioural therapy.

The clinical effect of digital cognitive behavioural therapy for insomnia in subgroups with depressive and anxiety symptoms: A secondary analysis of a randomized-controlled trial.

Insomnia is a highly prevalent mental disorder, and is often co-occurring with depression and anxiety disorders. Cognitive behavioural therapy for insomnia as treatment of choice for insomnia can also be applied digitally (digital cognitive behavioural therapy for insomnia), making it more accessible. This is a secondary data analysis of a two-armed parallel randomized-controlled trial. In the primary publication, N = 238 participants meeting criteria for the 5th edition of Diagnostic and Statistical Manual of Mental Disorders chronic insomnia disorder were randomly assigned to either 8 weeks of digital cognitive behavioural therapy for insomnia + treatment-as-usual, or waitlist + treatment-as-usual. To determine the clinical effects of digital cognitive behavioural therapy for insomnia in populations with comorbid anxiety and depression symptoms, this secondary analysis focused on two subgroups: (1) participants with high initial depressive symptoms; and (2) participants with high initial anxiety symptoms. Symptoms of insomnia, depression and anxiety as primary outcome measures were obtained at baseline, 8 weeks post-randomization and, in the intervention group only, at 6- and 12-months follow-up. At 8 weeks post-randomization, the use of digital cognitive behavioural therapy for insomnia in both subgroups was associated with large reductions in insomnia severity in comparison to control (depression subgroup: d = 2.37; anxiety subgroup: d = 2.13). Between-group treatment effects were also observed for symptoms of depression in the depression subgroup (d = 1.59), and for symptoms of anxiety in the anxiety subgroup (d = 1.28). Within-group effects were stable over time (d = 0.64-1.63). This secondary analysis shows that digital cognitive behavioural therapy for insomnia reduces insomnia and comorbid symptoms in participants with high initial symptoms of either depression or anxiety with sustained long-term effects.

Virtual reality roleplays for patients with depression: A user experience evaluation.

Background: Virtual reality (VR) has been used successfully and effectively in psychotherapy for a variety of disorders. In the field of depression, there are only a few VR interventions and approaches. Although simple social interactions have been successfully modeled in VR for several mental disorders, there has been no transfer to the field of depression therapy. VR may be employed for psychodynamic psychotherapy to work on interpersonal conflict patterns. In this study, we developed and evaluated a VR intervention for the simulation of roleplay situations in the context of supportive-expressive therapy. Methods: We conducted a clinical user experience (UX) study at a psychotherapeutic clinic in Düsseldorf, Germany. Eight inpatients with depression and four therapists were included. Semi-structured interviews and qualitative content analysis were used to identify UX issues of the developed VR intervention. Usability questionnaires and technical usage data were also considered. The VR intervention consisted of two therapist-controlled roleplay scenarios designed to support work on the core conflictual relationship theme by allowing patients to interact in typical problematic social situations. Recorded VR roleplays allow for therapeutic debriefing with a change of perspective. Therapists were given the option of using the roleplay in multiple sessions. Results: All therapists conducted one session per patient with the VR intervention. From the patient interviews, 26 UX issues were extracted, of which one technical malfunction and two unclarities in the interaction with the VR agent were rated as major problems. From the therapist interviews, 14 UX issues were extracted, of which five were rated as major problems related to the interface in the dialog control or the complex system setup. Conclusion: The main problem was designing a dialog structure that allows both complex conversational flows and a clear control interface. In principle, VR roleplays could be integrated well and safely into therapy. The VR intervention shows promise for providing an emotional experience of interpersonal conflict patterns in the context of psychotherapy. Additionally, other roleplay situations involving various social problem areas must be created and evaluated in terms of the fit to the patients' core conflictual relationship themes.

Perfectionism, perceived stress, and presleep arousal in insomnia: effects on sleep in a daily life study.

