Network Intervention Analyses of cognitive therapy and behavior therapy for insomnia: Symptom specific effects and process measures.

Cognitive therapy (CT) and behavior therapy (BT) are both effective for insomnia. In this study we applied Network Intervention Analysis to investigate specific effects of CT and BT on outcomes and process measures. The analysis was based on a randomized controlled trial comparing CT (n = 65), BT (n = 63) and cognitive behavioral therapy for insomnia (n = 60; not included in this study). In the first networks, the separate items of the Insomnia Severity Index and sleep efficiency were included. In the second networks, the pre-specified process measures for BT and CT, sleep efficiency, and the sum-score of the Insomnia Severity Index were included. At the different time points, we found CT-effects on worry, impaired quality of life, dysfunctional beliefs, and monitoring sleep-related threats, and BT-effects on sleep efficiency, difficulty maintaining sleep, early morning awakening, time in bed, sleep incompatible behaviors and bed- and rise time variability. These observed effects of CT and BT were consistent with their respective theoretical underpinnings. This study provided new information on the mechanisms of change in CT and BT. In the future, this may guide us to the most effective treatment modules or even subsets of interventions.

You'll feel better in the morning: slow wave activity and overnight mood regulation in interepisode bipolar disorder.

BACKGROUND: Sleep disturbances are prominent correlates of acute mood episodes and inadequate recovery in bipolar disorder (BD), yet the mechanistic relationship between sleep physiology and mood remains poorly understood. Using a series of pre-sleep mood inductions and overnight sleep recording, this study examined the relationship between overnight mood regulation and a marker of sleep intensity (non-rapid eye movement sleep slow wave activity; NREM SWA) during the interepisode phase of BD. METHODS: Adults with interepisode BD type 1 (BD; n = 20) and healthy adult controls (CTL; n = 23) slept in the laboratory for a screening night, a neutral mood induction night (baseline), a happy mood induction night, and a sad mood induction night. NREM SWA (0.75-4.75 Hz) was derived from overnight sleep EEG recordings. Overnight mood regulation was evaluated using an affect grid pleasantness rating post-mood induction (pre-sleep) and the next morning. RESULTS: Overnight mood regulation did not differ between groups following the sad or happy inductions. SWA did not significantly change for either group on the sad induction night compared with baseline. In BD only, SWA on the sad night was related to impaired overnight negative mood regulation. On the happy induction night, SWA increased relative to baseline in both groups, though SWA was not related to overnight mood regulation for either group. CONCLUSIONS: These findings indicate that SWA disruption may play a role in sustaining negative mood state from the previous night in interepisode BD. However, positive mood state could enhance SWA in bipolar patients and healthy adults.

Hypersomnia subtypes, sleep and relapse in bipolar disorder.

BACKGROUND: Though poorly defined, hypersomnia is associated with negative health outcomes and new-onset and recurrence of psychiatric illness. Lack of definition impedes generalizability across studies. The present research clarifies hypersomnia diagnoses in bipolar disorder by exploring possible subgroups and their relationship to prospective sleep data and relapse into mood episodes. METHOD: A community sample of 159 adults (aged 18-70 years) with bipolar spectrum diagnoses, euthymic at study entry, was included. Self-report inventories and clinician-administered interviews determined features of hypersomnia. Participants completed sleep diaries and wore wrist actigraphs at home to obtain prospective sleep data. Approximately 7 months later, psychiatric status was reassessed. Factor analysis and latent profile analysis explored empirical groupings within hypersomnia diagnoses. RESULTS: Factor analyses confirmed two separate subtypes of hypersomnia ('long sleep' and 'excessive sleepiness') that were uncorrelated. Latent profile analyses suggested a four-class solution, with 'long sleep' and 'excessive sleepiness' again representing two separate classes. Prospective sleep data suggested that the sleep of 'long sleepers' is characterized by a long time in bed, not long sleep duration. Longitudinal assessment suggested that 'excessive sleepiness' at baseline predicted mania/hypomania relapse. CONCLUSIONS: This study is the largest of hypersomnia to include objective sleep measurement, and refines our understanding of classification, characterization and associated morbidity. Hypersomnia appears to be comprised of two separate subgroups: long sleep and excessive sleepiness. Long sleep is characterized primarily by long bedrest duration. Excessive sleepiness is not associated with longer sleep or bedrest, but predicts relapse to mania/hypomania. Understanding these entities has important research and treatment implications.

