A Systematic Review Assessing Bidirectionality between Sleep Disturbances, Anxiety, and Depression

Perfectionism related to self-reported insomnia severity, but not when controlled for stress and emotion regulation

BACKGROUND

Perfectionism is understood as a set of personality traits such as unrealistically high and rigid standards for performance, fear of failure, and excessive self-criticism. Previous studies showed a direct association between increased perfectionism and poor sleep, though without taking into account possible mediating factors. Here, we tested the hypothesis that perfectionism was directly associated with poor sleep, and that this association collapsed, if mediating factors such as stress and poor emotion regulation were taken into account.

METHODS

Three hundred and forty six young adult students (M=23.87 years) completed questionnaires relating to perfectionism traits, sleep, and psychological functioning such as stress perception, coping with stress, emotion regulation, and mental toughness.

RESULTS

Perfectionism was directly associated with poor sleep and poor psychological functioning. When stress, poor coping, and poor emotion regulation were entered in the equation, perfectionism traits no longer contributed substantively to the explanation of poor sleep.

CONCLUSION

Though perfectionism traits seem associated with poor sleep, the direct role of such traits seemed small, when mediating factors such as stress perception and emotion regulation were taken into account.

Sleep disturbances in a community-based sample of women with polycystic ovary syndrome

STUDY QUESTION

Is there an excess of sleep disturbances in women with polycystic ovary syndrome (PCOS) in a community-based sample?

STUDY ANSWER

Sleep disturbances are almost twice as common in women with PCOS compared with women of similar age without PCOS, with the association slightly accounted for by body weight and, to a greater extent, by depressive symptoms.

WHAT IS KNOWN ALREADY

There is an excess of sleep-disordered breathing in clinical samples of women with PCOS, after accounting for their profile of body weight. Poor sleep patterns increase insulin resistance and thus may exacerbate PCOS symptoms and longer-term risk of metabolic disease.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study of 724 women, comprising 74% of a cohort study established retrospectively when women were around age 30 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Comparisons were made between 87 women with PCOS, diagnosed using the Rotterdam criteria, and 637 women without this diagnosis in Adelaide, South Australia. Differences in sleep disturbances, assessed using a modified version of the Jenkins questionnaire, were investigated using ordered logistic regression.

MAIN RESULTS AND THE ROLE OF CHANCE

Sleep disturbances were twice as common in women with PCOS compared with those without. Specifically, PCOS was associated with increasing occurrence of difficulty falling asleep (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.28-2.95); this association was attenuated but still statistically significant after accounting for BMI and depressive symptoms. Increasing occurrence of difficulty maintaining sleep (OR 1.92 95% CI 1.12-3.31) was mediated by obesity and depressive symptoms, together. Other factors did not change these findings.

LIMITATIONS, REASONS FOR CAUTION

The cross-sectional nature of the study means that the direction of associations between PCOS and sleep disturbances is unclear, although bi-directionality for the mediators is likely based on data in the wider literature.

WIDER IMPLICATIONS OF THE FINDINGS

Our results indicate that assessment and management of both sleep and mental health problems in women with PCOS should be undertaken. Longitudinal data would be valuable to see how poor sleep affects longer-term health profiles.

Sleep in infancy and childhood: implications for emotional and behavioral difficulties in adolescence and beyond

PURPOSE OF REVIEW

Extensive scientific efforts have been made in an attempt to identify early markers of behavioral and emotional problems. In this context, sleep has received considerable research attention, as it appears to be closely linked to developmental psychopathology. The present review synthesizes some of the most recent findings regarding the concurrent and longitudinal associations between psychopathology and behavioral manifestations of sleep in childhood and adolescence.

RECENT FINDINGS

Recent evidence suggests that compromised sleep is associated with both internalizing and externalizing problems in childhood and adolescence. Moreover, sleep problems have been shown to predict the development of various emotional and behavioral problems, including depression, anxiety, attention-deficit hyperactivity disorder, risk-taking and aggression. Yet, inconsistencies are apparent, particularly among findings that are based on objective sleep measurement.