STUDY OBJECTIVES: Perfectionism is considered a predisposing and maintaining factor for insomnia disorder. However, previous studies were predominantly based on retrospective self-reports of sleep and have yielded mixed results. Here, we investigated associations between perfectionism, daily stress levels, pre-sleep arousal, and actigraphic and sleep diary-derived sleep in insomnia using an experience sampling design. METHODS: Individuals with insomnia (n = 63) reported their trait perfectionism levels and completed assessments on seven consecutive days. Momentary stress levels were reported on mobile phones at three semirandom time points each day. Presleep arousal levels were rated each morning for the previous night. Sleep onset latency, total sleep time, wake after sleep onset, and sleep efficiency were assessed prospectively using actigraphic watches and sleep diaries. RESULTS: Perfectionism dimensions and daily stress levels did not predict self-reported or actigraphic sleep parameters. Higher levels of somatic and cognitive presleep arousal were robustly associated with indicators of poorer same-night sleep. The concern over mistakes and doubts dimension of perfectionism interacted with cognitive presleep arousal in predicting self-reported sleep parameters. In the presence of higher presleep arousal, participants with high concern over mistakes and doubts experienced shorter self-reported total sleep time and lower sleep efficiency (both Ps < .01) than on days with lower cognitive arousal. CONCLUSIONS: Taken together, our results did not indicate an impact of heightened perfectionism levels on sleep in individuals with insomnia, based on prospective sleep assessments. However, our findings provide further evidence for the role of somatic and cognitive presleep arousal, potentially interacting with perfectionism, in the perpetuation of insomnia symptoms. CITATION: Küskens A, Stricker J, Hertrampf LS, Pietrowsky R, Gieselmann A. Perfectionism, perceived stress, and presleep arousal in insomnia: effects on sleep in a daily life study. J Clin Sleep Med. 2024;20(3):433-443.

The clinical effects of digital cognitive behavioral therapy for insomnia in a heterogenous study sample: results from a randomized controlled trial.

STUDY OBJECTIVES: Numerous studies worldwide have reported the beneficial effects of digital cognitive behavioral therapy for insomnia (dCBT-I). However, few focus on real-world study samples that reflect people in regular care. To test whether dCBT-I is suitable within German regular care, we designed a randomized controlled trial recruiting a heterogenous insomnia population. METHODS: Participants aged ≥18 who met the criteria for insomnia disorder were randomized to 8-weeks dCBT-I + care-as-usual (CAU) or they were set on a waitlist + CAU. The intervention group was followed-up at 6- and 12-months. The primary outcome was self-reported insomnia severity, assessed with the Insomnia Severity Index (ISI) at 8-weeks post-randomization. A one-way ANCOVA with baseline score as a covariate was fitted to determine group differences. Secondary outcomes included measures of daytime functioning, quality of life, depression, anxiety, dreams, and nightmares. RESULTS: Of the N = 238 participants (67.6% female), age range 19-81 years, n = 118 were randomized to dCBT-I and n = 120 to the control group. At posttreatment, the use of dCBT-I was associated with a large reduction in the ISI (Diffadj = -7.60) in comparison to WLC (d = -2.08). This clinical improvement was also reflected in responder and remission rates. Treatment effects were also observed for daytime functioning, quality of life, symptoms of depression and anxiety (ds = 0.26-1.02) and at long-term follow-up (intervention group only; ds = 0.18-1.65). No effects were found for dream and nightmare frequency. CONCLUSIONS: This study showed that dCBT-I reduces insomnia symptoms and improves daytime functioning in a heterogenous insomnia population in Germany with sustained long-term treatment effects in the intervention group. Our results underscore the potential of digital health applications, their suitability within regular care, and their role in facilitating widespread implementation of CBT-I as a first-line treatment for insomnia.

Multidimensional perfectionism and poor sleep: A meta-analysis of bivariate associations.