Rotational cooling of HD+ molecular ions by superelastic collisions with electrons.

Merging an HD+ beam with velocity matched electrons in a heavy ion storage ring we observed rapid cooling of the rotational excitations of the HD+ ions by superelastic collisions (SEC) with the electrons. The cooling process is well described using theoretical SEC rate coefficients obtained by combining the molecular R-matrix approach with the adiabatic nuclei rotation approximation. We verify the DeltaJ=-2 SEC rate coefficients, which are predicted to be dominant as opposed to the DeltaJ=-1 rates and to amount to (1-2)x10;{-6} cm;{3} s;{-1} for initial angular momentum states with J< or =7, to within 30%.

Pre-sleep imagery under the microscope: a comparison of patients with insomnia and good sleepers.

During the pre-sleep period and in the natural home environment patients with insomnia (N=20) and good sleepers (N=20) were asked to record when an image came to mind by pressing a handheld counter. They then provided an oral description of the image and indicated whether the image was 'pleasant', 'unpleasant', or 'neutral' (responses captured via a voice-activated tape recorder). Subjective and objective (actigraphy) estimates of sleep-onset latency (SOL) were recorded. On both the handheld counter and the audiotape recording, participants with insomnia reported fewer images than the good sleepers. The insomnia group had a higher percentage of unpleasant images compared to good sleepers. For the insomnia group, but not the good sleeper group, there was a positive correlation between unpleasant images and subjective SOL. The insomnia group experienced more images regarding 'intimate relationships' and 'sleep' and fewer regarding 'random/non-connected topics' compared to the good sleeper group. The results are discussed with reference to proposals made by Borkovec, Ray and Stöber (Cognitive Ther. Res., 22, (1998) 561) in the context of generalised anxiety disorder (GAD).

A cognitive model of insomnia.

Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.

Insomnia: symptom or diagnosis?

Is insomnia a clinical entity in its own right or is it simply a symptom of an underlying medical or psychological disorder? The widely held view among many clinicians and researchers is that insomnia is secondary to or an epiphenomenon of a 'primary' medical or psychological disorder. Consequently, insomnia 'symptoms' have tended to be trivialized or ignored. This paper aims to highlight the assumptions and implications of distinguishing between 'primary' and 'secondary' insomnia and reviews the evidence for the distinction by considering (1) issues relating to the diagnosis and classification of insomnia, (2) whether insomnia is a symptom of other medical and psychological disorders, (3) whether insomnia is comorbid with other disorders, (4) whether insomnia is 'secondary' to other disorders, and (5) whether insomnia occurs in the absence of comorbidity. It is concluded that viewing insomnia as a symptom or epiphenomenon of other disorders can be unfounded. This view may deprive many patients of treatment, which might not only cure their insomnia, but may also reduce symptoms associated with the assumed 'primary' disorder. Finally, directions for future research to further illuminate the relationship between insomnia and comorbid disorders are discussed.

Chronic pain and posttraumatic stress disorder: mutual maintenance?

Common sequelae following a traumatic event include chronic pain and posttraumatic stress disorder (PTSD). Over the last decade, the literature relating to PTSD has become progressively more sophisticated, resulting in well-supported theories and treatments for sufferers. Equivalent research relating to chronic pain has more recently gathered momentum. However, to date there has been minimal attention devoted to the concurrence of the two disorders, even though high comorbidity has been noted. This review begins by briefly summarizing the literature relating to the two disorders in terms of symptoms, prevalence and comorbidity. It explicates the major psychological theories of chronic pain and PTSD and reviews the evidence relating what factors maintain the disorders. A number of pathways by which chronic pain and PTSD may be mutually maintaining are highlighted. We conclude that chronic pain and PTSD are mutually maintaining conditions and that there are several pathways by which both disorders may be involved in the escalation of symptoms and distress following trauma. Treatment implications are considered, as are issues for future research.

Reconstructing trauma memories: a prospective study of "amnesic" trauma survivors.

The purpose of this study was to investigate memory for trauma in patients who were initially amnesic of the trauma as a result of mild traumatic brain injury (MTBI). Motor vehicle accident survivors who sustained a MTBI were assessed for their memory within 1-month posttrauma (n = 79) and again at 2-years posttrauma (n = 50). Consistent with their brain injury, all patients reported significant amnesia of their accident at initial assessment. At 2-year posttrauma, 40% were able to remember their accident. Reporting memory for the trauma was associated with shorter duration of posttraumatic amnesia. These findings suggest that people reconstruct memories of trauma in the absence of complete encoding of the experience. Possible mechanisms for memory reconstruction are considered.

