Metacognitions, worry and sleep in everyday life: Studying bidirectional pathways using Ecological Momentary Assessment in GAD patients

Intolerance of Uncertainty as a Central Influence on Social Media Use: A School-Based Program for Adolescents

This study evaluated a classroom program to address Intolerance of uncertainty (IU) in secondary school students in Australia. IU is a transdiagnostic vulnerability factor for a range of psychological difficulties. A universal classroom program aimed to increase student understanding of feelings of uncertainty and explored socioemotional factors that could influence behaviors when facing uncertainty. Classroom teachers in two high schools were trained to deliver an 18-lesson program under naturalistic classroom conditions. Relative to the control group, the intervention lowered IU at post-test, but not at a later follow-up. The only socioemotional outcome measure to demonstrate a concurrent change was social media use. Limitations of the study were associated with the naturalistic classroom intervention, including the high level of attrition. Future studies may need to address broader factors in the students' context that could influence intolerance of uncertainty.

A within-person test of the metacognitive model: Daily dynamics between metacognitive beliefs, metacognitive strategies, and negative affect

The metacognitive model of psychological disorders highlights that emotional distress is maintained by metacognitive strategies, which are related to underlying metacognitive beliefs. Considerable empirical evidence has supported the role of metacognitions in psychopathology, but few studies have examined the suggested links between metacognitive beliefs, metacognitive strategies, and symptoms within individuals. Within-person effects provide better empirical tests of theory-based hypotheses derived from clinical models as they relate to change at the individual level. Thus, the current study sought to test central predictions from the metacognitive model at the within-person level using Dynamic Structural Equation Modelling (DSEM). A sample of 222 participants gathered at convenience participated in a 26-day long assessment period where they reported daily measures of metacognitive beliefs, metacognitive strategies, and negative affect. Temporal precedence and bidirectional relations between the variables, and the possible day-to-day and within days mediation role of metacognitive strategies between metacognitive beliefs and negative affect, were tested. When controlling for previous days effects, metacognitions and negative affect (but not metacognitive strategies) predicted each other the next day, showing a reciprocal relationship. However, metacognitive strategies were significant mediators between metacognitions and negative affect within days and day-to-day. Implications and future directions based on these findings are discussed.

Common and differential variables of anxiety and depression in adolescence: a nation-wide smartphone-based survey

BACKGROUND

Mental health in adolescence is critical in its own right and a predictor of later symptoms of anxiety and depression. To address these mental health challenges, it is crucial to understand the variables linked to anxiety and depression in adolescence.

METHODS

Here, we analyzed data of 278 adolescents that were collected in a nation-wide survey provided via a smartphone-based application during the COVID-19 pandemic. We used an elastic net regression machine-learning approach to classify individuals with clinically relevant self-reported symptoms of depression or anxiety. We then identified the most important variables with a combination of permutation feature importance calculation and sequential logistic regressions.

RESULTS

40.30% of participants reported clinically relevant anxiety symptoms, and 37.69% reported depressive symptoms. Both machine-learning models performed well in classifying participants with depressive (AUROC = 0.77) or anxiety (AUROC = 0.83) symptoms and were significantly better than the no-information rate. Feature importance analyses revealed that anxiety and depression in adolescence are commonly related to sleep disturbances (anxiety OR = 2.12, depression OR = 1.80). Differentiating between symptoms, self-reported depression increased with decreasing life satisfaction (OR = 0.43), whereas self-reported anxiety was related to worries about the health of family and friends (OR = 1.98) as well as impulsivity (OR = 2.01).

CONCLUSION

Our results show that app-based self-reports provide information that can classify symptoms of anxiety and depression in adolescence and thus offer new insights into symptom patterns related to adolescent mental health issues. These findings underscore the potentials of health apps in reaching large cohorts of adolescence and optimize diagnostic and treatment.

The Relationship between Metacognition, Rumination, and Sleep in University Students with a Tendency toward Generalized Anxiety Disorder

People with generalized anxiety disorder tend to have sleep problems, and studies have found correlations between metacognition, rumination, and sleep, but it is unclear how metacognition and rumination work in people with a tendency towards generalized anxiety disorder. The goal of this paper is to investigate the correlation between metacognition, rumination, and sleep in university students with a tendency towards generalized anxiety disorder, and the mediating role of rumination in the effect of metacognition on sleep. The Generalized Anxiety Disorder Scale (GAD-7), the Meta-Cognition Questionnaire (MCQ-30), the Ruminative Responses Scale (RRS), and the Insomnia Severity Index (ISI) were used to investigate and psychometrically measure 566 university students in Anyang Normal College. The results of correlation analysis showed significant positive correlations between metacognition and sleep, ruminative thinking and sleep, and metacognition and rumination in university students with a tendency towards generalized anxiety disorder. Mediation analysis showed that rumination partially mediated the effect of metacognition on sleep, with the mediating effect accounting for 51.1% of the total effect. There is a strong correlation between metacognition, rumination, and sleep in university students with a tendency towards generalized anxiety disorder, and both metacognition and rumination can predict sleep, while metacognition can affect sleep through the mediating effect of rumination.