The link between perfectionism and poor sleep has been intensively debated, and previous studies on perfectionism-sleep associations have yielded mixed results. Recent research suggests that the two-dimensional perfectionism model, differentiating perfectionistic concerns (centered around concerns over imperfections) and perfectionistic strivings (centered around excessively high personal standards), may reconcile previously inconclusive findings, as both dimensions might be differentially related to sleep. Thus, to clarify the perfectionism-sleep link, this meta-analysis investigated relations of perfectionistic concerns and strivings with two well-established self-report measures of poor sleep. A systematic literature search yielded 55 effect sizes from 15 studies (N = 10,275) for inclusion in this meta-analysis. Perfectionistic concerns correlated positively with the Insomnia Severity Index (r+ = 0.221, 95% CI [0.102, 0.333], p = .004) and the Pittsburgh Sleep Quality Index (r+ = 0.248, 95% CI [0.172, 0.321], p < .001). Perfectionistic strivings correlated positively, albeit less strongly, with the Insomnia Severity Index (r+ = 0.114, 95% CI [0.039, 0.189], p = .010), but not significantly with the Pittsburgh Sleep Quality Index (r+ = 0.028, 95% CI [-0.026, 0.082], p = .247). These meta-analytic findings indicate that perfectionistic concerns are substantially linked to poor sleep, whereas the relation of perfectionistic strivings with sleep is less evident. Although the identified associations were less robust for perfectionistic strivings than for perfectionistic concerns, previously used labels like "positive" or "adaptive" appear inappropriate for perfectionistic strivings in the context of sleep.

Nightmare distress is related to traumatic childhood experiences, critical life events and emotional appraisal of a dream rather than to its content.

Nightmares are a substantial burden for sleep quality. Previous studies have shown that traumatic experiences can increase the probability of nightmares, and also waking-life distress can enhance this effect. There is evidence that the intensity of negative dream emotions is more responsible for rating a dream as a nightmare than threatening dream contents. However, there is still a lack of research concerning effects on nightmare distress. We hypothesise that traumatic childhood experiences (such as emotional abuse, obtained by the Childhood Trauma Questionnaire), critical life events (obtained by the Social Readjustment Rating Scale) and threatening dream contents are associated with nightmare distress. A sample of N = 103 participants kept a dream diary over 28 consecutive days. About 60% of the sample were frequent nightmare dreamers. The participants recorded their violent dream contents and dream emotions in their diary. To predict nightmare distress, regression models were constructed; nightmare distress was measured with the Nightmare Distress Questionnaire. Results showed that emotional abuse in childhood and critical life events predicted nightmare distress. Moreover, violent dream contents were associated with nightmare distress but, after we controlled for nightmare frequency and the intensity of negative dream emotions, the significant impact of violent dream contents decreased. The results suggest that the emotional appraisal of a dream has a substantial influence on nightmares in addition to traumatic childhood experiences and critical life events.

No perfect sleep! A systematic review of the link between multidimensional perfectionism and sleep disturbance.

The view that perfectionists are prone to experiencing sleep disturbance is widely held. Yet, almost three decades of empirical research have yielded conflicting results. Whereas some researchers viewed perfectionism as a risk factor for sleep disturbance, others spoke of "adaptive" or "positive" forms of perfectionism in the context of sleep. The multidimensional conceptualisation of perfectionism may resolve this disagreement. Thus, this systematic review aimed to clarify the perfectionism-sleep disturbance link using the widely accepted two-dimensional perfectionism model, differentiating perfectionistic concerns (defined by worries over imperfections) and perfectionistic strivings (defined by excessively high personal standards). A systematic literature search returned 24 relevant empirical studies. Perfectionistic concerns were robustly linked to sleep disturbance. Perfectionistic strivings displayed comparatively small and inconsistent relations with sleep disturbance. Finally, cross-sectional mediation studies suggested that psychological distress and dysfunctional cognitive processes might underlie the perfectionistic concerns-sleep disturbance link. These findings show that considering perfectionistic concerns in explaining, predicting, and treating sleep disturbance may be a promising approach. In contrast, perfectionistic strivings appeared neither universally adaptive nor maladaptive. We identified several critical gaps in the empirical literature and point towards future research directions, highlighting the need for more longitudinal studies.

