Adolescents with greater mental toughness show higher sleep efficiency, more deep sleep and fewer awakenings after sleep onset

Mental health, substance use, and a composite of sleep health in adults, 2018 Ohio behavioral risk factor surveillance system

OBJECTIVES

Various factors impact sleep health including mental health and substance use. Mental health issues and substance use continue to rise in the United States. Yet, the association between mental health, substance use and sleep health in adults remains unclear.

METHODS

We used multivariable linear regression models to examine the associations between mental health (poor mental health days in the past 30 days) and substance use (marijuana, tobacco, alcohol) with sleep health (individual dimensions of sleep: alertness, sleep efficiency, duration, and sleep health composite score) in 4333 participants from the 2018 Ohio Behavioral Risk Factor Surveillance System Survey.

RESULTS

Better mental health was associated with higher alertness, higher sleep efficiency, longer sleep duration and a higher sleep health composite score even after controlling for covariates (individual: sex at birth, age, body mass index, race, education, sleep disordered breathing, and area-level: socioeconomic deprivation) (all p < .001). Higher marijuana and tobacco use were associated with lower individual sleep health dimensions (marijuana with sleep efficiency and duration and tobacco use with lower efficiency) and a lower sleep health composite score even after controlling for covariates for tobacco use (p < .001). Contrary to the hypothesis, higher alcohol use was associated with higher alertness and a higher sleep health composite score (p < .001), however after adjusting for covariates these associations were no longer significant.

CONCLUSIONS

The implications of these trends on sleep health are important to address as mental health and substance use are modifiable targets to consider when addressing sleep health.

The relationship between chronotype and mental toughness in adolescents: Is resilience a mediator?

OBJECTIVE

This study was designed to examine the mediator role of resilience in the relationship between chronotype and mental toughness in adolescents.

METHODS

The descriptive correlational study was completed with 342 high school students from one school in Türkiye (mean age 17.25±1.11 years). Data were collected with the Morningness-Eveningness Scale for Children, Child and Youth Resilience Measure, and Mental Toughness Scale for Adolescents. Hierarchical regression analyses with PROCESS Model 4 were used to evaluate the mediator effect.

RESULTS

It was observed that the morning chronotype tendency increased resilience (p < 0.001) mental toughness (p < 0.001). Higher resilience led to increased mental toughness. When the mediation effect was examined, resilience was a full mediator in the relationship between chronotype characteristics and mental toughness (β=0.396; p = 0.000).

CONCLUSIONS

According to these results, a morning chronotype tendency in adolescents increases their resilience and, therefore, mental toughness. These results suggest that effective methods for enhancing mental toughness in adolescents should be multifaceted. Additionally, it highlights the importance of identifying and regulating chronotype tendencies among adolescents, while also emphasizing the need to increase resilience in this demographic.

Symptoms of Post-Traumatic Stress and Mental Health in a Sample of University Students: The Mediating Role of Resilience and Psychological Well-Being

The COVID-19 pandemic has been one of the most stressful events in recent times across the world. The long-term effect of these experiences raises several concerns, including the development of post-traumatic stress symptomatology. However, little is known about the psychological processes that mediate this association. The aim of this study was to explore the association of emotional exhaustion and anxiety in post-traumatic stress symptomatology, and the mediating role of resilience and psychological well-being in university students. A total of 526 university students of both sexes participated in this study, and they were aged between 17 and 62 years old. Symptoms of anxiety and emotional exhaustion were significantly higher in females, in contrast, males showed on average more resilience and psychological well-being. Additionally, participants with COVID-19 infection had higher levels of emotional exhaustion, anxiety, and PTSD. The results indicated that the variables were correlated with each other (p < 0.001). A conceptual model was confirmed that describes anxiety and emotional exhaustion as predictors, post-traumatic stress symptomatology as an outcome variable, and resilience and psychological well-being as mediators. Resilience and psychological well-being can be important protective factors for adaptive responses in stressful situations. The findings obtained in this study will provide a theoretical basis for designing targeted interventions to improve psychological health, whether for crisis intervention, the process of adapting to higher education, or for recovery plans from psychological trauma.

Improved resilience following digital cognitive behavioral therapy for insomnia protects against insomnia and depression one year later

BACKGROUND

While the negative consequences of insomnia are well-documented, a strengths-based understanding of how sleep can increase health promotion is still emerging and much-needed. Correlational evidence has connected sleep and insomnia to resilience; however, this relationship has not yet been experimentally tested. This study examined resilience as a mediator of treatment outcomes in a randomized clinical trial with insomnia patients.

METHODS

Participants were randomized to either digital cognitive behavioral therapy for insomnia (dCBT-I; n = 358) or sleep education control (n = 300), and assessed at pre-treatment, post-treatment, and 1-year follow-up. A structural equation modeling framework was utilized to test resilience as a mediator of insomnia and depression. Risk for insomnia and depression was also tested in the model, operationalized as a latent factor with sleep reactivity, stress, and rumination as indicators (aligned with the 3-P model). Sensitivity analyses tested the impact of change in resilience on the insomnia relapse and incident depression at 1-year follow-up.

RESULTS

dCBT-I resulted in greater improvements in resilience compared to the sleep education control. Furthermore, improved resilience following dCBT-I lowered latent risk, which was further associated with reduced insomnia and depression at 1-year follow-up. Sensitivity analyses indicated that each point improvement in resilience following treatment reduced the odds of insomnia relapse and incident depression 1 year later by 76% and 65%, respectively.

CONCLUSIONS

Improved resilience is likely a contributing mechanism to treatment gains following insomnia therapy, which may then reduce longer-term risk for insomnia relapse and depression.

Impact of mental toughness on athlete's performance and interventions to improve

Mental toughness is the ability to handle pressure, adversity, and stress by overcoming failures. It is also the state of persisting without refusing to quit, with the possession of superiority in mental skills. This review aimed to describe the effect of mental toughness on the performance of athletes and also to have an insight into the various interventions to improve mental toughness. For this, PubMed was searched using the appropriate keywords till December 2021 and a narrative synthesis was performed. Mental tightness was evident to be correlated with many important aspects such as better performance, goal progress, withholding stress, coping, optimism and self-reflection. It also helps in a better level of confidence, constancy, control, positive cognition, visualization and challenges than the opponent team. Many interventional strategies have been adopted in previous years which mainly focused on personalized programs including psychological skills training, coping and optimism training, mindfulness, yoga, general relaxation, imagery, and a combination of both, and many more other aspects were observed to be effective in improving mental toughness. However, physical training alone did not observe to be beneficial. The current evidence indicates the important role of mental toughness on the sports performance of athletics and the role of various interventional strategies focusing on mindfulness and psychological interventions in improving mental toughness. All these interventional strategies need to be implemented in the actual practice.