The relationships among metacognitive functions, sleep-related thought-control strategies and sleep quality: A mediation analysis

In the context of sleep disturbances, increasing evidence suggests a critical role of sleep-related dysfunctional metacognitive activity, including metacognitive control of intrusive thoughts in the pre-sleep period. Although the relationship between sleep-related thought-control strategies and poor sleep quality is well recognized, the possible contribution of general metacognitive functioning within this relation is still unclear. In this study, we performed a mediation analysis to examine the role of thought-control strategies on the relationship between metacognitive abilities and sleep quality in individuals with different self-reported sleep characteristics. Two-hundred and forty-five individuals participated in the study. Participants completed the Pittsburgh Sleep Quality Index, the Thought Control Questionnaire Insomnia-Revised, and the Metacognition Self-Assessment Scale to evaluate sleep quality, thought-control strategies and metacognitive functions, respectively. The results showed that worry strategy in the pre-sleep period mediates the relationship between metacognitive functions and sleep quality. Particularly, the ability to understand one's mental states and mastery functions could be the two metacognitive domains primarily involved in the dysfunctional metacognitive thought-control activity responsible for reduced sleep quality. The observed effect suggests that inadequate metacognitive functioning is associated with poor sleep quality in healthy subjects via the mediation of dysfunctional worry strategy. These findings suggest the potential relevance of clinical interventions to enhance specific metacognitive abilities, with the aim to promote more functional strategies for managing cognitive and emotional processes during the pre-sleep period.

Experience sampling methodology study of anxiety and depression in adolescents with epilepsy: The role of metacognitive beliefs and perseverative thinking

Emotional distress is common in young people with epilepsy (YPwE). According to the Self-Regulatory Executive Function (S-REF) model, maladaptive metacognitive beliefs and perseverative thinking are fundamental in the development and maintenance of emotional distress. As emotional distress and perseverative thinking can highly fluctuate over short intervals in YPwE, it is important to account for this variability when testing the utility of psychological models. Experience sampling methodology (ESM) was therefore used to explore the momentary relationship between metacognitive beliefs, perseverative thinking, and emotional distress in YPwE. Eighteen participants diagnosed with epilepsy (aged 12-17 years) completed the 10-day ESM period. Participants were prompted to complete the ESM assessment five times daily. The ESM assessment assessed participant's momentary levels of metacognitive beliefs, perseverative thinking (i.e., worry and rumination), and emotional distress (i.e., anxiety and depression). A series of multilevel regression analyses indicated that metacognitive beliefs were significantly positively associated with worry, rumination, anxiety and depression. After controlling for worry and rumination, respectively, metacognitive beliefs did not account for additional variance in anxiety or depression. Findings provide preliminary support for the utility of the S-REF model for emotional distress in YPwE. Metacognitive therapy, which is underpinned by the S-REF model, may be an appropriate intervention for emotional distress in YPwE. Future studies should assess the mediational relationship between metacognitive beliefs, perseverative thinking, and emotional distress using time-lagged models.

Prospective Relations Between Dysfunctional Metacognitive Beliefs, Metacognitive Strategies, and Anxiety: Results From a Four-Wave Longitudinal Mediation Model

The metacognitive model of psychological disorders suggests that emotional disorders are related to maladaptive metacognitive strategies corresponding to underlying dysfunctional metacognitive beliefs. There is substantial empirical evidence supporting a role of metacognition in psychopathology, but fewer studies have evaluated the metacognitive model using longitudinal data and taken into consideration its differentiation between components and how they are hypothesized to be related to each other. Thus, more specific model evaluation is important as it relates to identifying mechanisms of disorder with a potential to provide clinical advances. In the present study, 868 participants took part in a 4-wave survey and reported on metacognitive beliefs and strategies and anxiety symptoms. Two longitudinal mediation models (forward and reversed causation) were run to test temporal precedence and bidirectional relations. The results indicated that metacognitive beliefs significantly predicted metacognitive strategies, which further predicted anxiety symptoms and mediated the indirect effect in the relationship between metacognitive beliefs and anxiety over time. The relationship between metacognitive beliefs and anxiety symptoms over time were bidirectional, but this relationship was not accounted for by metacognitive strategies. These findings largely support central predictions set forward by the metacognitive model and indicate that metacognitions play a preceding and maintaining role in anxiety.

Applying ensemble machine learning models to predict individual response to a digitally delivered worry postponement intervention

OBJECTIVE

Generalized anxiety disorder (GAD) is a prevalent mental health disorder that often goes untreated. A core aspect of GAD is worry, which is associated with negative health outcomes, accentuating a need for simple treatments for worry. The present study leveraged pretreatment individual differences to predict personalized treatment response to a digital intervention.

METHODS

Linear mixed-effect models were used to model changes in daytime and nighttime worry duration and frequency for 163 participants who completed a six-day worry postponement intervention. Ensemble-based machine learning regression and classification models were implemented to predict changes in worry across the intervention. Model feature importance was derived using SHapley Additive exPlanation (SHAP).

RESULTS

Moderate predictive performance was obtained for predicting changes in daytime worry duration (test r2 = 0.221, AUC = 0.77) and nighttime worry frequency (test r2 = 0.164, AUC = 0.72), while poor predictive performance was obtained for nighttime worry duration and daytime worry frequency. Baseline levels of worry and subjective health complaints were most important in driving model predictions.

LIMITATIONS

A complete-case analysis was leveraged to analyze the present data, which was collected from participants that were Dutch and majority female.

CONCLUSIONS

This study suggests that treatment response to a digital intervention for GAD can be accurately predicted using baseline characteristics. Particularly, this worry postponement intervention may be most beneficial for individuals with high baseline worry but fewer subjective health complaints. The present findings highlight the complexities of and need for further research into daily worry dynamics and the personalizable utility of digital interventions.