Simulated malingering in pain patients: a study with the Pain Patient Profile.

OBJECTIVE: To investigate the utility of the Pain Patient Profile (P3) in detecting those who are faking or exaggerating complaints of pain while attempting to avoid detection. METHOD: A control group of pain patients ('Pain Controls'; PC; N = 62) was compared with a general clinical group who did not report pain but were instructed to simulate malingered pain ('General Rehabilitation Simulators', GR, N = 34); and a group whose primary problem was chronic pain who were instructed to exaggerate the extent of their pain and related problems ('Pain Simulators' PS; N = 26). RESULTS: Both groups of simulating participants reported significantly higher scores on all clinical scales (anxiety, depression, somatization) compared with non-simulating control participants and were more likely to obtain an abnormal T-score on the clinical scales. The validity scale was able to differentiate the PS group from the PC group, but the GR group was not differentiated from the PC group by the validity scale. CONCLUSIONS: The results indicate that with further study, the P3 may be a useful adjunct to the clinical assessment of symptom magnification in pain claimants.

Suppressing and attending to pain-related thoughts in chronic pain patients.

Attempted suppression of pain-related thoughts was investigated in consecutive referrals for pain management (N = 39). Participants monitored their pain-related thoughts for three 5-min periods. In period 1, all participants were instructed to think about anything. For period 2, participants were instructed to either suppress pain-related thoughts, attend to pain-related thoughts, or to continue to think about anything. In period 3, all participants were again instructed to think about anything. Participants instructed to attend to their pain reported more pain-related thoughts than suppressors and controls in both periods 2 and 3. Suppressors experienced reduced pain-related thoughts during period 2. There was no immediate enhancement or delayed increase.

Telephone crisis intervention skills: a simulated caller paradigm.

Counseling skills were evaluated in a telephone counseling service for Vietnam veterans. Thirty simulated crisis calls were made to telephone counselors by experienced clinical psychologists. The counselors' responses were rated on dimensions that indexed general counseling skills, knowledge of veteran needs, and provision of appropriate advice. Whereas the majority of callers demonstrated adequate counseling skills, many lacked knowledge of veterans' posttraumatic stress, common veteran terminology, and the nature of veterans' experiences. The findings suggest that telephone counseling services that target specific populations should employ comprehensive training to ensure that counselors possess adequate and relevant knowledge about callers and their presenting problems. The simulated caller paradigm appears to be an effective paradigm for training and evaluation of telephone counselors.

Pre-sleep cognitive activity: a comparison of sleep-onset insomniacs and good sleepers.

OBJECTIVE: Pre-sleep cognitive activity has been implicated in the maintenance of sleep-onset insomnia. The present study aimed to investigate the focus of attention, content and characteristics of cognition during the pre-sleep period. METHOD: A semi-structured clinician-administered interview designed to index the content of pre-sleep cognition was completed by individuals diagnosed with sleep-onset insomnia (N = 30) and good sleepers (N = 30). RESULT: The pre-sleep cognitive activity of insomniacs could be distinguished from that of good sleepers by being more focused on worries, problems and noises in the environment, and less focused on 'nothing in particular'. In terms of content, the insomnia group were more likely to think about not sleeping or about something that had happened during the day. Insomniacs experienced their pre-sleep cognitive activity as more occupying, less intentional, for a longer duration, and as causing more difficulty with sleep onset compared to good sleepers. Pre-sleep imagery was reported at similar rates across diagnosis, but was more distressing and more likely to be associated with strong physical sensations for the insomniac group compared with the good sleeper group. CONCLUSION: The present study provides a comprehensive investigation of pre-sleep cognitive activity and raises a number of areas for future research including monitoring of bodily sensations, imagery, problem-solving and non-active strategies in facilitating sleep onset.

Memory for acute stress disorder symptoms: a two-year prospective study.