Sleep Quality and Well-Being in Junior Elite Athletes

Abstract. Little cross-sectional and even less longitudinal research has been conducted on sleep quality and well-being in junior elite athletes. This study analyzed the relationship between subjective sleep quality and both psychological and physiological well-being in junior elite athletes using both a cross-sectional ( N = 625 athletes; 49.9 % = female; M = 16.4 years, SD = 3.5 years) and a longitudinal approach ( n = 79; 44.3 % = female; M = 16.4 years, SD = 3.5 years) over a period of M = 1.66 years ( SD = 0.87 years). The results demonstrated that both samples showed that subjective sleep quality is correlated with well-being in junior elite athletes. In addition, the results showed that athletes of prepuberty age reported significantly better sleep quality than athletes during and after puberty, and that the relationship between sleep quality and psychological well-being is stronger in female junior athletes than in male athletes. This study emphasizes the need to ensure quality sleep in junior elite athletes.

When Much Is Too Much-Compared to Light Exercisers, Heavy Exercisers Report More Mental Health Issues and Stress, but Less Sleep Complaints

BACKGROUND

Physical inactivity has become a global somatic and mental health issue. To counterbalance, promoting regular physical activity appears plausible, above all among adults, where physical inactivity is particularly high. However, some, but sparse, research also indicates that excessive exercising might be associated with unfavorable mental health dimensions. Here, we tested the hypothesis that excessive exercising was associated with more mental health issues. To this end, we assessed mental health issues, stress, mental toughness, and sleep disturbances among heavy and light adult exercisers.

METHODS

A total of 200 adults (mean age: 35 years; 62% females) took part in the study. Of those, 100 were heavy exercisers (18-22 h/week), and 100 were light exercisers (1-6 h/week). Participants completed questionnaires covering sociodemographic information, mental health issues, perceived stress, mental toughness, and sleep disturbances.

RESULTS

Compared with light exercisers, heavy exercisers reported higher mental health issues, more stress, but also higher mental toughness scores and less sleep disturbances. Higher age, lower mental toughness scores, heavy exerciser-status, and more sleep disturbances predicted higher mental health complaints.

CONCLUSIONS

Compared with light exercising, heavy exercising might be associated with more mental health issues. As such, it appears that the association between exercise frequency, intensity, and duration and psychological well-being might be related to an optimum point, but not to a maximum point. In a similar vein, heavily exercising athletes, their coaches, parents, and representatives of sports associations should get sensitized to possible adverse psychological effects of excessive physical activity patterns.

The Potential Benefits of Non-skills Training (Mental Toughness) for Elite Athletes: Coping With the Negative Psychological Effects of the COVID-19 Pandemic

The spread of COVID-19 has had a significant impact on global sport. This is especially true at the elite level, where it has disrupted training and competition. Concomitantly, restrictions have disrupted long-term event planning. Many elite athletes remain unsure when major events will occur and worry about further interruptions. Although some athletes have successfully adapted to the demands of the COVID-19 crisis, many have experienced difficulties adjusting. This has resulted in psychological complications including increased stress, anxiety, and depression. This article critically examines the extent to which non-cognitive skills training, in the form of increased awareness of Mental Toughness, can help elite athletes inoculate against and cope with negative psychological effects arising from the COVID-19 pandemic. Non-cognitive skills encompass intrapersonal (motivations, learning strategies, and self-regulation) and interpersonal (interactions with others) domains not directly affected by intellectual capacity. Previous research indicates that enhancement of these spheres can assist performance and enhance mental well-being. Moreover, it suggests that training in the form of increased awareness of Mental Toughness, can improve the ability to cope with COVID-19 related challenges. In this context, Mental Toughness encompasses a broad set of enabling attributes (i.e., inherent and evolved values, attitudes, emotions, and cognitions). Indeed, academics commonly regard Mental Toughness as a resistance resource that protects against stress. Accordingly, this article advocates the use of the 4/6Cs model of Mental Toughness (i.e., Challenge, Commitment, Control, and Confidence) to counter negative psychological effects arising from COVID-19.

Sources of Sleep Disturbances and Psychological Strain for Hospital Staff Working during the COVID-19 Pandemic

Hospital staff members reported increased stress-related workload when caring for inpatients with COVID-19 (“frontline hospital staff members”). Here, we tested if depression, anxiety, and stress were associated with poor sleep and lower general health, and if social support mediated these associations. Furthermore, we compared current insomnia scores and general health scores with normative data. A total of 321 full-time frontline hospital staff members (mean age: 36.86; 58% females) took part in the study during the COVID-19 pandemic. They completed a series of questionnaires covering demographic and work-related information, symptoms of depression, anxiety, stress, social support, self-efficacy, and symptoms of insomnia and general health. Higher symptoms of depression, anxiety, and stress were associated with higher symptoms of insomnia and lower general health. Higher scores of depression, anxiety, and stress directly predicted higher insomnia scores and lower general health scores, while the indirect effect of social support was modest. Compared to normative data, full-time frontline hospital staff members had a 3.14 higher chance to complain about insomnia and a significantly lower general health. Symptoms of insomnia and general health were unrelated to age, job experience, educational level, and gender. Given this background, it appears that the working context had a lower impact on individuals’ well-being compared to individual characteristics.