An empirical test of the metacognitive model of generalized anxiety disorder

The metacognitive model of generalized anxiety disorder (GAD) places worrying, meta-worry ("worry about worry") and corresponding underlying metacognitive beliefs (i.e., beliefs about worry) as central in the maintenance of symptoms. Previous research has demonstrated significant relationships between these factors and symptoms, but no study has tested the statistical fit of this influential model including its hypothesized components and the suggested paths between them. The aim of the current study was therefore to evaluate the fit of the metacognitive model of GAD. A total of 312 participants constituting an analogue GAD sample were included in a cross-sectional study and completed self-report measures of anxiety and depression symptoms and scales relevant to the metacognitive model. Metacognitions, worry, and meta-worry in their hypothesized order provided a good model fit and explained significant and substantial variance in symptoms. These results provide further support for the metacognitive model of GAD and demonstrates separate and unique contributions from worry and meta-worry to generalized anxiety symptoms of which meta-worry was the most influential.

Daily Associations of Sleep Quality and Sleep Duration with Anxiety in Young Adults: The Moderating Effect of Alexithymia

OBJECTIVES

The present study examined the daily, within-individual associations of anxiety with sleep quality and sleep duration and the moderating effects of alexithymia on these associations in community-dwelling young adults. It was hypothesized that daily anxiety and sleep parameters would be bidirectionally related and alexithymia would moderate these relationships.

METHOD

Participants completed morning and evening diaries assessing daily anxiety and sleep parameters for 30 consecutive days. They also completed questionnaires assessing baseline sleep parameters, anxiety, and alexithymia. Multilevel modeling was used to evaluate the within-individual associations between daily anxiety and sleep parameters and whether between-individual differences in alexithymia moderated these associations.

RESULTS

Higher anxiety relative to personal averages across the study period was associated with shorter sleep duration at night. Poorer sleep quality and shorter sleep duration relative to personal averages were associated with higher next-day anxiety. A significantly stronger association between poorer sleep quality and higher next-day anxiety was observed in individuals with higher levels of alexithymia.

CONCLUSION

Daily anxiety and sleep quantity are bidirectionally associated within individuals in community-dwelling young adults. Poorer sleep quality was associated with higher next-day anxiety but not vice versa. Individuals with higher levels of alexithymia might be more vulnerable to the effects of poor sleep on next-day anxiety.

An experimental investigation of intolerance of uncertainty and its impact on sub-clinical psychopathology

BACKGROUND

Intolerance of Uncertainty (IU) is a transdiagnostic construct that is implicated in psychological difficulties, including Major Depressive Disorder (MDD), Generalised Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), and eating disorders (ED). However, most studies exploring IU have been correlational in nature. This study examined (1) whether a linguistic manipulation of the Intolerance of Uncertainty Scale (IUS) would successfully manipulate IU in an undergraduate sample, (2) whether experimentally increased or decreased levels of IU affect symptoms of MDD, GAD, OCD and ED, and (3) whether increased baseline symptom severity influences the magnitude of change in symptom severity post-manipulation.

METHODS

A linguistic manipulation of the IUS was used to manipulate participants' beliefs about their ability to tolerate uncertainty. N = 106 undergraduate participants were randomised to one of two conditions: high IU (HIU; n = 54) or low IU (LIU; n = 52), and completed measures on symptom severity at baseline and one-week follow-up.

RESULTS

The manipulation successfully reduced IU in LIU. Participants in this group did not experience significant changes in symptom severity post-manipulation. However, individuals with higher baseline OCD in LIU demonstrated greater decreases in post-manipulation OCD symptoms, compared with individuals in HIU.

LIMITATIONS

Only the LIU manipulation was effective, limiting the findings from the HIU. The one-week follow-up and relatively small sample size of predominantly female undergraduate students may dilute and limit the generalisability of results.

CONCLUSION

Findings support the utility of this manipulation in reducing IU, and the significance of different levels of IU in OCD.

Daily stress and sleep associations vary by work schedule: A between- and within-person analysis in nurses

Nurses experience poor sleep and high stress due to demanding work environments. Night shift work is common among nurses and may exacerbate stress-sleep associations. We examined bidirectional associations between daily stress and sleep, and moderation by recent shift worker status and daily work schedule among nurses. Participants were 392 nurses (92% female; 78% White, mean age = 39.54, SD = 11.15) who completed 14 days of electronic sleep diaries and actigraphy. They simultaneously completed assessments of daily stress and work schedule upon awakening (day shift vs. night shift [work between 9 p.m.-6 a.m.] vs. off work). Participants were classified as recent night shift workers if they worked at least one night shift during the past 14 days (n = 101; 26%). In the entire sample, greater daily stress predicted shorter self-reported total sleep time and lower self-reported sleep efficiency that night. Shorter self-reported and actigraphy total sleep time and lower self-reported sleep efficiency predicted higher next-day stress. Compared with recent night shift workers, day workers reported higher stress after nights with shorter total sleep time. Stress-sleep associations mostly did not vary by nurses' daily work schedule. Sleep disturbances and stress may unfold in a toxic cycle and are prime targets for tailored interventions among nurses. Night shift workers may be less susceptible to the effects of short sleep on next-day stress. Research is needed to understand the short- and long-term effects of shift work and address the unique sleep challenges nurses face.

Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up

STUDY OBJECTIVES

Insomnia is highly prevalent and associated with anxiety and depression in patients with coronary heart disease patients. The development of effective psychological interventions is needed. Worry and rumination are potential risk factors for the maintenance of insomnia, anxiety, and depression that may be modified by psychological treatment grounded in the Self-Regulatory Executive Function model. However, the relationships between worry, rumination, anxiety and depression, and insomnia are not known. Therefore, we investigated these relationships both cross-sectionally and longitudinally among patients with coronary heart disease.