[Sleep disorders reduce the therapeutic success of inpatient psychosomatic treatments for depressive disorders]. / Schlafstörungen verringern den Therapieerfolg stationärer psychosomatischer Behandlungen bei depressiven Störungen.

Sleep disorders reduce the therapeutic success of inpatient psychosomatic treatments for depressive disorders Objective: What influence do difficulties in falling and staying asleep in patients with depressive disorders have on the success of psychosomatic treatment? Method: The Data were collected in a naturalistic, multicenter observational study (STOP-D) at the beginning (T1), the end (T2) and six months later after discharge (T3). The sample consisted of female patients with depressive disorders (N = 487) who were treated for M = 61.7 days (SD = 26.8). An insomnia scale with a total of seven items was created subsequently to T1 from Items of the Beck Depression Inventory (BDI-I), from the Hamilton Depression Scale (HAMD) and from the Global Severe Index (GSI) from the Symptom Checklist 90 (SCL-90-R). Then groups were formed on changes in insomnia symptoms from T1 to T2. These two groups "sleep improver" and "sleep deteriorators" were tested by analysis of variance. Results: The subsequently constructed insomnia scale showed good psychometric characteristics in the performed analyses. Patients who reported an improvement in their sleep disturbances during inpatient psychosomatic treatment had significantly lower depression scores in the self-evaluation inventories (BDI-I und SCL-90-R) than patients without improvements in their sleep patterns. This effect was even more pronounced for the catamnestic period. Discussion: Insomnia symptoms in depressed female patients can be an important indicator of the effect of inpatient psychosomatic treatment and can have negative impact on the sustainability of the therapy success.

Communication Formats and Their Impact on Patient Perception and Working Mechanisms: A Mixed-Methods Study of Chat-Based vs. Face-to-Face Psychotherapy for Insomnia.

The application of Internet-based interventions within stepped-care models raises the question of when patients should receive Internet-based treatment and when patients should receive face-to-face (FtF) treatment. To address this question, the patient perception and effects of working mechanisms were evaluated after brief psychotherapy for insomnia applying a mixed-methods approach. Treatment was either delivered through a text-based chat or it was delivered FtF. Almost half of the patients who received the chat-based treatment indicated that chat-based communication was appropriate for them when dealing with sleep difficulties, but that they would prefer FtF communication for more sensitive topics. Results from the therapists' evaluations of working mechanisms yielded that these working mechanisms were more strongly associated with treatment outcome in the FtF condition than they were in the chat-based condition. To understand and to interpret the results, media richness theory may be a useful tool: More severely impaired patients and patients with more complex concerns may need more complex (richer) communication formats for treatment delivery. Such heuristics may help to better justify treatment recommendations and optimize media choice in Internet-based interventions, e.g., by defining moments when human interaction is needed and moments when communication could be conducted by nonhuman chatbots.

[Internet-based cognitive behavioral therapy of insomnia and nightmare disorder]. / Internetbasierte kognitive Verhaltenstherapie der Insomnie und Albtraumstörung.

Cognitive behavioral therapeutic interventions are considered to be one of the most effective forms of treatment of various mental disorders. Besides being very frequent, sleep disorders, such as insomnia and nightmare disorder are often not treated effectively and guideline-conform, mainly due to the lack of qualified psychotherapists. Implementation of modern technical options, such as web-based psychotherapy can help to overcome this problem. This article presents the current situation in the treatment of insomnia and nightmare disorders as particularly well-suited fields of application. For insomnia there are several English language and also recently German language options, which for example were also evaluated for the application to work-related stress and sleep disorders. In this respect, procedures with and without contact to a therapist or multicomponent procedures and single interventions can be differentiated. For nightmare disorders imagery rehearsal therapy provides a structure, which can also easily be transferred to an internet-based therapy program. The currently beginning use of internet-based treatment of sleep disorders does not yet utilize all theoretically available technical possibilities. The potential of internet-based therapy is extremely versatile and it remains for medical sleep experts to consider which method can be used for which indications.