"When I Sleep Poorly, It Impacts Everything": An Exploratory Qualitative Investigation of Stress and Sleep in Junior Endurance Athletes

On their journeys toward senior athletic status, junior endurance athletes are faced with a multitude of stressors. How athletes react to stressors plays a vital part in effective adaptation to the demanding, ever-changing athletic environment. Sleep, the most valued recovery strategy available to athletes, has the potential to influence and balance athletic stress, and enable optimal functioning. However, sleep is sensitive to disturbances by stress, which is described by the concept of sleep reactivity. Among athletes, poor sleep quality is frequently reported, but our understanding of the associations between stress and sleep in junior athletes is currently incomplete. The present study therefore investigated the themes of stress and sleep, and the associations between these variables with the use of in-depth semi-structured interviews in six junior endurance athletes (three men and three women, mean age 17.7 ± 0.5 years). Data was analyzed qualitatively based on the Grounded Theory. The qualitative material was supplemented with quantitative data on subjective sleep quality (Pittsburg Sleep Quality Index), sleep reactivity (Ford Insomnia Response to Stress Test), and mental strain (visual analog scale). The main results showed that stress could be differentiated into relevant stressors (encompassing poor performance, uncertainty in relation to training, school, daily hassles, and sleep) and reactions to stress (with sub-categories facilitative and maladaptive). Sleep could be differentiated into sleep benefits (encompassing energy levels and athletic functioning) and sleep quality (with sub-categories satisfactory and inadequate). All athletes identified relevant stressors, and all athletes were aware of the benefits of sleep for athletic functioning. However, athletes formed two distinctive categories based on the interactions between stress and sleep: three exhibited facilitative reactions to stress and good sleep quality, as well as low sleep reactivity, and low mental strain. The remaining participants exhibited maladaptive reactions to stress and poor sleep quality, as well as high sleep reactivity and high mental strain. Conceptualizing sleep quality based on the evaluation of stressors, reactions to stress, degree of mental strain, and the propensity to stress-related sleep disturbance may offer a plausible explanation for why the occurrence of stressors leads to poor sleep quality in some athletes, but not others.

Can athletes be tough yet compassionate to themselves? Practical implications for NCAA mental health best practice no. 4

Recent tragic events and data from official NCAA reports suggest student-athletes' well-being is compromised by symptoms of mental health (MH) disorders. Self-compassion (SC) and mental toughness (MT) are two psychological constructs that have been shown effective against stressors associated with sports. The purpose of this study was to investigate SC, MT, and MH in a NCAA environment for the first time and provide practical suggestions for MH best practice No.4. In total, 542 student-athletes participated across Divisions (M_age = 19.84, SD = 1.7). Data were collected through Mental Toughness Index, Self-Compassion Scale, and Mental Health Continuum–Short Form. MT, SC (including mindfulness), and MH were positively correlated. Males scored higher than females on all three scales. No differences were found between divisions. SC partially mediated the MT-MH relationship, but moderation was not significant. Working towards NCAA MH best practice should include training athletes in both MT and SC skills (via mindfulness).

Growing up strong: The importance of physical, mental, and emotional strength during childhood and adolescence with focus on dietary factors

Childhood and adolescence are critical time periods for growth and development. Given the current physical and psychological health concerns affecting United States youth, an emerging area of interest exists supporting the importance of physical and psychological aspects of strength for health, resilience, and well-being through these life stages. This synopsis highlights the key concepts that were presented within the 2018 Strength Summit conference, entitled The Role of Strength in Optimal Health and Well-being. During the conference, strength was broadly defined as the ability to successfully respond to a challenge. Although much of the current research focuses on strength from a muscle function and performance perspective, mental and emotional strength are also important components of overall health and well-being, especially in children and adolescents. This paper provides a brief overview of the clinical and/or research-based strength outcomes, summarizes the relationship between strength and health, and discusses evidence-based dietary factors that promote strength in children and adolescents. Novelty Building physical, mental, and emotional strength during childhood and adolescence lays the foundation for health and well-being. Emerging evidence indicate positive associations between diet quality and strength in children and adolescents. Promising areas include the promotion of family-based meals, with focus on breakfast, for improved strength in United States youth.

Better Objective Sleep Was Associated with Better Subjective Sleep and Physical Activity; Results from an Exploratory Study under Naturalistic Conditions among Persons with Multiple Sclerosis

Persons with multiple sclerosis (PwMS) often complain about sleep problems. There is less known about objective sleep-electroencephalography (EEG) dimensions within naturalistic conditions (i.e., home and/or familiar setting). The present cross-sectional study examined the associations between objective and subjective sleep, depression, physical activity scores, and MS-related information among PwMS in their familiar setting. The sample consisted of 16 PwMS (mean age: 50.3 years; median Expanded Disability Status Scale (EDSS): 5.5) who completed questionnaires covering subjective sleep (symptoms of insomnia, restless legs syndrome (RLS) and sleep-disordered breathing), as well as daytime sleepiness, subjective physical activity, depression, and MS-related information (fatigue, EDSS; disease-modifying treatments). Objective sleep was assessed with a mobile sleep-EEG device under naturalist conditions within the home. Descriptively, better objective sleep patterns were associated with lower sleep complaints (r_s = −0.51) and daytime sleepiness (r_s = −0.43), and with lower symptoms of RLS (r_s = −0.35), but not with sleep-disordered breathing (r_s = −0.17). More deep sleep was associated with higher moderate physical activity levels (r_s = 0.56). Objective sleep parameters were not associated with vigorous physical activity levels (r_s < 0.25). Descriptively, moderate and vigorous physical activity scores were associated with lower symptoms of RLS (r_s = −0.43 to −0.47). Results from this small study carried out under naturalistic conditions suggest that among PwMS, better objective sleep correlated with better subjective sleep and higher moderate physical activity levels.

Exploring the bi-directional relationship between sleep and resilience in adolescence

OBJECTIVE

The study examined whether overall sleep quality and the sleep components comprising the Pittsburgh Sleep Quality Index (PSQI) have a bi-directional relationship with resilience among adolescents, after adjusting for sex, age, depression, and socioeconomic status, and investigated which sleep components have a stronger effect on resilience.

METHODS

A total of 1299 students (58% females; mean age, 15.79 years) participated at baseline, with 840 finishing all four study waves over the course of 24 months. Data were collected through questionnaires, including socio-demographics, the Pittsburgh Sleep Quality Index, Patient Health Questionnaire 9-item, and the Connor-Davidson Resilience Scale. Cross-lagged models were used to analyze the relationships between sleep and resilience.

RESULTS

Both daytime dysfunction and sleep disturbance had an independent bi-directional relationship with resilience. Higher resilience scores predicted overall better sleep quality and shorter sleep latency, but not vice versa. Sleep disturbance and daytime dysfunction had stronger effects on resilience.

CONCLUSIONS

These findings highlight the importance of future school interventions for sleep to improve students' resilience.

Difficulties in Getting to Sleep and their Association with Emotional and Behavioural Problems in Adolescents: Does the Sleeping Duration Influence this Association?