METHODS

A cross-sectional study consecutively included 1,082 patients in 2014-2015, and 686 were followed up after mean of 4.7 years. Data were gathered from hospital records and self-report questionnaires comprising assessment of worry (Penn State Worry Questionnaire), rumination (Ruminative Responses Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and insomnia (Bergen Insomnia Scale).

RESULTS

Insomnia correlated moderately with all other psychological variables (R 0.18-0.50, all P values < .001). After adjustments for anxiety and depression, odds ratios for insomnia at baseline were 1.27 (95% confidence interval 1.08-1.50) and 1.60 (95% confidence interval 1.31-1.94) per 10 points increase of worry and rumination, respectively. Corresponding odds ratios for insomnia at follow-up were 1.28 (95% confidence interval 1.05-1.55) and 1.38 (95% confidence interval 1.09-1.75). Depression was no longer significantly associated with insomnia after adjustments for worry and rumination, but anxiety remained significant.

CONCLUSIONS

Worry and rumination predicted insomnia both cross-sectionally and prospectively, even after controlling for anxiety and depression, although anxiety remained significant. Future studies may test psychological interventions targeting these factors in patients with coronary heart disease and insomnia.

CITATION

Frøjd LA, Papageorgiou C, Munkhaugen J, et al. Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up. J Clin Sleep Med. 2022;18(3):779-787.

Moderators of Cognitive Behavioral Treatment for Insomnia on Depression and Anxiety Outcomes

PURPOSE OF REVIEW

With a focus on reviewing adequately powered randomized controlled trials, we present recent research on the potential of cognitive behavioral therapy for insomnia (CBT-I) to improve depression and anxiety outcomes among patients with insomnia and one of the following comorbid psychiatric disorders: major depressive disorder (MDD), generalized anxiety disorder (GAD), or posttraumatic stress disorder (PTSD). We also examine potential moderators of CBT-I on depression and anxiety outcomes in this population.

RECENT FINDINGS

Despite high comorbidity rates, current behavioral and pharmacological treatments for MDD, GAD, and PTSD do not substantially target or improve insomnia symptoms; residual insomnia is exceedingly common even among patients who experience remission. Insomnia plays a critical role in the onset and maintenance of depression and anxiety, and treating insomnia with CBT-I may improve global outcomes for patients with MDD, GAD, and PTSD. CBT-I is superior to traditional depression/anxiety treatment in improving insomnia symptoms among patients with comorbid psychiatric disorders. Results are mixed on whether CBT-I (either alone or augmented with depression/anxiety treatment) is effective in improving overall MDD, GAD, and PTSD outcomes. Evening circadian preference and depression/anxiety symptom severity may moderate the effect of CBT-I on depression and anxiety outcomes.

The relationship between repetitive negative thinking, sleep disturbance, and subjective fatigue in women with Generalized Anxiety Disorder

Objectives

Fatigue is a prominent symptom of Generalized Anxiety Disorder (GAD). However, the pathways contributing to elevated fatigue in GAD are poorly understood. Sleep disturbance, also prominent in GAD, only partially explains elevated fatigue in GAD. Repetitive negative thinking (RNT) is a cognitive feature of both GAD and sleep disturbance, and RNT has recently also been associated with elevated fatigue. Therefore, this study assessed whether elevated fatigue in GAD is accounted for by a combination of sleep quality and RNT.

Design

Between‐group, correlational design in 64 primarily university‐educated women with and without a GAD diagnosis.

Methods

Women completed self‐report questionnaires assessing RNT experienced in the past few days, previous night’s sleep quality, and current physical and mental fatigue. Hierarchical linear regressions were conducted to assess whether the relationship between GAD status and fatigue is accounted for by RNT and sleep quality.

Results

Women with GAD reported lower sleep quality, and higher RNT and physical and mental fatigue, compared to women without GAD. Sleep quality partly accounted for group differences in both types of fatigue (β’s > −0.4), whereas RNT fully accounted for group differences in both types of fatigue (β’s > 0.29). The relationship between RNT and both types of fatigue was fully accounted for by sleep quality (β’s > −0.39).

Conclusions

These findings indicate that heightened RNT amongst women with GAD may be associated with elevated physical and mental fatigue via its detrimental effects on sleep quality. Interventions that reduce RNT may help to alleviate fatigue symptoms in women with GAD.

Practitioner points

Women with Generalized Anxiety Disorder (GAD) have elevated fatigue and repetitive negative thinking (RNT), and poorer self‐reported sleep quality, relative to women without GAD.

Whereas sleep quality only partially accounts for elevated fatigue in GAD, RNT fully accounts for elevated fatigue, and the relationship between RNT and fatigue is fully accounted for by sleep quality.

These findings provide novel evidence that women with GAD may have elevated fatigue because of the detrimental effects of RNT on sleep.

These findings suggest that targeting RNT in treatment for GAD may help to reduce fatigue in GAD, by improving sleep quality.

A brief scale of pathological worry that everyone already has

Worry is a central process in a wide range of psychopathological and somatic conditions. Three studies (N = 856) were used to test whether a subscale composed of five items of the most commonly used trait anxiety questionnaire, Spielberger’s State Trait Anxiety Inventory-Trait version (STAI-T), is appropriate to measure worry. Results showed that the subscale, named the Brief Worry Scale (BWS), had excellent internal consistency and temporal stability. Convergent and divergent validity were supported by correlation analyses using worry questionnaires and measures of anxious arousal and depression. The BWS was a particularly good predictor of the pathogenic aspects of worry, including worry perseveration in daily life (study 1), measures of clinical worry (study 2) and the uncontrollability of experimentally induced worry (study 3). Taken together, these studies demonstrate that the BWS might be a valuable scale for pathological worry, for which many researchers already have data.