Nightmare distress revisited: Cognitive appraisal of nightmares according to Lazarus' transactional model of stress.

Aim of the current research was to newly conceptualize nightmare distress. The special focus was on the appraisal of nightmare distress while applying a theory-driven approach based on Lazarus' transactional model of stress. It was argued that individuals feel the more distressed the more they feel threatened and harmed by their nightmares (primary appraisal according to Lazarus) and the more they lack of adequate coping skills to deal with the stressor (secondary appraisal). Based on these assumptions, the questionnaire of Cognitive Appraisal of Nightmares (CAN) was challenged empirically in two studies of patients who have experienced distressing nightmares using explorative and confirmative factor analyses (N = 504 and N = 402). Items and scales showed good psychometric properties and plausible correlations. The CAN sum score was more distinct from nightmare frequency than the frequently used Nightmare Distress Questionnaire (NDQ), underpinning that frequency and distress are both different approaches to what patients suffer from. The NDQ was particularly associated with acted out behaviors after a nightmare, while the CAN was particularly associated with physiological and emotional consequences of a nightmare. In order to obtain a multifactorial and theory-driven picture about how individuals appraise their nightmares, the CAN may be convenient.

Portable PSG for sleep stage monitoring in sports: Assessment of SOMNOwatch plus EEG.

Current sport-scientific studies mostly neglect the assessment of sleep architecture, although the distribution of different sleep stages is considered an essential component influencing an athlete's recovery and performance capabilities. A mobile, self-applied tool like the SOMNOwatch plus EEG might serve as an economical and time-friendly alternative to activity-based devices. However, self-application of SOMNOwatch plus EEG has not been validated against conventional polysomnography (PSG) yet. For evaluation purposes, 25 participants (15 female, 10 male; M age = 22.92 ± 2.03 years) slept in a sleep laboratory on two consecutive nights wearing both, conventional PSG and SOMNOwatch plus EEG electrodes. Sleep parameters and sleep stages were compared using paired t-tests and Bland-Altman plots. No significant differences were found between the recordings for Sleep Onset Latency, stages N1 to N3 as well as Rapid Eye Movement stage. Significant differences (Bias [95%-confidence interval]) were present between Total Sleep Time (9.95 min [-29.18, 49.08], d = 0.14), Total Wake Time (-13.12 min [-47.25, 23.85], d = -0.28), Wake after Sleep Onset (-11.70 min [-47.25, 23.85], d = -0.34) and Sleep Efficiency (2.18% [-7.98, 12.34], d = 0.02) with small effect sizes. Overall, SOMNOwatch plus EEG can be considered a valid and practical self-applied method for the examination of sleep. In sport-scientific research, it is a promising tool to assess sleep architecture in athletes; nonetheless, it cannot replace in-lab PSG for all clinical or scientific purposes.

The effects of brief chat-based and face-to-face psychotherapy for insomnia: a randomized waiting list controlled trial.