Sleep problems are common in adolescence with a negative impact on the mental health and functioning of adolescents. However, the roles of different sleep problems in relation to emotional and behavioural problems (EBPs), classified according to the 10th version of the International Classification of Diseases as emotional, conduct, hyperactivity and social functioning disorders, are not clear. The first aim of the study was to investigate the association between difficulties in getting to sleep and EBPs in adolescents. The second aim was to explore the role of sleep duration in this association. We used data from the Health Behaviour in School-aged Children (HBSC) study conducted in 2018 in Slovakia. Presented are results for specific age groups of 13-year-old (N = 1909) and 15-year-old (N = 1293) adolescents. Subjective measures of sleep variables were used. Binary logistic regression models adjusted for age and gender were used to assess associations between difficulties in getting to sleep, sleep duration and EBPs measured using the Strengths and Difficulties Questionnaire. Modification of the association between difficulties in getting to sleep and EBPs by sleep duration was also explored. We found that difficulties in getting to sleep at least once a week as well as insufficient sleep (less than 8 h) increased the probability of EBPs. Interactions of sleep duration with difficulties in getting to sleep on EBPs were found to be non-significant. The results suggest that caregivers and clinicians should screen and intervene for both sleep quality and quantity problems in adolescents as they might indicate and promote EBPs.

Relationship between resilience and insomnia among the middle-aged and elderly: mediating role of maladaptive emotion regulation strategies

This study aimed to investigate the relationships between cognitive emotion regulation (CER) strategies, resilience, and insomnia and the underlying mechanism that explains the relationships. Six hundred and fifty-three middle-aged and old people recruited from community service centers in Henan province completed questionnaires related to CER strategies, resilience, and insomnia. Results showed refocus on planning and positive reappraisal negatively predicted insomnia, and catastrophising, rumination and self-blame positively predicted insomnia. Moreover, maladaptive emotion regulation strategies (especially catastrophising) mediated the relationship between resilience and insomnia. The findings suggest the middle-aged and elderly with insomnia tended to employ maladaptive emotion regulation strategies and had lower resilience. Maladaptive emotion regulation strategies buffered the positive effect of resilience on sleep.

A community-based cross-sectional study of sleep quality among internal migrant workers in the service industry

BACKGROUND

Internal migrant workers in the service industry are an important population in China, but the sleep quality of this population has not been well studied. The aims of the present study were to examine the prevalence of poor sleep quality among internal migrant workers in the service industry, explore the risk factors associated with poor sleep quality, and assess the correlation between insomnia and psychiatric factors.

METHODS

We conducted a cross-sectional study in Shenzhen, a migrant city in China. The respondent-driven sampling (RDS) method was used to recruit participants. Sociodemographic data and physical and psychiatric health status were investigated using questionnaires. In total, 1756 internal migrant workers completed the questionnaires. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality, the General Anxiety Disorder-7 (GAD-7) and Center for Epidemiologic Studies Depression (CES-D) scales were used to assess anxiety and depression, respectively. Mental resilience was assessed by the Chinese version of the Connor-Davidson Resilience Scale (CD-RISC). Regression analysis was used to identify the risk factors of poor sleep quality. A structural equation model (SEM) was used to analyze the relationships among sleep, anxiety, depression and resilience.

RESULTS

The prevalence of poor sleep quality among internal migrant workers in the service industry was 25.4%. Multivariate regression analysis revealed that participants who were older (OR = 1.452), worked >8 h per day (OR = 1.553), had experienced physical illness in the past 2 weeks (OR = 3.631) and had psychiatric problems such as anxiety (OR = 1.695-3.331) and depression (OR = 1.437) had an increased risk of poor sleep quality (P < 0.05). Moreover, the risk of poor sleep quality increased as the severity of anxiety increased. We also detected sex-specific risk factors and depression associated with sleep quality in women (OR = 1.480, P < 0.05) but not in men. The SEM showed that sleep was mutually correlated with anxiety (r = 0.277, P < 0.001), depression (r = 0.301, P < 0.001), and resilience (r = -0.103, P < 0.001). Resilience was mutually correlated with anxiety (r = -0.179, P < 0.001) and depression (r = -0.222, P < 0.001).

CONCLUSIONS

Our study indicated that poor sleep quality was common among internal migrant workers in the service industry. Older age, long working hours, and poor physical and psychiatric health status contributed to poor sleep quality. Compared to males, sleep quality in females was more likely to be impacted by depression. Optimum working hours and physical and psychological health are critical to improving sleep quality. Interventions for ameliorating sleep quality might have different priorities for males and females.

Prevalence and Related Factors of Insomnia Among Chinese Medical Staff in the Middle and Late Stage of COVID-19

Background: The outbreak of novel coronavirus disease (COVID-19) has brought serious psychological pressure to people, especially medical health staff. At present, there are few studies on insomnia and related factors of medical health staff in the middle and late stage of the epidemic of COVID-19. Therefore, the purpose of this study was to investigate the prevalence of insomnia and its related risk factors among medical workers in China in the middle and later stage of COVID-19 epidemic, as well as the relationship between insomnia and psychological resilience. Methods: From February 14 to March 29, 2020, a cross-sectional survey was conducted among 606 medical staff in China through Ranxing Technology's "SurveyStar" network platform. All subjects were assessed with the Insomnia Severity Index (ISI) and simplified Chinese version of Connor-Davidson Resilience scale (CD-RISC-10). Results: In the middle and later stages of the COVID-19 outbreak, the incidence of insomnia among medical staff was 32.0%. Compared with non-insomnia group, the insomnia group had younger age, lower education level, longer daily working hours and less psychological resilience. In addition, the prevalence of insomnia was higher in medical staff with a history of somatic diseases. The severity of insomnia of Chinese medical staff was associated with age, education level, daily working hours, psychological resilience and somatic diseases. Conclusions: Our study shows that nearly 1/3 of Chinese medical workers suffer from insomnia nearly a month after the COVID-19 outbreak. Compared with the general population, medical staff who are working with COVID are more prone to insomnia. Risk factors for insomnia include younger age, lower education level, longer working hours per day, and physical illness. The tenacious dimension of psychological resilience is a protective factor for insomnia.