Compliance With Mobile Ecological Momentary Assessment of Self-Reported Health-Related Behaviors and Psychological Constructs in Adults: Systematic Review and Meta-analysis

Background

Mobile ecological momentary assessment (mEMA) permits real-time capture of self-reported participant behaviors and perceptual experiences. Reporting of mEMA protocols and compliance has been identified as problematic within systematic reviews of children, youth, and specific clinical populations of adults.

Objective

This study aimed to describe the use of mEMA for self-reported behaviors and psychological constructs, mEMA protocol and compliance reporting, and associations between key components of mEMA protocols and compliance in studies of nonclinical and clinical samples of adults.

Methods

In total, 9 electronic databases were searched (2006-2016) for observational studies reporting compliance to mEMA for health-related data from adults (>18 years) in nonclinical and clinical settings. Screening and data extraction were undertaken by independent reviewers, with discrepancies resolved by consensus. Narrative synthesis described participants, mEMA target, protocol, and compliance. Random effects meta-analysis explored factors associated with cohort compliance (monitoring duration, daily prompt frequency or schedule, device type, training, incentives, and burden score). Random effects analysis of variance (P≤.05) assessed differences between nonclinical and clinical data sets.

Results

Of the 168 eligible studies, 97/105 (57.7%) reported compliance in unique data sets (nonclinical=64/105 [61%], clinical=41/105 [39%]). The most common self-reported mEMA target was affect (primary target: 31/105, 29.5% data sets; secondary target: 50/105, 47.6% data sets). The median duration of the mEMA protocol was 7 days (nonclinical=7, clinical=12). Most protocols used a single time-based (random or interval) prompt type (69/105, 65.7%); median prompt frequency was 5 per day. The median number of items per prompt was similar for nonclinical (8) and clinical data sets (10). More than half of the data sets reported mEMA training (84/105, 80%) and provision of participant incentives (66/105, 62.9%). Less than half of the data sets reported number of prompts delivered (22/105, 21%), answered (43/105, 41%), criterion for valid mEMA data (37/105, 35.2%), or response latency (38/105, 36.2%). Meta-analysis (nonclinical=41, clinical=27) estimated an overall compliance of 81.9% (95% CI 79.1-84.4), with no significant difference between nonclinical and clinical data sets or estimates before or after data exclusions. Compliance was associated with prompts per day and items per prompt for nonclinical data sets. Although widespread heterogeneity existed across analysis (I²>90%), no compelling relationship was identified between key features of mEMA protocols representing burden and mEMA compliance.

Conclusions

In this 10-year sample of studies using the mEMA of self-reported health-related behaviors and psychological constructs in adult nonclinical and clinical populations, mEMA was applied across contexts and health conditions and to collect a range of health-related data. There was inconsistent reporting of compliance and key features within protocols, which limited the ability to confidently identify components of mEMA schedules likely to have a specific impact on compliance.

Cognitive behavioural therapy for insomnia for patients with co-morbid generalized anxiety disorder: an open trial on clinical outcomes and putative mechanisms

BACKGROUND

Very little is known concerning the efficacy of psychosocial treatments for patients with insomnia disorder co-morbid with generalized anxiety disorder (GAD).

AIM

The aim was to examine the efficacy of cognitive behavioral therapy for insomnia (CBT-I) for patients with insomnia disorder co-morbid with GAD.

METHOD

Given the limited, previous research on therapies for patients with insomnia disorder co-morbid with GAD, an open trial design was used. Twenty-four patients with insomnia disorder and GAD were administered CBT-I across 10 weeks. Across the study period to 6 months follow-up, the participants completed measures indexing insomnia, anxiety, worry, depression, functional impairment, quality of life, treatment perception (credibility, expectancy and satisfaction), adverse events and putative mechanisms.

RESULTS

Moderate to large effect sizes for CBT-I were observed for insomnia symptoms. In terms of insomnia severity, approximately 61% of the patients responded to CBT-I and 26-48% remitted. Moderate to large effect sizes were also demonstrated for GAD symptoms, depression, functional impairment and quality of life. Roughly one-third of the participants reported an adverse event during CBT-I. Five of the seven putative mechanisms were significantly reversed in the expected direction, i.e. all four cognitive process measures and time in bed.

CONCLUSIONS

This open trial indicates that CBT-I is an efficacious intervention for patients with insomnia disorder co-morbid with GAD. The results highlight the need for further research using a randomized controlled trial design with analyses of mechanisms of change.

Tobacco use and sleep loss over worry among adolescents aged 12-15 years: A population-based study of 38 countries

BACKGROUND

Sleep loss is increasingly recognized as a key public health issue among adolescents. Tobacco use is one of the leading causes of preventable disease and death in the world. Yet, the association between tobacco use and sleep loss has been understudied in the adolescent population. This study aimed to examine this association utilizing nationally representative samples of adolescents.

METHODS

Cross-sectional data on 109 408 adolescents (12-15 years) from 38 countries were derived from the Global School-based Student Health Survey (GSHS). Weighted age- and sex-adjusted distribution of each sample characteristics was calculated. Multivariate logistic regression and meta-analyses were performed to assess the association of sleep loss over worry with any tobacco use, while controlling for important confounders, including age, gender, loneliness, physical attack victimization, parental knowledge/warmth, and perceived peer kindness/helpfulness.

