Sleep Initiation and Maintenance Disorders: Espie CA

Espie CA. · University of Glasgow Sleep Centre, Sackler Institute of Psychobiological Research, Glasgow, United Kingdom. · Sleep Med. · Pubmed #18346675 No free full text.

Abstract: Cognitive models of insomnia have received growing support in recent years and are embraced by the current diagnostic framework. Many people with insomnia report that mental events, such as intrusive thoughts or a racing mind, prevent them from achieving or maintaining sleep. Dysfunctional cognition may play an important role in perpetuating insomnia, with many individuals with psychophysiological insomnia reporting a distorted perception of sleep. Neurocognitive studies have indicated that high-frequency EEG activity associated with cognitive processes is enhanced in patients with insomnia at or around sleep onset, which may distort the individual's judgement about sleep initiation and duration. A subtype of psychophysiological insomnia has been proposed--attention-intention-effort (AIE) syndrome--that takes into consideration the interaction between behavioral and cognitive factors in the development and maintenance of insomnia. A series of studies from the University of Glasgow Sleep Centre using cognitive probe tasks has provided insight into this pathway, particularly with regard to the role of attention bias towards sleep stimuli in mediating insomnia. Further research is required to explore the cortical correlates of attention bias, investigate AIE as a potential causal mechanism of insomnia and examine AIE in other insomnia groups.

Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. · Université Laval, Québec, Canada. · Sleep. · Pubmed #17162986 No free full text.

Abstract: BACKGROUND: Recognition that psychological and behavioral factors play an important role in insomnia has led to increased interest in therapies targeting these factors. A review paper published in 1999 summarized the evidence regarding the efficacy of psychological and behavioral treatments for persistent insomnia. The present review provides an update of the evidence published since the original paper. As with the original paper, this review was conducted by a task force commissioned by the American Academy of Sleep Medicine in order to update its practice parameters on psychological and behavioral therapies for insomnia. METHODS: A systematic review was conducted on 37 treatment studies (N = 2246 subjects/patients) published between 1998 and 2004 inclusively and identified through Psyclnfo and Medline searches. Each study was systematically reviewed with a standard coding sheet and the following information was extracted: Study design, sample (number of participants, age, gender), diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings. Criteria for inclusion of a study were as follows: (a) the main sleep diagnosis was insomnia (primary or comorbid), (b) at least 1 treatment condition was psychological or behavioral in content, (c) the study design was a randomized controlled trial, a nonrandomized group design, a clinical case series or a single subject experimental design with a minimum of 10 subjects, and (d) the study included at least 1 of the following as dependent variables: sleep onset latency, number and/or duration of awakenings, total sleep time, sleep efficiency, or sleep quality. RESULTS: Psychological and behavioral therapies produced reliable changes in several sleep parameters of individuals with either primary insomnia or insomnia associated with medical and psychiatric disorders. Nine studies documented the benefits of insomnia treatment in older adults or for facilitating discontinuation of medication among chronic hypnotic users. Sleep improvements achieved with treatment were well sustained over time; however, with the exception of reduced psychological symptoms/ distress, there was limited evidence that improved sleep led to clinically meaningful changes in other indices of morbidity (e.g., daytime fatigue). Five treatments met criteria for empirically-supported psychological treatments for insomnia: Stimulus control therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavior therapy. DISCUSSION: These updated findings provide additional evidence in support of the original review's conclusions as to the efficacy and generalizability of psychological and behavioral therapies for persistent insomnia. Nonetheless, further research is needed to develop therapies that would optimize outcomes and reduce morbidity, as would studies of treatment mechanisms, mediators, and moderators of outcomes. Effectiveness studies are also needed to validate those therapies when implemented in clinical settings (primary care), by non-sleep specialists. There is also a need to disseminate more effectively the available evidence in support of psychological and behavioral interventions to health-care practitioners working on the front line.

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.

Edinger JD, Bonnet MH, Bootzin RR, Doghramji K, Dorsey CM, Espie CA, Jamieson AO, McCall WV, Morin CM, Stepanski EJ, Anonymous00028. · VA Medical Center, Durham, NC, USA. · Sleep. · Pubmed #15683149 No free full text.