The Interactive Effect of Positive Mental Health and Subjective Sleep Quality on Depressive Symptoms in High School Students

Objective/Background: The objective of this study was to observe the effect of positive mental health (PMH) and subjective sleep quality (SQ) on depressive symptoms in high school students. Participants: This cross-sectional study evaluated 2,186 students (55% female and 45% male) with a mean age of 16.8 years (SD ± 0.7) at 20 private high schools in Mexico City. Methods: An electronic survey was used, which included a questionnaire on sleep habits that is a Spanish-language adaptation of Rosenthal's Sleep-Wake Activity Inventory, the Pittsburgh Sleep Quality Index (PSQI), the Morningness-Eveningness Scale for Children and Adolescents (MESC), the combined scales to evaluate positive aspects of mental health, and the Patient Health Questionnaire (PHQ-9). Results: Main and interaction effects of PMH and SQ were observed, demonstrating that students with high-PMH (p ≤ .0001) or good-SQ (p ≤ .0001) had fewer depressive symptoms. Thus, the students with both high-PMH and good-SQ had the lowest depressive symptomatology (p ≤ .01). Conclusion: Depressive symptoms are associated with a combination of sleep quality and positive mental health.

Psychometric Assessment of Shortened Mental Toughness Questionnaires (MTQ): Factor Structure of the MTQ-18 and the MTQ-10

The 18-item Mental Toughness Questionnaire (MTQ-18) is a brief, widely used measure of mental toughness. The MTQ-18 derives from the longer MTQ-48, which comprises four independent but correlated factors (challenge, commitment, control, and confidence). Despite sampling items from across MTQ-48 dimensions, the MTQ-18 (as intended) provides a global, unidimensional score. Researchers have recently developed a further abridged version of the MTQ-18, the MTQ-10, which has demonstrated promising psychometric performance. The current paper assessed the factorial structure, reliability, predictive validity and invariance of the MTQ-18 and MTQ-10 in a sample of 944 students from English independent schools (year 11, aged 16 years). Respondents completed the MTQ-18 items online alongside the Satisfaction with Life Scale. Confirmatory factor analysis revealed that the MTQ-10 was a superior general measure, because the MTQ-18 possessed additional variance to that accounted for by an unidimensional solution. Additionally, the MTQ-10 evidenced higher factor loadings and demonstrated better data-model fit. Tests of concurrent validity revealed the MTQ-10 was a stronger predictor of well-being (life satisfaction). Both the MTQ-18 and MTQ-10 demonstrated gender invariance at the configural, metric, and scalar level. Overall, although the MTQ-18 was a psychometrically acceptable measure, the MTQ-10 was a superior unidimensional measure of MT.

Effects of two types of exercise training on psychological well-being, sleep, quality of life and physical fitness in patients with high-grade glioma (WHO III and IV): study protocol for a randomized controlled trial

BACKGROUND

There is existing evidence on whether and to what degree regular exercise training improves the quality of life (QoL) among cancer survivors. However, in regards to patients with high-grade glioma (HGG; WHO grade III and IV), no conclusive study has been performed so far. The present trial aims to fill this gap by examining whether psychological well-being, sleep, QoL and physical fitness might be improved with two different types of exercise, as compared to an active control condition. Active control condition represent individuals participating at regular meetings to talk about their current life situation, though, the meetings were not intended as that of the psychotherapy group. Regular meetings are of the same frequency, duration, and intensity as the exercise interventions.

METHODS

A total of 45 patients with HGG after undergoing neurosurgery and adjuvant radiotherapy, chemotherapy, or chemoradiotherapy will be consecutively and randomly assigned to (a) an endurance training, (b) a resistance training or (c) to an active control condition. The intervention will last for 6 consecutive weeks, consisting of 2 weekly sessions (30-45 min per session). Measurements would take place at three time points, namely at the beginning of the study (baseline), 3 weeks after the beginning of the study, and 6 weeks after the beginning of the study. The last measurement also represents the end of the study. Aerobic exercise performance will be assessed objectively with a 6-min walking test, and a handgrip test will be used to assess the upper body strength. Further, participants will complete a battery of questionnaires covering sociodemographic information, QoL, sleep quality and sleep patterns, coping with stress, state- and trait-anxiety, depression, and fatigue. In parallel, experts will use the Hamilton Depression Rating Scale to determine and rate participants' symptoms of depression.

SIGNIFICANCE

The present study will be the first to investigate and compare the impact of two different exercise modalities, namely endurance and resistance training, on physical fitness and dimensions of well-being, and sleep among patients with HGG who underwent neurosurgery followed by adjuvant radiotherapy, chemotherapy, or chemoradiotherapy. Importantly, unlike the majority of previous studies, the control condition consists of an active set-up to detect possible factual beneficial effects of exercise training, irrespective of social interactions. Trial registration https://register.clinicaltrials.gov ; identifier: NCT03775369.

An Exploratory Case Study of Mental Toughness Variability and Potential Influencers over 30 Days

The purpose of this study was to explore whether mental toughness varies across a 30-day training block and whether such variability is associated with specific antecedents. This exploratory case study research investigated mental toughness variability using the Mental Toughness Index (MTI) with thirteen elite master runners across a series of self-selected training sessions, followed by interviews and follow-up questionnaires, to identify primary influencers of variability. There were significant differences in the MTI scores between baseline (before the training period), and the minimum and the maximum reported score over five self-selected training sessions (p's < 0.004). The proceeding follow-up interviews and questionnaires then provided insights into factors influencing this intra-individual variability. These higher-level themes included foundational wellbeing, specific preparation, and actions utilized in the moment. This study is the first to demonstrate within-person MTI variability across specific training sessions and provides initial insights for both athletes and practitioners into potential influencers of mental toughness.

The effects of family dysfunction trajectories during childhood and early adolescence on sleep quality during late adolescence: Resilience as a mediator

RATIONALE

Sleep quality has been linked to several behavioral and psychological problems. No longitudinal study has examined the associations and underlying mechanisms between the trajectories of family characteristics and sleep quality in adolescents.

OBJECTIVE

This study investigates the effects of heterogeneous trajectories of family dysfunction on sleep quality in adolescents and examines whether resilience mediates these associations.

METHOD

Data came from 2280 adolescents participating in a longitudinal study across grades 2 through 11 in northern Taiwan. Group-based trajectory modeling was used to identify discrete developmental patterns of family dysfunction. Multiple linear regression was applied to examine the associations between family dysfunction trajectories and sleep quality. Mediation analysis was conducted to test whether resilience mediates the associations examined.