BACKGROUND: Recent studies have directly compared the effects of Internet-based self-help interventions with face-to-face (FtF) treatment, but groups may also differ regarding other aspects, aside from the fact that the former is online and the latter offline. Thus, we examined the effects of a brief three-session psychotherapy for insomnia that was delivered FtF or through synchronous text-based chats. METHODS: Seventy-three patients diagnosed with insomnia were randomized to either FtF treatment, a chat-based treatment, or to a waiting list control group (WL). Treatment included topics that covered imagination, sleep restriction, sleep hygiene, repetition, and consolidation. RESULTS: Compared to WL, patients in both groups improved regarding sleep quality (dFtF = 1.02, dchat = 1.69) and improvements remained at the two-month follow-up (FU; dFtF = 1.18, dchat = 2.40). Improvements in actigraphic sleep onset latency that had been gained at the post-test time point, disappeared at FU, while subjective improvements remained. At FU, patients in the chat group outperformed FtF patients regarding subjective total sleep time, anxiety, depression, and cognitive pre-sleep arousal. CONCLUSION: Three sessions were efficacious in treating insomnia, and the chat-based treatment slightly outperformed FtF treatment. This may be caused by the highly individualized treatment approach, by the fact that chatting forces both patients and therapists to adhere to the essence of the treatment goal, by increased feelings of privacy, autonomy, and a sense of felt responsibility for treatment. These hypotheses should be validated in future studies. So far, we can summarize that chat-based communication facilitates the treatment of patients who cannot or who do not want to attend FtF treatment.

Aetiology and treatment of nightmare disorder: State of the art and future perspectives.

This consensus paper provides an overview of the state of the art in research on the aetiology and treatment of nightmare disorder and outlines further perspectives on these issues. It presents a definition of nightmares and nightmare disorder followed by epidemiological findings, and then explains existing models of nightmare aetiology in traumatized and non-traumatized individuals. Chronic nightmares develop through the interaction of elevated hyperarousal and impaired fear extinction. This interplay is assumed to be facilitated by trait affect distress elicited by traumatic experiences, early childhood adversity and trait susceptibility, as well as by elevated thought suppression and potentially sleep-disordered breathing. Accordingly, different treatment options for nightmares focus on their meaning, on the chronic repetition of the nightmare or on maladaptive beliefs. Clinically, knowledge of healthcare providers about nightmare disorder and the delivery of evidence-based interventions in the healthcare system is discussed. Based on these findings, we highlight some future perspectives and potential further developments of nightmare treatments and research into nightmare aetiology.

The Effects of an Internet-Based Imagery Rehearsal Intervention: A Randomized Controlled Trial.

BACKGROUND: Nightmares are extremely dysphoric dreams, which are prevalent and associated with psychological strain. This study investigated (a) the efficacy of an internet-based imagery rehearsal therapy (IRT), (b) the role of imagery rescription, and (c) the role of guidance during internet-based IRT. METHODS: A total of 127 patients suffering from mainly idiopathic nightmares were randomly assigned to 1 of 2 IRT internet-based groups (guided IRT; unguided IRT) or to 1 of 2 active control groups (frequency control group; narrative control group). RESULTS: IRT was more effective than a nightmare frequency control condition with respect to nightmare frequency and nightmare distress. Compared to the narrative control group, IRT was only superior in improving nightmare distress but not in nightmare frequency because the narrative control group also improved regarding nightmare frequency. Guidance by a nightmare coach did not affect efficacy, compliance, or dropout. CONCLUSION: Internet-based IRT seems to be an effective treatment even when offered with minimal guidance by a nightmare coach. Describing the nightmare narrative in detail already decreased nightmare frequency. However, with regard to inducing decreases in nightmare frequency and nightmare distress, IRT was superior to the narrative control group. The results are discussed with reference to the mastery hypothesis.

When you have to climb downhill to reach the top: the effect of action versus state orientation on solvinga goal-subgoal conflict in the Tower of Hanoi task.

Complex problems often include a response conflict between a subgoal and a final goal. The present experiment investigated the roles of situational demands and individual differences in self-regulation on solving goal-subgoal conflicts in a computerized Tower of Hanoi task. Action-oriented versus state-oriented individuals were randomly assigned to a demanding condition in which they deliberated about a personal decision problem, or to a nondemanding control condition. In line with expectations state-oriented individuals had greater difficulties to solve goal-subgoal conflicts in the demanding compared to the nondemanding condition. Action-oriented individuals performed well in both conditions. In line with Personality Systems Interactions theory (Kuhl, 2000) the findings show that complex problem solving depends on how well people are able to deal with situational demands.