Abstract: Insomnia is a highly prevalent, often debilitating, and economically burdensome form of sleep disturbance caused by various situational, medical, emotional, environmental and behavioral factors. Although several consensually-derived nosologies have described numerous insomnia phenotypes, research concerning these phenotypes has been greatly hampered by a lack of widely accepted operational research diagnostic criteria (RDC) for their definition. The lack of RDC has, in turn, led to inconsistent research findings for most phenotypes largely due to the variable definitions used for their ascertainment. Given this problem, the American Academy of Sleep Medicine (AASM) commissioned a Work Group (WG) to review the literature and identify those insomnia phenotypes that appear most valid and tenable. In addition, this WG was asked to derive standardized RDC for these phenotypes and recommend assessment procedures for their ascertainment. This report outlines the WG's findings, the insomnia RDC derived, and research assessment procedures the WG recommends for identifying study participants who meet these RDC.

Espie CA. · Department of Psychological Medicine, Academic Centre, University of Glasgow, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH, Scotland. · Annu Rev Psychol. · Pubmed #11752485 No free full text.

Abstract: This paper critically reviews the evidence base for previously reported conceptual models of the development and persistence of insomnia. Although a number of perspectives have some empirical support, no one approach emerges as preeminent. Importantly, the efficacy of any particular psychological intervention cannot be taken as confirmation of presumed, underlying mechanisms. An integrated psychobiological inhibition model of insomnia is developed that accounts for the research data. The model views insomnia as arising from inhibition of de-arousal processes associated with normal sleep. It is proposed that sleep homeostatic and circadian factors are compromised by impairment of the automaticity and plasticity associated with good sleep, and that cognitive/affective processes activate the clinical complaint of insomnia. Common pathways for the action of cognitive-behavioral interventions are identified, and a research agenda is set for further conceptual and clinical study.

Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. · Université Laval, Ecole de Psychologie, Ste-Foy, Quebec, Canada. · Sleep. · Pubmed #10617176 No free full text.

Abstract: This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.

Harvey L, Inglis SJ, Espie CA. · University of Glasgow, Department of Psychological Medicine, Academic Centre, Gartnavel Royal Hospital, UK. · Behav Res Ther. · Pubmed #11762429 No free full text.

Abstract: Although there is considerable evidence for the efficacy of non-pharmacological treatment of insomnia, many of the larger trials have delivered CBT in multicomponent format. This makes it impossible to identify critical ingredients responsible for improvement. Furthermore, compliance with home implementation is difficult to ascertain in psychological therapies, and even more so when trying to differentiate across a range of elements. In the present report, 90 patients who had completed 12 month follow-up after participation in a clinical effectiveness study of CBT in general medical practice, responded to a questionnaire asking them about their use of the ten components of the programme. Reports of home use were then entered as predictors of clinical response to treatment. Results indicated that reported home use of stimulus control/sleep restriction was the best predictor of clinical improvement in sleep latency and nighttime wakefulness. Cognitive restructuring also contributed significantly to reduction in wakefulness. In spite of being the most highly endorsed component (by 79% of respondents) use of relaxation did not predict improvement on any variable. Similarly, sleep hygiene was unrelated to sleep pattern change and use of imagery training was modestly predictive of poor response in terms of sleep latency. There are methodological limitations to this type of post hoc analysis, nevertheless, these results being derived from a large patient outcome series raise important issues both for research and clinical practice.

Espie CA, Inglis SJ, Tessier S, Harvey L. · Department of Psychological Medicine, University of Glasgow, UK. · Behav Res Ther. · Pubmed #11125723 No free full text.