RESULTS

Four distinct trajectories of family dysfunction were identified: low persistent (26%), escalating dysfunction (21%), moderate stable (25%), and high persistent (28%). Compared to adolescents in the low-persistent trajectory, those in the escalating-dysfunction, moderate-stable, and high-persistent trajectories had significant lower levels of sleep quality (B = -0.19, p < .001, B = -0.14, p < .01, and B = -0.13, p < .05, respectively). Resilience significantly mediated the effects of all family dysfunction trajectories (relative to the low-persistent trajectory) on sleep quality (95% bootstrap confidence intervals are -0.06 to -0.02, -0.05 to -0.02, and -0.08 to -0.03 for escalating-dysfunction, moderate-stable, and high-persistent trajectories, respectively).

CONCLUSIONS

Family dysfunction conferred risks for poor sleep quality in adolescents and the negative effects, in part, were through decreasing resilience. Interventions to improve sleep quality in adolescents by targeting family function may be more effective when incorporating resilience.

Cross-Sectional and Longitudinal Associations Between Athlete Burnout, Insomnia, and Polysomnographic Indices in Young Elite Athletes

Few studies have examined the association between sleep and burnout symptoms in elite athletes. We recruited 257 young elite athletes (M_age = 16.8 years) from Swiss Olympic partner schools. Of these, 197 were reassessed 6 months later. Based on the first assessment, 24 participants with clinically relevant burnout symptoms volunteered to participate in a polysomnographic examination and were compared with 26 (matched) healthy controls. Between 12% and 14% of young elite athletes reported burnout symptoms of potential clinical relevance, whereas 4-11% reported clinically relevant insomnia symptoms. Athletes with clinically relevant burnout symptoms reported significantly more insomnia symptoms, more dysfunctional sleep-related cognitions, and spent less time in bed during weeknights (p < .05). However, no significant differences were found for objective sleep parameters. A cross-lagged panel analysis showed that burnout positively predicted self-reported insomnia symptoms. Cognitive-behavioral interventions to treat dysfunctional sleep-related cognitions might be a promising measure to reduce subjective sleep complaints among young elite athletes.

Acute psychosocial stress in mid-aged male rats causes hyperthermia, cognitive decline, and increased deep sleep power, but does not alter deep sleep duration

Aging is associated with altered sleep architecture and worsened hippocampus-dependent cognition, highly prevalent clinical conditions that detract from quality of life for the elderly. Interestingly, exposure to psychosocial stress causes similar responses in young subjects, suggesting that age itself may act as a stressor. In prior work, we demonstrated that young animals show loss of deep sleep, deficits in cognition, and elevated body temperature after acute stress exposure, whereas aged animals are hyporesponsive on these measures. However, it is unclear if these age-altered stress responses occur in parallel over the course of aging. To address this, here we repeated the experiment in mid-aged animals. We hypothesized that mid-aged stress responses would be intermediate between those of young and aged subjects. Sixteen mid-aged (12 months) male F344 rats were implanted with EEG/EMG emitters to monitor sleep architecture and body temperature, and were trained on the Morris water maze for 3 days. On the fourth day, half of the subjects were restrained for 3 hours immediately before the water maze probe trial. Sleep architecture and body temperature were measured during the ensuing inactive period, and on the following day, endpoint measures were taken. Restrained mid-aged animals showed resistance to deep sleep loss, but demonstrated stress-induced water maze probe trial performance deficits as well as postrestraint hyperthermia. Taken in the context of prior work, these data suggest that age-related loss of sleep architecture stress sensitivity may precede both cognitive and body temperature-related stress insensitivity.

Mental toughness latent profiles in endurance athletes

Mental toughness in endurance athletes, while an important factor for success, has been scarcely studied. An online survey was used to examine eight mental toughness factors in endurance athletes. The study aim was to determine mental toughness profiles via latent profile analysis in endurance athletes and whether associations exist between the latent profiles and demographics and sports characteristics. Endurance athletes >18 years of age were recruited via social media outlets (n = 1245, 53% female). Mental toughness was measured using the Sports Mental Toughness Questionnaire (SMTQ), Psychological Performance Inventory-Alternative (PPI-A), and self-esteem was measured using the Rosenberg Self-Esteem Scale (RSE). A three-class solution emerged, designated as high mental toughness (High MT), moderate mental toughness (Moderate MT) and low mental toughness (Low MT). ANOVA tests showed significant differences between all three classes on all 8 factors derived from the SMTQ, PPI-A and the RSE. There was an increased odds of being in the High MT class compared to the Low MT class for males (OR = 1.99; 95% CI, 1.39, 2.83; P<0.001), athletes who were over 55 compared to those who were 18–34 (OR = 2.52; 95% CI, 1.37, 4.62; P<0.01), high sports satisfaction (OR = 8.17; 95% CI, 5.63, 11.87; P<0.001), and high division placement (OR = 2.18; 95% CI, 1.46,3.26; P<0.001). The data showed that mental toughness latent profiles exist in endurance athletes. High MT is associated with demographics and sports characteristics. Mental toughness screening in athletes may help direct practitioners with mental skills training.

The Moderating Effect of Mental Toughness: Perception of Risk and Belief in the Paranormal

This research demonstrates that higher levels of mental toughness provide cognitive-perceptual processing advantages when evaluating risk. No previous research, however, has examined mental toughness in relation to perception of risk and paranormal belief (a variable associated with distorted perception of causality and elevated levels of perceived risk). Accordingly, the present paper investigated relationships between these factors. A sample of 174 participants completed self-report measures assessing mental toughness, general perception of risk, and paranormal belief. Responses were analyzed via correlations and moderation analyses. Results revealed that mental toughness correlated negatively with perception of risk and paranormal belief, whereas paranormal belief correlated positively with perception of risk. For the moderation effects, simple slopes analyses indicated that high levels of MT and subfactors of commitment and confidence reduced the strength of association between paranormal belief and perceived risk. Therefore, MT potentially acts as a protective factor among individuals who believe in the paranormal, reducing the tendency to perceive elevated levels of risk.