The present study aimed to index the accuracy of memory for acute trauma symptoms by comparing the symptoms reported by motor vehicle accident (MVA) victims within 1 month posttrauma with the recall of these symptoms at 2 years posttrauma. Ninety-two consecutive MVA admissions were assessed for the presence of acute stress disorder (ASD) within 1 month posttrauma. At 2 years posttrauma, 61% (N = 56) of the sample were reassessed for posttraumatic stress disorder (PTSD) and for accuracy of recall of the symptoms reported during the first assessment. At least one of the four ASD diagnostic clusters was recalled inaccurately by 75% of patients. High levels of posttraumatic stress severity and high subjective ratings of injury severity at 2 years posttrauma were associated with errors of addition (i.e., recalling the presence of acute symptoms 2 years posttrauma that were not reported during the first assessment). Low levels of posttraumatic stress severity and low subjective ratings of injury severity at 2 years posttrauma were associated with errors of omission (i.e., omitting to recall acute symptoms 2 years posttrauma that were reported during the first assessment). These results suggest that retrospective reports of acute stress symptoms should be interpreted cautiously because of the influence of current symptoms on recall of acute symptoms.

A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder.

This study investigated the role of acute arousal in the development of posttraumatic stress disorder (PTSD). Hospitalized motor-vehicle-accident survivors (n = 146) were assessed for acute stress disorder (ASD) within 1 month of the trauma and were reassessed (n = 113) for PTSD 6 months posttrauma. Heart rate (HR) and blood pressure (BP) were assessed on the day of hospital discharge. Participants with subclinical ASD had higher HR than those with ASD and no ASD. Participants who developed PTSD had higher HR in the acute posttrauma phase than those without PTSD. Diagnosis of ASD and resting HR accounted for 36% of the variance of the number of PTSD symptoms. A formula composed of a diagnosis of ASD or a resting HR of > 90 beats per minute possessed strong sensitivity (88%) and specificity (85%) in predicting PTSD. These findings are discussed in terms of acute arousal and longer term adaptation to trauma.

Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury.

OBJECTIVE: To assess the ability of acute stress disorder to predict posttraumatic stress disorder (PTSD), the relationship between acute stress disorder and PTSD over the 2 years following mild traumatic brain injury was determined. METHOD: Survivors of motor vehicle accidents who sustained mild traumatic brain injuries were assessed for acute stress disorder within 1 month of the trauma (N=79) and for PTSD at 6 months (N=63) and 2 years (N=50) posttrauma. RESULTS: Acute stress disorder was diagnosed in 14% of the patients. Among the patients who participated in all three assessments, 80% of the subjects who met the criteria for acute stress disorder were diagnosed with PTSD at 2 years. Of the total initial group, 73% of those diagnosed with acute stress disorder had PTSD at 2 years. CONCLUSIONS: This study provides further support for the utility of the acute stress disorder diagnosis as a predictor of PTSD but indicates that the predictive power of the diagnostic criteria can be increased by placing greater emphasis on reexperiencing, avoidance, and arousal symptoms.

The relationship between acute stress disorder and posttraumatic stress disorder: a 2-year prospective evaluation.

Previous research established that 78% of a sample of motor vehicle accident survivors initially diagnosed with acute stress disorder (ASD) were subsequently diagnosed with posttraumatic stress disorder (PTSD) at 6 months posttrauma. Although the previous study provided initial evidence for the utility of the ASD diagnosis, the relationship between ASD and PTSD was assessed over a relatively short period. The present study reassessed that original sample 2 years following the trauma to establish the longer term relationship between ASD and PTSD. ASD was diagnosed in 13% of participants, and 21% were diagnosed with subsyndromal ASD. In terms of participants who participated in all 3 assessments, 63% who met the criteria for ASD, 70% who met the criteria for subsyndromal ASD, and 13% who did not meet the criteria for ASD were diagnosed with PTSD at 2 years posttrauma. These findings indicate the importance of considering multiple pathways to the development of PTSD.

A qualitative investigation of the organization of traumatic memories.

OBJECTIVE: Previous research has indicated that cohesive organization of traumatic memories may be necessary for the processing and resolution of post-trauma symptoms. The present study aimed to evaluate the qualitative features of memory organization, dissociation and perception of threat in traumatic memories recalled by individuals with and without acute stress disorder (ASD). DESIGN: Survivors of motor vehicle accidents (MVA) with either ASD or no ASD participated in a study on traumatic memories within 12 twelve days of the MVA. METHOD: Participants' audiotaped recollections of their memories of the MVA were coded in terms of disorganized structure, dissociative content and perception of threat. RESULT: The recollections of ASD participants were characterized by disorganization and dissociation more than those of non-ASD participants. CONCLUSION: The current findings suggest that disorganized memory structure may be one process that impedes access to, and modification of, trauma-related cognitive schema.