Abstract: Chronic insomnia is a very common clinical condition which may respond well to non-pharmacological treatment. Indeed, the literature supports the efficacy of cognitive behaviour therapy (CBT). However, there has been no substantial study of clinical effectiveness. Since insomniacs typically present in general medical practice this is a crucial gap in the outcome research. This study, therefore, specifically investigated the clinical effectiveness of CBT delivered by Health Visitors (primary care nurses) trained as therapists. One hundred and thirty-nine insomniacs (mean age 51 yr) were randomised to CBT or Self-Monitoring Control (SMC) in a controlled trial. CBT comprised six group sessions (n=4 to 6 patients). After the controlled phase, SMC patients entered deferred treatment (CBT-DEF), allowing both treatment replication and long-term outcome to be investigated for a sizeable, treated sample. Repeated measures ANOVAs demonstrated superiority of CBT over SMC in substantially reducing sleep latency and wakefulness during the night. CBT-DEF replicated similar effects and maintained improvement was observed in both groups one year later. Furthermore, total sleep increased significantly during follow-up and 84% of patients initially using hypnotics remained drug-free. Results suggest that CBT administered by Health Visitors offers a clinically effective treatment for insomnia.

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.

Morin CM, Bélanger L, LeBlanc M, Ivers H, Savard J, Espie CA, Mérette C, Baillargeon L, Grégoire JP. · Université Laval, Ecole de psychologie, Pavillon Félix-Antoine Savard, Québec City, QC G1K 0A6, Canada. · Arch Intern Med. · Pubmed #19273774 No free full text.

Abstract: BACKGROUND: Despite its high prevalence, little information is available about the natural history of insomnia. The extent to which episodes of insomnia will persist or remit over time is difficult to predict. We examined the natural history of insomnia and describe the most common trajectories over 3 years. METHODS: Three hundred eighty-eight adults (mean [SD] age, 44.8 [13.9] years; 61% women) were selected from a larger population-based sample on the basis of the presence of insomnia at baseline. They completed standardized sleep/insomnia questionnaires at 3 annual follow-up assessments. For each follow-up assessment, participants were classified into 1 of 3 groups (individuals with an insomnia syndrome, individuals with insomnia symptoms, and individuals with good sleep) on the basis of algorithms using standard diagnostic criteria for insomnia. Rates of persistent insomnia, remission, and relapse were computed for each group. RESULTS: Of the study sample, 74% reported insomnia for at least 1 year (2 consecutive assessments) and 46% reported insomnia persisting over the entire 3-year study. The course of insomnia was more likely to be persistent in those with more severe insomnia at baseline (ie, insomnia syndrome) and in women and older adults. Remission rate was 54%; however, 27% of those with remission of insomnia eventually experienced relapse. Individuals with subsyndromal insomnia at baseline were 3 times more likely to remit than worsen to syndrome status, although persistence was the most frequent course in that group as well. CONCLUSION: These findings indicate that insomnia is often a persistent condition, in particular when it reaches the diagnostic threshold for an insomnia disorder.

Espie CA, Fleming L, Cassidy J, Samuel L, Taylor LM, White CA, Douglas NJ, Engleman HM, Kelly HL, Paul J. · University of Glasgow Sleep Centre, Southern General Hospital, Glasgow, G51 4TF United Kingdom. · J Clin Oncol. · Pubmed #18591549 No free full text.

Abstract: PURPOSE: Persistent insomnia is a common complaint in cancer survivors, but is seldom satisfactorily addressed. The adaptation to cancer care of a validated, cost-effective intervention may offer a practicable solution. The aim of this study was to investigate the clinical effectiveness of protocol-driven cognitive behavior therapy (CBT) for insomnia, delivered by oncology nurses. PATIENTS AND METHODS: Randomized, controlled, pragmatic, two-center trial of CBT versus treatment as usual (TAU) in 150 patients (103 females; mean age, 61 years.) who had completed active therapy for breast, prostate, colorectal, or gynecological cancer. The study conformed to CONSORT guidelines. Primary outcomes were sleep diary measures at baseline, post-treatment, and 6-month follow-up. Actigraphic sleep, health-related quality of life (QOL), psychopathology, and fatigue were secondary measures. CBT comprised five, small group sessions across consecutive weeks, after a manualized protocol. TAU represented normal clinical practice; the appropriate control for a clinical effectiveness study. RESULTS: CBT was associated with mean reductions in wakefulness of 55 minutes per night compared with no change in TAU. These outcomes were sustained 6 months after treatment. Standardized relative effect sizes were large for complaints of difficulty initiating sleep, waking from sleep during the night, and for sleep efficiency (percentage of time in bed spent asleep). CBT was associated with moderate to large effect sizes for five of seven QOL outcomes, including significant reduction in daytime fatigue. There was no significant interaction effect between any of these outcomes and baseline demographic, clinical, or sleep characteristics. CONCLUSION: CBT for insomnia may be both clinically effective and feasible to deliver in real world practice.