RESULTS

The weighted age- and sex-adjusted prevalence of SLOW and use of any tobacco product was 6.4% and 7.4% respectively across 38 countries. The overall odds of sleep loss over worry were 1.89 times (95% confidence interval (CI) = 1.75, 2.03) greater among tobacco users than among non-users, with low level of between-country heterogeneity (I2  = 24.0%, P = 0.095). The odds of sleep loss over worry were 1.61 times (95% CI = 1.52, 1.71) greater among those reporting physical attack victimization than among non-victims, and 5.55 times (95% CI = 4.95, 6.21) greater among those reporting frequent than less frequent loneliness.

CONCLUSIONS

Tobacco use, physical attack victimization, and loneliness can be key indicators of SLOW, and may be included in the assessment and prevention of SLOW to generate a more comprehensive picture. Further studies are needed to determine if reducing tobacco use, loneliness, or physical attack victimization would make a meaningful impact on reducing SLOW.

Anhedonia is central for the association between quality of life, metacognition, sleep, and affective symptoms in generalized anxiety disorder: A complex network analysis

BACKGROUND

Poor quality of life, sleep problems, anhedonia, and negative metacognitions are common in anxiety and depression. To examine the nature of the relationship between these features and the role of metacognitions, anhedonia, and quality of life in anxiety and depression, we conducted a complex network analysis with items of self-report measures assessing quality of life, sleep, negative thinking styles, anxiety, and depression.

METHODS

Participants were 226 treatment seeking individuals with a primary DSM-5 diagnosis of generalized anxiety disorder. Node centrality, strength, expected influence, community, and bridge estimation were calculated using partial correlation coefficients and glasso regularization.

RESULTS

Results revealed that anhedonia was the most central node followed by quality of life nodes. Moreover, anhedonia exhibited the highest strength and expected influence, which were both stable, reliable metrics within the network. Metacognitions were not central nodes in the network, but were strong bridge symptoms between communities.

LIMITATIONS

The results are limited by the cross-sectional nature of the data and the administration of self-report scales at one time-point, despite different rating anchors.

CONCLUSION

These findings suggest that anhedonia is a crucial element for the association between quality of life, sleep problems, and negative cognitions.

Assessing repetitive negative thinking in daily life: Development of an ecological momentary assessment paradigm

Repetitive negative thinking (RNT) is a transdiagnostic process and a promising target for prevention and treatment of mental disorders. RNT is typically assessed via self-report questionnaires with most studies focusing on one type of RNT (i.e., worry or rumination) and one specific disorder (i.e., anxiety or depression). However, responses to such questionnaires may be biased by memory and metacognitive beliefs. Recently, Ecological Momentary Assessment (EMA) has been employed to minimize these biases. This study aims to develop an EMA paradigm to measure RNT as a transdiagnostic process in natural settings. Based on empirical and theoretical considerations, an item pool was created encompassing RNT content and processes. We then (1) tested model fit of a content-related and a process-related model for assessing RNT as an individual difference variable, (2) investigated the reliability and construct validity of the proposed scale(s), and (3) determined the optimal sampling design. One hundred fifty healthy participants aged 18 to 40 years filled out baseline questionnaires on rumination, worry, RNT, symptoms of depression, anxiety, and stress. Participants received 8 semi-random daily prompts assessing RNT over 14 days. After the EMA phase, participants answered questionnaires on depression, anxiety, and stress again. Multilevel confirmatory factor analysis revealed excellent model fit for the process-related model but unsatisfactory fit for the content-related model. Different hybrid models were additionally explored, yielding one model with satisfactory fit. Both the process-related and the hybrid scale showed good reliability and good convergent validity and were significantly associated with symptoms of depression, anxiety, and stress after the EMA phase when controlling for baseline scores. Further analyses found that a sampling design of 5 daily assessments across 10 days yielded the best tradeoff between participant burden and information retained by EMA. In sum, this paper presents a promising paradigm for assessing RNT in daily life.

Daily Worry in Trauma-Exposed Afghan Refugees: Relationship with Affect and Sleep in a Study Using Ecological Momentary Assessment

Background

Repetitive negative thinking—and worry as a common variant—have been suggested to be transdiagnostic maintaining factors of psychopathology in refugees. Using an ecological momentary assessment (EMA) approach, this study tested the feasibility of EMA and the hypothesis of a self-reinforcing relationship (a) between worry and affect and (b) between worry and sleep in refugees. Additionally, we examined whether worry interacts with postmigration stress to impact on affect and sleep.

Methods

For 1 week, 45 trauma-exposed Afghan refugees received five prompts per day asking them to report on momentary levels of worrying and negative as well as positive affect. In addition, sleep quality was assessed in the morning and the occurrence of postmigration stress at night.

Results

Our findings did not indicate a bidirectional relationships (a) between worry and affective experiences and (b) between worry and poor sleep quality. However, worry experienced on a given day predicted increased negative affect on the next day; in turn, positive affect predicted decreased worrying on the next day. Hypotheses on the interaction between worry and stress in predicting affect and sleep were not supported.

Conclusion

These preliminary findings suggest unidirectional effects of daily worry on negative affect and positive affect on daily worry. However, the low compliance rate and the small sample size precludes drawing firm conclusions. Implications for further EMA research among refugees are discussed.