Further Evidence of the Zero-Association Between Symptoms of Insomnia and Facial Emotion Recognition-Results From a Sample of Adults in Their Late 30s

Background: Restoring sleep is associated with favorable cognitive, emotional, and behavioral adaptations. As regards the association between sleep duration and facial emotion recognition (FER), results are conflicting, and as regards the association between symptoms of insomnia and FER, no study has been performed so far. Accordingly, the aim of the present study was to investigate whether subjective sleep was associated with FER, along with perceived stress and mental toughness. Method: A total of 201 police officers (mean age = 38.5 years, 64.2% males) took part in the present cross-sectional study. They completed questionnaires covering socio-demographic data, subjective symptoms of insomnia, perceived stress, and mental toughness. Further, they underwent a computerized FER test, consisting of facial emotion labeling and facial emotion matching. Results: Performance of FER (accuracy, speed) was unrelated to subjective symptoms of insomnia. Lower FER was associated with higher age, but not to perceived stress or mental toughness. No gender differences were observed. Higher symptoms of insomnia were associated with higher stress scores and lower scores of mental toughness. Conclusions: The pattern of results suggests that FER was not associated with symptoms of insomnia, understood as a proxy of sleep quality, among adults. This observation replicates those studies showing a zero-association between sleep and FER.

"Always Look on the Bright Side of Life!" - Higher Hypomania Scores Are Associated with Higher Mental Toughness, Increased Physical Activity, and Lower Symptoms of Depression and Lower Sleep Complaints

Background: In the present study, we explored the associations between hypomania, symptoms of depression, sleep complaints, physical activity and mental toughness. The latter construct has gained interest for its association with a broad variety of favorable behavior in both clinical and non-clinical samples.

Subjects and Methods: The non-clinical sample consisted of 206 young adults (M = 21.3 years; age range: 18–24 years; 57.3% males). They completed questionnaires covering hypomania, mental toughness, symptoms of depression, physical activity, and sleep quality.

Results: Higher hypomania scores were associated with higher mental toughness, increased physical activity, lower symptoms of depression and lower sleep complaints. No gender differences were observed. Higher hypomania scores were predicted by higher scores of mental toughness subscales of control and challenge, and physical activity.

Conclusion: The pattern of results suggests that among a non-clinical sample of young adults, self-rated hypomania scores were associated with higher scores on mental toughness and physical activity, along with lower depression and sleep complaints. The pattern of results further suggests that hypomania traits are associated with a broad range of favorable psychological, behavioral and sleep-related traits, at least among a non-clinical sample of young adults.

Mental Toughness and Individual Differences in Learning, Educational and Work Performance, Psychological Well-being, and Personality: A Systematic Review

Mental toughness (MT) is an umbrella term that entails positive psychological resources, which are crucial across a wide range of achievement contexts and in the domain of mental health. We systematically review empirical studies that explored the associations between the concept of MT and individual differences in learning, educational and work performance, psychological well-being, personality, and other psychological attributes. Studies that explored the genetic and environmental contributions to individual differences in MT are also reviewed. The findings suggest that MT is associated with various positive psychological traits, more efficient coping strategies and positive outcomes in education and mental health. Approximately 50% of the variation in MT can be accounted for by genetic factors. Furthermore, the associations between MT and psychological traits can be explained mainly by either common genetic or non-shared environmental factors. Taken together, our findings suggest a 'mental toughness advantage' with possible implications for developing interventions to facilitate achievement in a variety of settings.

Do Individual Differences in Emotion Regulation Mediate the Relationship Between Mental Toughness and Symptoms of Depression?

Abstract. Mental Toughness (MT) provides crucial psychological capacities for achievement in sports, education, and work settings. Previous research examined the role of MT in the domain of mental health and showed that MT is negatively associated with and predictive of fewer depressive symptoms in nonclinical populations. The present study aimed at (1) investigating to what extent mentally tough individuals use two emotion regulation strategies: cognitive reappraisal and expressive suppression; (2) exploring whether individual differences in emotion regulation strategy use mediate the relationship between MT and depressive symptoms. Three hundred sixty-four participants (M = 24.31 years, SD = 9.16) provided self-reports of their levels of MT, depressive symptoms, and their habitual use of cognitive reappraisal and expressive suppression. The results showed a statistically significant correlation between MT and two commonly used measures of depressive symptoms. A small statistically significant positive correlation between MT and the habitual use of cognitive reappraisal was also observed. The correlation between MT and the habitual use of expressive suppression was statistically significant, but the size of the effect was small. A statistical mediation model indicated that individual differences in the habitual use of expressive suppression mediate the relationship between MT and depressive symptoms. No such effect was found for the habitual use of cognitive reappraisal. Implications of these findings and possible avenues for future research are discussed.

Sleep Quality, Sleep EEG Pattern, Mental Well-Being and Cortisol Secretion in Patients with Ruptured Aneurysm Post-Treatment: A Comparison with Post-Surgery Meningioma Patients and Controls

BACKGROUND

Although the chance of surviving an aneurysmal subarachnoid haemorrhage (aSAH) has increased steadily, disturbed sleep and persistent psychological complaints are frequently experienced post-ictus. To date, however, few studies have sought to determine whether physiological parameters, such as objectively measured sleep and cortisol secretion, interrelate significantly with low sleep quality and psychological complaints such as depression. Furthermore, there is little evidence as to whether post-ictal complaints differ between aSAH patients and other groups who have experienced stressful medical intervention.

METHODS

Data on objective and subjective sleep, sleep-related dysfunctional cognitions, psychological functioning and cortisol secretion were collected from 15 patients who had undergone medical intervention for aSAH. Data were also collected from a group of 16 individuals who had undergone surgery for a meningioma and a third group made up of 17 healthy participants.

RESULTS

aSAH patients and meningioma patients had significantly poorer subjective sleep than healthy controls and reported more sleep-related dysfunctional cognitions and hypochondriacal beliefs. They also had a significantly higher morning cortisol response. Finally, a non-significant trend was found showing that aSAH patients and meningioma patients reported poorer psychological functioning than healthy controls.

CONCLUSION

Following treatment, aSAH patients and meningioma patients experience poorer subjective sleep and some differences in objectively measured sleep, which might be attributable to increased sleep-related dysfunctional cognitions and poorer overall psychological functioning. Differences in cortisol production were also observed, suggesting that some physiological imbalances are still present post-ictus.

Children's Physical Resilience Outcomes: Meta-Analysis of Vulnerability and Protective Factors

Resilience has generally been understood as positive coping and adaptation despite stress and adversity and as a buffer against stress. Researchers examining resilience have typically focused on children's psychological resilience because of the well-established impact of stress on children's mental health. However, although it has also been well-established that high levels of stress can impact children's physical health, their physical health has received little attention in resilience research.

