Sleep Initiation and Maintenance Disorders: Broomfield NM

Espie CA, Broomfield NM, MacMahon KM, Macphee LM, Taylor LM. · Sleep Research Laboratory, Section of Psychological Medicine, University of Glasgow, Southern General Hospital, Glasgow G51 4TF, Scotland, UK. · Sleep Med Rev. · Pubmed #16809056 No free full text.

Abstract: Psychophysiologic insomnia (PI) is the most common form of persistent primary insomnia. Its 'behavioral phenotype', comprising elements such as conditioned arousal, sleep-incompatible behavior and sleep preoccupation, has not changed markedly across several generations of diagnostic nosology. Moreover, a substantial outcome literature demonstrates that PI can be treated effectively using a range of psychological interventions. It seems evident that behavioral and cognitive factors play a part. What is less clear is exactly how PI develops and what are its crucial maintaining factors. This paper proposes an explanatory model, that we call the attention-intention-effort pathway. The argument is that sleep normalcy is a relatively automatic process. Consequently, it is vulnerable, and may be inhibited, by focused attention and by direct attempts to control its expression. Drawing upon parallels in the literature on adult psychopathology, and upon recent clinical and experimental studies on insomnia, the evidence for this pathway is considered and a research agenda is outlined. In particular, computerized tests of cognitive bias are seen as offering an objective means of appraising mental processes in insomnia. These may be applied concurrently with somatic measurements in future studies to better understand this common psycho-physiologic condition.

Mooney P, Espie CA, Broomfield NM. · Elizabeth Martin Clinic, Inverclyde, PA16 0NT, Scotland. · Behav Sleep Med. · Pubmed #19330582 No free full text.

Abstract: This study considers the role of pre-sleep cognitive arousal, worry, and inhibition in sleep onset difficulties. The Pennebaker writing task, which promotes emotional processing by asking people to write about their thoughts, worries, and emotions, has proven effective in several areas of health. Here, the paradigm's ability to reduce pre-sleep cognitive arousal (PSCA) and sleep onset latency (SOL) in people with insomnia was tested. Twenty-eight people with insomnia were randomized to three nights of Pennebaker writing or a control condition, following a one-night baseline. The outcomes of change over baseline at Day 4 in pre-sleep cognitive arousal and SOL were compared. Writing significantly reduced pre-sleep cognitive arousal on one out of two measures, but did not significantly reduce SOL.

Waine J, Broomfield NM, Banham S, Espie CA. · University of Glasgow Sleep Research Laboratory, Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow G51 4TF, Scotland, UK. · J Behav Ther Exp Psychiatry. · Pubmed #18452893 No free full text.

Abstract: Patients with Primary insomnia often experience intrusive, worrisome cognitive activity in the pre-sleep period. Metacognitive beliefs may explain this yet no valid reliable scale exists. The present study, therefore, developed the Metacognitions Questionnaire--Insomnia (MCQ-I). Following initial metacognitive insomnia profiling interviews, item refinement produced a preliminary 60-item MCQ-I. This was administered to 34 primary insomniacs and 37 normal sleepers. Psychometric data indicate primary insomniac patients score significantly higher than normal sleepers on MCQ-I. Test-retest reliability is good. Face, concurrent, construct and discriminant validity, scale sensitivity and specificity are all acceptable. Further research with larger primary insomnia and normal sleeper samples is now required.

Espie CA, MacMahon KM, Kelly HL, Broomfield NM, Douglas NJ, Engleman HM, McKinstry B, Morin CM, Walker A, Wilson P. · University of Glasgow Sleep Research Laboratory, Southern General Hospital, Scotland, UK. · Sleep. · Pubmed #17552372 No free full text.