International Nursing: A Study of Sleep Quality Among Nurses and Its Correlation With Cognitive Factors

The objective of this study was to evaluate sleep quality and its relationship to cognitive factors among nurses. Sleep quality among nurses is an important issue, which requires more extensive study. Its correlation with cognitive ability has not been sufficiently considered. Five hundred forty nurses (66.3% female) working in 6 hospitals were selected as the sample of the study. Results show that nurses do not experience good quality of sleep. That is, 77.4% of the sample population of nurses have a poor quality of sleep, and nurses working the night shift have more sleep problems than other nurses. The results show that there is a relationship between dysfunctional beliefs and attitudes about sleep and metacognitive process and the quality of sleep, and that these variables can predict sleep quality. Based on the results of the study, it can be said that cognitive and metacognitive processes play an important role in sleep quality. Lack of sufficient sleep can create numerous problems for nurses and patients. Attention to the role of cognitive and metacognitive processes can help improve the sleep quality of nurses.

Convergence of psychiatric symptoms and restless legs syndrome: A cross-sectional study in an elderly French population

OBJECTIVE

The objective was to evaluate the association between restless legs syndrome (RLS) with generalized anxiety disorder (GAD), major depression disorder (MDD), dysthymia, and GAD-depression comorbidity. Secondary aims were to examine the association between RLS with the cognitive-affective and somatic-vegetative disturbances experienced as part of depression and GAD.

METHODS

This was a cross-sectional study of 1493 elderly participants (median age 80.6 years, 64% women) from Dijon, France. Probable RLS was assessed using the minimal diagnostic criteria of the International Restless Legs Study Group and RLS symptom frequency and treatment. Participants underwent structured interviews for MDD, dysthymia, and GAD. Participants also completed the Center for Epidemiological Studies-Depression scale (CES-D). The association between RLS and psychiatric disorders, their criterion symptoms, or symptom factors was examined using logistic regression.

RESULTS

The point prevalence of probable RLS in this sample was 8.2%. Probable RLS was associated with isolated GAD (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.01-4.68) and comorbid GAD-any depression disorder (OR 3.26, 95% CI 1.14-9.29), but not MDD or dysthymia. Probable RLS was also associated with the GAD criterion worry most days and feeling tense, and the CES-D factors representing depressed affect, somatic symptoms, and positive affect.

CONCLUSIONS

Probable RLS was associated with GAD-depression comorbidity as well as isolated GAD. The findings challenge previous reports linking RLS solely with MDD, suggesting the association is partly driven by GAD-depression comorbidity.

Differential associations between chronotype, anxiety, and negative affect: A structural equation modeling approach

BACKGROUND

Increasing evidence implicates circadian rhythms, including chronotype, in anxiety symptoms and disorders. However, it remains unclear whether this relation is accounted for by sleep disturbance. Likewise, given overlap between anxiety and negative affect, a unique link between chronotype and anxiety remains to be established. The present study addressed these questions using a multimethod approach to determine whether there is a unique relation between chronotype and anxiety symptoms, controlling for sleep disturbance.

METHODS

Indicators of chronotype, sleep disturbance, anxiety, and negative affect were collected in a sample of adults (N = 151) using a combination of subjective and behavioral measures both within and outside the laboratory over a 9-day period. Structural equation modeling was used to examine associations between latent constructs.

RESULTS

Results revealed significant associations between sleep disturbance and both anxiety and negative affect. A significant association was found between chronotype and anxiety, over and above the effect of sleep disturbance. In contrast, the relation between chronotype and negative affect was nonsignificant after controlling for sleep disturbance.

LIMITATIONS

Unselected sample, lack of experimental manipulation, cross-sectional design.

CONCLUSIONS

These findings suggest a unique role of chronotype in anxiety and point to circadian disruption as a potential biological mechanism in anxiety-related disorders.

Night-time rumination in PTSD: development and validation of a brief measure

Background: Pre-sleep cognitive activity and arousal have long been implicated in the maintenance of insomnia. However, despite high comorbidity between insomnia and posttraumatic stress disorder (PTSD), pre-sleep thoughts in PTSD and their associations with disturbed sleep, have not yet been investigated. Objective: This study presents the development and preliminary validation of a brief self-report measure of the content of trauma-related pre-sleep thoughts: the Trauma Thoughts before Sleep Inventory (TTSI). Methods: Participants (N = 285) were recruited online into five groups: three groups with clinical symptoms, 1) PTSD; 2) depression without PTSD; 3) insomnia without depression or PTSD; and two healthy control groups 4) nontrauma-exposed controls; 5) trauma-exposed controls. The questionnaire was administered at baseline, and for a subsample (n = 157) again one week later to assess test-retest reliability. At baseline, participants also completed questionnaires of sleep quality, PTSD and depression symptoms, and insomnia-related thoughts. Results: The TTSI had good reliability and validity; it discriminated participants with PTSD from those with depression and insomnia, those with depression from insomnia, and correlated with existing measures of pre-sleep thoughts, self-reported pre-sleep arousal and poor sleep. Conclusions: The results support the utility of the TTSI for measuring thoughts that keep people with PTSD awake, although replication in an independent clinical sample is required.