Espie CA, Kyle SD. · University of Glasgow Sleep Centre, Sackler Institute of Psychobiological Research, Faculty of Medicine, University of Glasgow, Scotland, UK. · Sleep. · Pubmed #18517027 links to  free full text

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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.

Kohn L, Espie CA. · University of Glasgow, Scotland, UK. · Sleep. · Pubmed #15700726 No free full text.

Abstract: STUDY OBJECTIVES: To explore proposed explanatory mechanisms in psychophysiologic insomnia by investigating the sensitivity and specificity of commonly used insomnia research tools in discriminating psychophysiologic insomnia, insomnia associated with mental disorder, and good sleepers. DESIGN: Cross-sectional, between-group comparison of responses from subjects with psychophysiologic insomnia, those with insomnia associated with mental disorder, and good sleepers to psychometrically robust self-report instruments. SETTING: Attendees at adult community outpatient clinics. PARTICIPANTS: Fifty-four adults (36 women, 18 men; average age 40 years) across 3 groups (n = 18 per group). Participants with psychophysiologic insomnia met combined Inteernational Classification of Sleep Disorders, Revised and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and had no history of mental disorder. Participants with insomnia associated with mental disorder satisfied the same criteria for sleep disturbance and met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Structured Clinical Interview for DSM-IV axis-I Disorders) criteria for depressive disorder. The majority had comorbid anxiety disorder. Insomnia duration in the groups with psychophysiologic insomnia and insomnia associated with mental disorder was around 10 years. Good sleepers served as a control group and included self-reported good sleepers with no history of sleep problems or psychiatric disorder. INTERVENTION: N/A. MEASUREMENTS AND RESULTS: Analyses of variance, adjusted for multiple comparisons, indicated no between-group differences on a measure of sleep-related stimulus control, and self-reported somatic arousal was higher in subjects with insomnia associated with mental disorder than in good sleepers or those with psychophysiologic insomnia. Subjects with insomnia associated with mental disorder and psychophysiologic insomnia had poorer sleep hygiene and were characterized by heightened mental arousal. Logistic regression indicated that "effortful preoccupation with sleep" discriminated subjects with both psychophysiologic insomnia (100% sensitivity, 94% specificity) and insomnia associated with mental disorder (100%, 100%) from good sleepers and that only depressive symptomatology discriminated insomnia associated with mental disorder from psychophysiologic insomnia. CONCLUSION: Psychophysiologic insomnia and insomnia associated with mental disorder may be on a continuum of insomnia severity, rather than categorically distinct. Insomnia associated with mental disorder may respond to psychological intervention. Factors specifically discriminating insomniacs from good sleepers require further investigation.

Taylor LM, Espie CA, White CA. · Department of Psychological Medicine, University of Glasgow, Scotland. · Behav Sleep Med. · Pubmed #15600215 No free full text.

Abstract: This study investigated the role of attentional bias in the development of persistent insomnia. Two groups of people with cancer who developed sleep-onset problems 0-3 months and 12-18 months after diagnosis completed a computerized emotional Stroop task comprising cancer-related and sleep-related word cues and self-complete measures. Both groups demonstrated attentional bias for cancer-related words, but only the persistent insomnia group demonstrated attentional bias for sleep-related words. High levels of presleep cognitive arousal were evident in both groups despite lower levels of psychological distress in the persistent insomnia group. Results suggest that secondary, sleep-related mental preoccupation may inhibit recovery to normal sleep after stress-related acute sleep disturbance. Findings are discussed in relation to current models of insomnia.