SUMMARY

Taken together, most recent findings suggest that poor sleep in childhood and adolescence constitutes a risk factor for psychopathological symptoms. Accordingly, the importance of early detection and intervention should be a primary goal in clinical settings. In the research domain, the underlying mechanism of these associations should receive future research attention, in an attempt to broaden the understanding of the relationship between sleep and psychopathology.

Daily mood and sleep: reciprocal relations and links with adjustment problems

Children's sleep problems are common and associated with increased risk for adjustment problems. We examined daily links between children's sleep and mood, using a daily diary method and actigraphy. We also tested children's daily mood as a mediator of relations among sleep and children's broader internalizing and externalizing symptoms. A community sample of 142 children (mean age = 10.69 years; 57% girls; 69% European American, 31% African American) and their parents participated. For 1 week, children wore actigraphs and parents completed a daily telephone interview about their child's mood. Following the week of actigraphy, mothers and fathers reported on their child's adjustment. Multi-level models indicated within-person relations between children's mood and subsequent sleep fragmentation (indicated by increased activity) and sleep latency, and between-person relations between sleep latency and subsequent mood on the next day. Significant indirect effects were found such that a more negative daily mood (aggregated across diary days) mediated relations between poor sleep efficiency and longer sleep latency and parent-reported internalizing and externalizing symptoms. Findings extend previous research by highlighting disruptions to children's daily mood as a potential mechanism linking sleep problems to children's mental health.

Adverse effects of two nights of sleep restriction on the hypothalamic-pituitary-adrenal axis in healthy men

CONTEXT

Insufficient sleep is associated with increased cardiometabolic risk. Alterations in hypothalamic-pituitary-adrenal axis may underlie this link.

OBJECTIVE

Our objective was to examine the impact of restricted sleep on daytime profiles of ACTH and cortisol concentrations.

METHODS

Thirteen subjects participated in 2 laboratory sessions (2 nights of 10 hours in bed versus 2 nights of 4 hours in bed) in a randomized crossover design. Sleep was polygraphically recorded. After the second night of each session, blood was sampled at 20-minute intervals from 9:00 am to midnight to measure ACTH and total cortisol. Saliva was collected every 20 minutes from 2:00 pm to midnight to measure free cortisol. Perceived stress, hunger, and appetite were assessed at hourly intervals by validated scales.

RESULTS

Sleep restriction was associated with a 19% increase in overall ACTH levels (P < .03) that was correlated with the individual amount of sleep loss (rSp = 0.63, P < .02). Overall total cortisol levels were also elevated (+21%; P = .10). Pulse frequency was unchanged for both ACTH and cortisol. Morning levels of ACTH were higher after sleep restriction (P < .04) without concomitant elevation of cortisol. In contrast, evening ACTH levels were unchanged while total and free cortisol increased by, respectively, 30% (P < .03) and 200% (P < .04). Thus, the amplitude of the circadian cortisol decline was dampened by sleep restriction (-21%; P < .05). Sleep restriction was not associated with higher perceived stress but resulted in an increase in appetite that was correlated with the increase in total cortisol.

CONCLUSION

The impact of sleep loss on hypothalamic-pituitary-adrenal activity is dependent on time of day. Insufficient sleep dampens the circadian rhythm of cortisol, a major internal synchronizer of central and peripheral clocks.

Insomnia in adult survivors of childhood cancer: a report from project REACH

PURPOSE

Insomnia is a common problem affecting cancer survivors even years after completion of therapy. Childhood cancer survivors may be at particular risk due to vulnerability to the effects of treatment and medical late effects which impact normal sleep development. Using an indicator of clinically significant insomnia (sleep efficiency), we examined a group of adult survivors of childhood cancer to (1) describe clinical insomnia rates, (2) identify physical and psychological correlates of insomnia, and (3) investigate the frequency with which sleep issues were evaluated during a cancer survivorship medical visit.

METHODS

A total of 122 adult survivors of childhood cancer completed standard measures of sleep, psychological distress, and health-related quality of life. Medical records of the 75 survivors with a survivorship medical visit on the day of self-report measure completion were reviewed for documentation of sleep-related issues.