Time of day effects on the relationship between daily sleep and anxiety: An ecological momentary assessment approach

Previous research has linked sleep disturbance to anxiety. However, evidence for this relation has been inconsistent, largely limited to retrospective reports that do not account for daily variability, and silent on when the association is most pronounced. Thus, the present study utilized ecological momentary assessment (EMA) to examine the effects of daily deviations in total sleep time (TST) and person-average TST on anxiety and whether these effects varied as a function of time of day in a sample of unselected adults (N = 138). Results indicate that the amount of TST on a given night, relative to personal average TST, negatively predicted anxiety, and this relation was significant in the morning and afternoon, but not evening. In contrast, person-average TST was unrelated to average anxiety. Relations between TST and anxiety did not differ across objective (e.g., actigraphy) and subjective (e.g., sleep diary) measures. Furthermore, the pattern of results remained the same when controlling for previous day's anxiety and were not bidirectional. These findings suggest that getting less sleep than is typical for the individual predicts subsequent anxiety, and this effect is particularly strong in the morning. Average sleep duration may be less important to the experience of anxiety than deviations from that average. These findings highlight the importance of EMA to examine how and when variability in sleep confers vulnerability for anxiety symptoms.

Shorter sleep duration and longer sleep onset latency are related to difficulty disengaging attention from negative emotional images in individuals with elevated transdiagnostic repetitive negative thinking

BACKGROUND AND OBJECTIVES

Repetitive negative thinking (RNT) is often associated with disruptions in sleep and circadian rhythms. Disruptions in sleep and circadian rhythms may deal a "second hit" to attentional control deficits. This study evaluated whether sleep and circadian rhythm disruptions are related to the top-down control of attention to negative stimuli in individuals with heightened repetitive negative thinking.

METHODS

Fifty-two community adults with high levels of transdiagnostic RNT and varying habitual sleep durations and bedtimes participated in a hybrid free-viewing and directed attention task using pairs of emotionally-evocative and neutral images while eye-tracking data were collected. Self-report and clinician-administered interviews regarding sleep were also collected.

RESULTS

Shorter habitual sleep duration was associated with more time looking at emotionally negative compared to neutral images during a free-viewing attention task and more difficulty disengaging attention from negative compared to neutral images during a directed attention task. In addition, longer sleep onset latencies were also associated with difficulty disengaging attention from negative stimuli. The relations between sleep and attention for positive images were not statistically significant.

LIMITATIONS

A causal link between sleep and attentional control cannot be inferred from these cross-sectional data. The lack of a healthy control sample means that the relations between sleep disruption, attention, and emotional reactivity may not be unique to individuals with RNT.

CONCLUSIONS

These findings suggest that sleep disruption may be associated with a specific impact on cognitive resources that are necessary for the top-down inhibitory control of attention to emotionally negative information.

Prospective Associations Between Sleep Disturbance and Repetitive Negative Thinking: The Mediating Roles of Focusing and Shifting Attentional Control

Although considerable evidence has linked sleep disturbance to symptoms of psychopathology, including repetitive negative thinking, few studies have examined how sleep disturbance may predict repetitive negative thinking over time. Further, no study to date has examined specific mechanisms that may account for this relationship. The present study sought to address these gaps in the literature by testing focusing and shifting attentional control as two potential mediators of the relationship between sleep disturbance and repetitive negative thinking over a 6-month period. A final sample of 445 unselected community participants completed measures of sleep disturbance and repetitive negative thinking at Time 1, measures of focusing and shifting attentional control 3 months later, and measures of repetitive negative thinking again 6 months later. Results revealed that focusing, but not shifting, attentional control mediated the relationship between sleep disturbance and repetitive negative thinking, specifically, worry, rumination, and obsessions. These findings provide preliminary evidence for focusing attentional control as a candidate mechanism that may explain the causal role of sleep disturbance in the development of repetitive negative thinking observed in various disorders.

I sleep with my Mind's eye open: Cognitive arousal and overgeneralization underpin the misperception of sleep

BACKGROUND AND OBJECTIVES

Misperception of sleep (e.g., underestimation of sleep time relative to objective measures) is a common feature of insomnia and other psychopathologies. To elucidate the mechanisms underlying this tendency, we examined the role of pre-sleep cognitive arousal and overgeneralization.

METHODS

We monitored the sleep of 54 community dwellers (the majority being university students), using actigraphy and a sleep diary for 7 days. Immediately after this period, the participants provided an additional global evaluation of their sleep for the past week. In this global evaluation, participants were asked to estimate their average number of hours of sleep and the duration of time taken to fall asleep (sleep onset latency) across the past seven nights.

RESULTS

Single-night misperceptions (difference between actigraphy and sleep diary estimations) of sleep time and sleep onset latency were significantly associated with pre-sleep cognitive arousal, but not with overgeneralization. In contrast, global misperception of sleep (difference between sleep diary and global estimations) were associated with overgeneralization, but not with cognitive arousal.

LIMITATIONS

Our sample mainly consisted of female university students, which limits the generalizability of the results.

CONCLUSIONS

Misperception of sleep occurs in two cases: (1) in the case of a single night due to excessive arousal, and (2) in the case of multiple nights due to overgeneralization.

The search for universal transdiagnostic and trans-therapy change processes: Evidence for intolerance of uncertainty

The search for universal processes associated with symptom change across emotional disorders and different forms of psychotherapy offers hope of increased theoretical parsimony and treatment efficiencies. This study investigated whether intolerance of uncertainty (IU) is a universal process by examining whether changes in IU were associated with changes in symptoms across three different cognitive behavior therapy protocols for depression (n=106), social anxiety disorder (n=88), or generalized anxiety disorder (n=62) in a community mental health clinic. IU was associated with reductions in repetitive negative thinking in all treatments, which is consistent with IU being a transdiagnostic and 'trans-therapy' process of change. Changes in IU were also associated with symptom relief in the social anxiety disorder and generalized anxiety disorder groups, but not in the depression group. Implications of these findings are discussed within the broader literature of transdiagnostic approaches to emotional disorders.