Abstract: STUDY OBJECTIVES: Persistent insomnia, although very common in general practice, often proves problematic to manage. This study investigates the clinical effectiveness and the feasibility of applying cognitive behavior therapy (CBT) methods for insomnia in primary care. DESIGN: Pragmatic randomized controlled trial of CBT versus treatment as usual. SETTING: General medical practice. PARTICIPANTS: Two hundred one adults (mean age, 54 years) randomly assigned to receive CBT (n = 107; 72 women) or treatment as usual (n = 94; 65 women). INTERVENTION: CBT comprised 5 sessions delivered in small groups by primary care nurses. Treatment as usual comprised usual care from general practitioners. MEASUREMENTS AND RESULTS: Assessments were completed at baseline, after treatment, and at 6-month follow-up visits. Sleep outcomes were appraised by sleep diary, actigraphy, and clinical endpoint. CBT was associated with improvements in self-reported sleep latency, wakefulness after sleep onset, and sleep efficiency. Improvements were partly sustained at follow-up. Effect sizes were moderate for the index variable of sleep efficiency. Participants receiving treatment as usual did not improve. Actigraphically estimated sleep improved modestly after CBT, relative to no change in treatment as usual. CBT was also associated with significant positive changes in mental health and energy/vitality. Comorbid physical and mental health difficulties did not impair sleep improvement following CBT. CONCLUSION: This study suggests that trained and supervised nurses can effectively deliver CBT for insomnia in routine general medical practice. Treatment response to small-group service delivery was encouraging, although effect sizes were smaller than those obtained in efficacy studies. Further research is required to consider the possibility that CBT could become the treatment of first choice for persistent insomnia in primary healthcare.

Robertson JA, Broomfield NM, Espie CA. · University of Glasgow Sleep Research Laboratory, Glasgow, UK. · J Sleep Res. · Pubmed #17542954 No free full text.

Abstract: Psychophysiological insomnia (PI) is the most common insomnia subtype, representing 12-15% of all sleep centre referrals. Diagnostic guidelines describe PI as an intrinsic sleep disorder involving both hyperarousal and learned sleep-preventing associations. Whilst evidence for the first component is reasonably compelling, evidence for learned (conditioned) sleep effects is markedly lacking. Indeed, to date no study has attempted to capture directly the conditioned arousal effect assumed to characterize the disorder. Accordingly, the present study explored variations in subjective arousal over time in 15 PI participants (sleep onset type) and 15 normal sleepers (NS). Self-report measures of cognitive arousal, somatic arousal and sleepiness were taken at three time points: 3 h before bedtime (early to mid-evening); 1 h before bedtime (late evening); and in the bedroom at lights out (bedtime) across four, 24-h cycles. Fluctuations in mean arousal and sleepiness values, and in day-to-day variation were examined using analyses of variance. Participants with PI were significantly more cognitive aroused and significantly less sleepy relative to NS, within the bedroom environment. These results support the tenet of conditioned mental arousal to the bedroom, although competing explanations cannot be ruled out. Results are discussed with reference to extant insomnia models.

MacMahon KM, Broomfield NM, Espie CA. · University of Glasgow Sleep Research Laboratory, Section of Psychological Medicine, Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow, Scotland, UK. · Sleep. · Pubmed #17162988 No free full text.

Abstract: STUDY OBJECTIVES: Cognitive models of primary insomnia (PI) suggest attention bias as a maintaining process. This study used a hallmark measure of attention bias, the dot-probe task, to determine whether attention bias to sleep-related stimuli is present in individuals with PI. Control groups of good sleepers (GS) and individuals with delayed sleep phase syndrome (DSPS), a sleep disorder with no presumed cognitive pathway and, hence, no predicted association with attention bias, were included. DESIGN: A between-groups (PI, DSPS, GS) design was employed. Participants completed a dot-probe task with stimuli comprising sleep-related and neutral words, balanced for length and frequency of usage. It was predicted a priori that PI would show greater attention bias to sleep stimuli compared with GS and DSPS groups. No difference between GS and DSPS was predicted. PARTICIPANTS: Sixty-three individuals completed the study (PI = 21; DSPS = 22; GS = 20), with those in PI and DSPS classified by International Classification of Sleep Disorders criteria according to self-report sleep diaries and actigraphy. GS scored < 5 on the Pittsburgh Sleep Quality Index, reported being good sleepers, and met no criteria for a current or previous sleep disorder. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: As predicted, PI showed increased vigilance for sleep-related stimuli relative to GS and DSPS. No differences between GS and those with DSPS were found. The PI group showed shorter response latencies relative to the GS and DSPS groups. CONCLUSIONS: Results support an association between attention bias and PI. Further work must determine whether or not attention bias is a causal factor. Speeded responses in the PI group suggest heightened arousal, indicating that physiologic factors may play a related role.