RESULTS

Twenty-eight percent of participants endorsed sleep efficiency below 85 %, indicating clinically significant insomnia. Insomnia was associated with poor physical health and anxiety but not with demographic or cancer treatment variables. Medical providers failed to document sleep in visit notes for 67 % of patients with self-reported insomnia.

CONCLUSIONS

A significant proportion of adult survivors of childhood cancer report insomnia, which is associated with physical and psychological health. Few survivors with insomnia discuss this issue with oncology providers during survivorship care. There is a clear need to screen for insomnia in this population. Patients and providers should take greater responsibility for discussing sleep issues and seeking out proper treatment referrals when it is identified.

Sleep-wake disturbances in sedentary community-dwelling elderly adults with functional limitations

OBJECTIVES

To evaluate sleep-wake disturbances in sedentary community-dwelling elderly adults with functional limitations.

DESIGN

Cross-sectional.

SETTING

Lifestyle Interventions and Independence in Elder (LIFE) Study.

PARTICIPANTS

Community-dwelling persons (mean age 78.9) who spent fewer than 20 min/wk in the previous month engaged in regular physical activity and fewer than 125 min/wk of moderate physical activity, and had a Short Physical Performance Battery (SPPB) score of <10 (N = 1,635).

MEASUREMENTS

Mobility was evaluated according to 400-m walk time (slow gait speed defined as <0.8 m/s) and SPPB score (≤ 7 defined moderate to severe mobility impairment). Physical inactivity was defined according to sedentary time, as a percentage of accelerometry wear time with activity of <100 counts/min; participants in the top quartile of sedentary time were classified as having a high sedentary time. Sleep-wake disturbances were evaluated using the Insomnia Severity Index (ISI) (range 0-28; ≥ 8 defined insomnia), Epworth Sleepiness Scale (ESS) (range 0-24; ≥ 10 defined daytime drowsiness), Pittsburgh Sleep Quality Index (PSQI) (range 0-21; >5 defined poor sleep quality), and Berlin Questionnaire (high risk of sleep apnea).

RESULTS

Prevalence rates were 43.5% for slow gait speed and 44.7% for moderate to severe mobility impairment, with 77.0% of accelerometry wear time spent as sedentary time. Prevalence rates were 33.0% for insomnia, 18.1% for daytime drowsiness, 47.8% for poor sleep quality, and 32.9% for high risk of sleep apnea. Participants with insomnia had a mean ISI score of 12.1, those with daytime drowsiness had a mean ESS score of 12.5, and those with poor sleep quality had a mean PSQI score of 9.2. In adjusted models, measures of mobility and physical inactivity were generally not associated with sleep-wake disturbances, using continuous or categorical variables.

CONCLUSION

In a large sample of sedentary community-dwelling elderly adults with functional limitations, sleep-wake disturbances were prevalent but only mildly severe and were generally not associated with mobility impairment or physical inactivity.

The independent relationships between insomnia, depression, subtypes of anxiety, and chronotype during adolescence

OBJECTIVES

To investigate the independent effects of depression and subtypes of anxiety on insomnia, and vice versa, and the independent effect of chronotype on insomnia, depression, and subtypes of anxiety.

METHODS

In all, 318 South Australian high school students from grades 7-11 (age range, 12-18years; mean, 14.97±1.34) participated in this cross-sectional study. Validated self-report questionnaires were used to assess insomnia, depression, subtypes of anxiety, and chronotype.

RESULTS

After confounder variables were controlled, insomnia predicted depression and panic disorder (PD), whereas insomnia was predicted by depression and generalized anxiety disorder (GAD). Obsessive-compulsive disorder (OCD), separation anxiety (SAD), and social phobia (SP) were not significantly related to insomnia. Eveningness predicted the models in which depression and PD predicted insomnia and vice versa. Eveningness also predicted the models in which insomnia was predicted by OCD, SAD, and SP.

CONCLUSIONS

Insomnia independently predicts depression and is predicted by depression and GAD, but not by other forms of anxiety. The independent prediction of insomnia on PD is unlikely to be clinically significant. Chronotype independently predicts and hence is a risk factor for insomnia and depression, but not subtypes of anxiety. Theoretical and clinical implications are discussed.