Harvey KJ, Espie CA. · Department of Psychological Medicine, University of Glasgow, UK. · Br J Clin Psychol. · Pubmed #15530211 No free full text.

Abstract: OBJECTIVE: To develop a self-report measure (the Glasgow Content of Thoughts Inventory [GCTI]) for the assessment of pre-sleep cognitive activity in adults with sleep-onset insomnia. DESIGN: A psychometric, scale development approach was used. METHOD: Over three consecutive nights, 12 people with insomnia provided 'live' audio-recordings of pre-sleep thought content, which were used to generate an item pool. The results were compared to the content and categorical structure of pre-sleep cognitive activity identified by Wicklow and Espie (2000), and commonalities in thought content were used to generate a draft scale. Following further piloting, a 25-item scale was developed and administered to two groups (29 people with insomnia and 29 good sleepers), along with other self-report measures, objective (actigraphic recordings) and subjective (diary) sleep indices, and results analysed to evaluate the psychometric properties of the scale. RESULTS: The GCTI demonstrated evidence of construct validity, successfully discriminated between individuals with insomnia and good sleepers, and was significantly correlated with existing measures of sleep disturbance. A score of 42 yielded a sensitivity of 100% and specificity of 83%. The GCTI demonstrated good test- retest reliability (ICC = .88) and internal consistency (alpha = .87). CONCLUSIONS: The GCTI appears to be a valid and reliable instrument for use with patients with sleep-onset insomnia.

Espie CA, Inglis SJ, Harvey L. · Department of Psychological Medicine, University of Glasgow, Scotland, United Kingdom. · J Consult Clin Psychol. · Pubmed #11302278 No free full text.

Abstract: The clinical efficacy of cognitive behavior therapy (CBT) for chronic insomnia has been established, yet clinical effectiveness is less clear. This study presents data on 109 patients from general practice during a formal evaluation of clinical effectiveness. Two thirds achieved normative values of < or =30 min for sleep latency and wakefulness during the night after CBT. Furthermore, almost half of the sample reduced sleeplessness by > or =50%. Logistic regression revealed that initial severity did not contraindicate good outcome. Rather, greater sleep disturbance was positively associated with large symptom reduction, although lower endpoint scores were less likely. Similarly, symptoms of anxiety, depression, and thinking errors positively predicted good outcome. Hypnotic using patients responded equally well to CBT, and demographic factors were of no significant predictive value. It is concluded that CBT is clinically and durably effective for persistent insomnia in routine practice.

Espie CA, Inglis SJ, Harvey L, Tessier S. · Department of Psychological Medicine, University of Glasgow, Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, UK. · J Psychosom Res. · Pubmed #10719130 No free full text.

Abstract: OBJECTIVE: Mental overactivity has been widely implicated in the development and maintenance of insomnia, making the accurate and valid measurement of cognitive variables of some importance. The purpose of this study was to investigate the psychometric properties of two existing attributional scales. METHODS: Data are presented from 178 clinic attending insomniacs who completed the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) and the Sleep Disturbance Questionnaire (SDQ). Standard procedures for the psychometric evaluation of scales were adopted. RESULTS: The internal consistency of the DBAS (30 items) was reasonable (Cronbach's alpha = 0.72); however, a revised ten-item short form (DBAS-10) demonstrated a more robust principal component structure than the original scale (three relatively "pure" factors explained 55% of the variance). The derived subscales achieved satisfactory internal consistency, and the DBAS-10 demonstrated treatment-related measurement sensitivity. The DBAS-10, nevertheless, correlated highly (r = 0.826) with the DBAS. A four-factor solution for the SDQ is also presented (61% explained variance) with alpha = 0.67. Internal consistency of these subscales ranged from 0.59 to 0.82. The association between the SDQ and DBAS-10 was modest (r = 0.28), suggesting that the scales have some independence. CONCLUSIONS: The scales offer potential for clinical and research work on insomnia and possible applications are discussed.