Marchetti LM, Biello SM, Broomfield NM, Macmahon KM, Espie CA. · Department of Psychology, University of Glasgow, Glasgow, UK. · J Sleep Res. · Pubmed #16704577 No free full text.

Abstract: Cognitive models of insomnia suggest that selective attention may be involved in maintaining the disorder. However, direct assessment of selective attention is limited. Using the inducing change blindness (ICB) paradigm we aimed to determine whether there is attentional preference for sleep-related stimuli in psychophysiological insomnia (PI) relative to delayed sleep phase syndrome (DSPS) and good sleepers (GS). In the ICB task, a visual scene, comprising both sleep-related and neutral stimuli, 'flickers' back and forth with one element (sleep or neutral) of the scene changing between presentations. Therefore, a 2 x 3 totally between-participants design was employed. The dependent variable was the number of flickers it took for the participant to identify the change. Ninety individuals (30 per group) were classified using ICSD-R criteria, self-report diaries and wrist actigraphy. As predicted, PI detected a sleep-related change significantly quicker than DSPS and GS, and significantly quicker than a sleep-neutral change. Unexpectedly, DSPS detected a sleep-related change significantly quicker than GS. No other differences were observed between the two controls. These results support the notion that there is an attention bias to sleep stimuli in PI, suggesting that selective attention tasks such as the ICB may be a useful objective index of cognitive arousal in insomnia. The results also suggest that there may be an element of sleep preoccupation associated with DSPS. Results are discussed with reference to other experiments on attentional processing in insomnia.

Broomfield NM, Espie CA. · Department of Psychological Medicine, Gartnavel Royal Hospital, University of Glasgow, Glasgow, UK. · J Sleep Res. · Pubmed #16364141 No free full text.

Abstract: A frequent clinical observation is that patients with insomnia strive to control their sleep. However, sleep is an involuntary physiological process, which cannot be placed under full voluntary control. Therefore, direct, voluntary attempts to control sleep may actually exacerbate and perpetuate insomnia. To date, no reliable scale has been available to test this hypothesis directly. Moreover, while sleep effort is a core International Classification of Sleep Disorders--Revised criterion for psychophysiological insomnia, clinicians lack a reliable measure with which to assess the construct. In this initial scale validation study, we present psychometric data for the Glasgow Sleep Effort Scale based on a relatively small but representative sample of patients with insomnia and good sleepers. The clinical and research value of the new scale is discussed and future research directions are described.

Jones BT, Macphee LM, Broomfield NM, Jones BC, Espie CA. · Department of Psychology, University of Glasgow, Glasgow, Scotland. · J Abnorm Psychol. · Pubmed #15869355 No free full text.

Abstract: Evidence was sought of an attentional bias toward a highly representative object of the bedroom environment in good, moderate, and poor (primary insomnia) sleepers. Using a flicker paradigm for inducing change blindness, the authors briefly presented a single scene comprising a group of bedroom environment and neutral objects to participants and then briefly replaced this scene with an identical scene containing a change made to either a bedroom environment or a neutral object. In a 3 x 2 entirely between-participants design, change-detection latencies revealed a sleep-related attentional bias in poor sleepers but not in good sleepers. A possible bias in moderate sleepers was also revealed. It is suggested that attentional bias has a role in the perpetuation and possibly precipitation of primary insomnia.