ELIGIBILITY CRITERIA

Articles were selected for review if they (1) had a variable that was in some way a measure of physical health in response to a psychosocial stressor; (2) had participants who were children or adolescents within the age range of 4-18years; and (3) were a peer-reviewed, empirical study.

SAMPLE

Two random-effect meta-analyses were conducted with a sample of 12,772 participants across 14 studies to determine the influence of protective and vulnerability factors on children's physical health in adverse experiences.

RESULTS

Protective factors had a moderate effect and vulnerability factors had a small-moderate effect on health measures across domains of physiological, sleep behavior, and overall health. The type of health measure moderated the effect size for vulnerability factors, but not for protective factors.

CONCLUSIONS

These findings suggest that protective factors may be associated with an environment that encourages children to thrive, as apparent by their physical health.

IMPLICATIONS

The results of this review and meta-analysis can be used to guide the methodological design of future studies on childhood resilience and to inform clinical practice with children and adolescents.

The Origins of Mental Toughness - Prosocial Behavior and Low Internalizing and Externalizing Problems at Age 5 Predict Higher Mental Toughness Scores at Age 14

Background: The concept of mental toughness (MT) has gained increasing importance among groups other than elite athletes by virtue of its psychological importance and explanatory power for a broad range of health-related behaviors. However, no study has focused so far on the psychological origins of MT. Therefore, the aims of the present study were: to explore, to what extent the psychological profiles of preschoolers aged five were associated with both (1) MT scores and (2) sleep disturbances at age 14, and 3) to explore possible gender differences.

Method: Nine years after their first assessment at age five (preschoolers), a total of 77 adolescents (mean age: 14.35 years; SD = 1.22; 42% females) took part in this follow-up study. At baseline, both parents and teachers completed the Strengths and Difficulties Questionnaire (SDQ), covering internalizing and externalizing problems, hyperactivity, negative peer relationships, and prosocial behavior. At follow-up, participants completed a booklet of questionnaires covering socio-demographic data, MT, and sleep disturbances.

Results: Higher prosocial behavior, lower negative peer relationships, and lower internalizing and externalizing problems at age five, as rated by parents and teachers, were associated with self-reported higher MT and lower sleep disturbances at age 14. At age 14, and relative to males, females had lower MT scores and reported more sleep disturbances.

Conclusion: The pattern of results suggests that MT traits during adolescence may have their origins in the pre-school years.

During early to mid adolescence, moderate to vigorous physical activity is associated with restoring sleep, psychological functioning, mental toughness and male gender

Numerous studies showed that regular physical activity (PA) is associated with both favourable and restorative sleep and improved psychological functioning (PF). However, there is little research on the topic covering the early to mid-adolescence period. Moreover, curiosity and exploratory behaviour (CEB) and mental toughness (MT) as a result of PA remains thus far uninvestigated, as do possible gender differences. The aim of the present study was to explore the associations between PA, subjective sleep (sS), PF, CEB, and MT during early to mid-adolescence. A total of 1361 participants (mean age = 13.37 years; range: 11-16 years; 51.2% female) took part in the study. They completed questionnaires covering PA, sS, PF, CEB, and MT. Greater PA was related to improved PF, better sS, and increased CEB and MT. Compared to male participants, females reported less PA, poorer sS, and had lower PF and MT scores. The present pattern of results suggests that during early and mid-adolescence greater PA was associated with more favourable sS and better PF, including CEB and MT, and that female participants reported lower scores in PA, sS, and PF. Accordingly, if PA has a favourable impact on sleep and psychological functioning, then data suggest that sports participation should be more tailored to increase motivation among female adolescents.

Mental toughness, sleep disturbances, and physical activity in patients with multiple sclerosis compared to healthy adolescents and young adults

BACKGROUND

Multiple sclerosis (MS) is the most common chronic autoimmune demyelinating and inflammatory disease of the central nervous system, afflicting both the body and mind. The risk of suffering from MS is 2.5-3.5 times greater in females than in males. While there is extant research on fatigue, depression, and cognitive impairment in patients with MS during its clinical course, there is a lack of research focusing on sleep, psychological functioning, and physical activity (PA) at the point of disease onset. The aims of the present study were therefore, to assess the markers of mental toughness (MT) as a dimension of psychological functioning, sleep disturbances (SD), and PA among patients at the moment of disease onset and to compare these with the corresponding values for healthy adolescents and young adults.

METHODS

A total of 23 patients with MS at disease onset (mean age =32.31 years; 91% females), 23 healthy adolescents (mean age =17.43 years; 82% females), and 25 healthy young adults (mean age =20.72 years; 80% females) took part in the study. They completed questionnaires covering sociodemographic data, MT, SD, and PA.

RESULTS

Patients with MS had similar scores for MT traits as those in healthy adolescents and healthy young adults, and equivalent levels of moderate-intensity PA and SD as young adults. MS patients reported lower levels of vigorous PA compared to both healthy adolescents and young adults.

CONCLUSION

The pattern of the results of the present study suggests that the onset of MS is not associated with poor MT, poor sleep, or reduced moderate-intensity PA. Lower levels of vigorous PA were observed in MS patients. Low levels of vigorous PA may lead to decreased cardiorespiratory fitness in patients with MS and, in the long run, to reduced cardiovascular health and degraded psychological functioning.

Examining Dark Triad traits in relation to mental toughness and physical activity in young adults

OBJECTIVE

The Dark Triad (DT) describes a set of three closely related personality traits: Machiavellianism, narcissism, and psychopathy. Mental toughness (MT) refers to a psychological construct combining confidence, commitment, control, and challenge. High MT is related to greater physical activity (PA) and, relative to men, women have lower MT scores. The aims of the present study were 1) to investigate the association between DT, MT, and PA, and 2) to compare the DT, MT, and PA scores of men and women.

METHODS

A total of 341 adults (M=29 years; 51.6% women; range: 18-37 years) took part in the study. Participants completed a series of questionnaires assessing DT, MT, and PA.

RESULTS

Machiavellianism, narcissism, and psychopathy were all significantly associated with higher MT scores (rs =0.45, 0.50, and 0.20, respectively). DT traits and MT were associated with more vigorous PA. Compared to men, women participants had lower scores for DT traits (overall score and psychopathy), while no differences were found for MT or PA in both sexes.

CONCLUSION

DT traits, high MT, and vigorous PA are interrelated. This pattern of results might explain why, for instance, successful professional athletes can at the same time be tough and ruthless.