Sleep disturbance and obsessive-compulsive symptoms: Results from the national comorbidity survey replication

Impact of sleep disruption on BDD symptoms and treatment response

BACKGROUND

Body dysmorphic disorder (BDD) is severe, undertreated, and relatively common. Although gold-standard cognitive behavioral therapy (CBT) for BDD has strong empirical support, a significant number of patients do not respond. More work is needed to understand BDD's etiology and modifiable barriers to treatment response. Given its high prevalence and impact on the development, maintenance, and treatment of related, frequently comorbid disorders, sleep disruption is a compelling, but not-yet studied factor.

METHODS

Data were drawn from a randomized controlled trial of guided smartphone app-based CBT for BDD. Included participants were offered 12-weeks of treatment, immediately (n = 40) or after a 12-week waitlist (n = 37). Sleep disruption and BDD symptom severity were assessed at baseline, week-6, and week-12.

RESULTS

Hypotheses and analysis plan were pre-registered. Two-thirds of patients reported significant insomnia symptoms at baseline. Baseline severity of sleep disruption and BDD symptoms were not related (r = 0.02). Pre-treatment sleep disruption did not predict BDD symptom reduction across treatment, nor did early sleep improvements predict greater BDD symptom improvement. Early BDD symptom improvement also did not predict later improvements in sleep.

LIMITATIONS

Limitations include the small sample, restricted ranges of BDD symptom severity and treatment response, and few metrics of sleep disruption.

CONCLUSIONS

Although insomnia was disproportionately high in this sample and both BDD symptoms and sleep improved in treatment, results suggest sleep and BDD symptoms may function largely independent of one another. More work is encouraged to replicate and better understand findings as well as potential challenges and benefits of addressing sleep in BDD.

The relationship between sleep disturbance and obsessive- compulsive symptoms: the mediation of repetitive negative thinking and the moderation of experiential avoidance

Background

Studies have found that sleep disturbance is associated with obsessive-compulsive symptoms. This study aimed to elaborate on the mediating and moderating mechanisms between these two variables. We hypothesized that repetitive negative thinking plays a mediating role in the relationship between sleep disturbance and obsessive-compulsive symptoms, and experiential avoidance plays a moderating role.

Method

This study included 639 Chinese adults. A questionnaire survey was used to assess sleep quality, obsessive-compulsive symptoms, experiential avoidance, repetitive negative thinking, and depression symptoms. A moderated mediation model was established.

Results

After controlling for depressive symptoms, repetitive negative thinking partially mediated the positive correlation between sleep disturbance and obsessive-compulsive symptoms. This indirect relationship was significant in individuals with lower experiential avoidance levels. Particularly, the relationship between sleep disturbance and repetitive negative thinking was significant among individuals with lower experiential avoidance levels, but not among individuals with higher experiential avoidance levels.

Conclusion

This study demonstrated that repetitive negative thinking partially mediated the impact of sleep disturbance on obsessive-compulsive symptoms. The findings suggest that when providing support to individuals with sleep disturbance and obsessive-compulsive symptoms, assessing their level of experiential avoidance is necessary for performing targeted interventions. Individuals with low experiential avoidance may benefit from a clinical intervention targeting repetitive negative thinking to improve sleep quality and obsessive-compulsive symptoms.

Sleep Health at the Genomic Level: Six Distinct Factors and Their Relationships With Psychopathology

Background

Poor sleep is associated with many negative health outcomes, including multiple dimensions of psychopathology. In the past decade, sleep researchers have advocated for focusing on the concept of sleep health as a modifiable health behavior to mitigate or prevent these outcomes. Sleep health dimensions often include sleep efficiency, duration, satisfaction, regularity, timing, and daytime alertness. However, there is no consensus on how to best operationalize sleep health at the phenotypic and genetic levels. In some studies, specific sleep health domains were examined individually, while in others, sleep health domains were examined together (e.g., with an aggregate sleep health score).

Methods

Here, we compared alternative sleep health factor models using genomic structural equation modeling on summary statistics from previously published genome-wide association studies of self-reported and actigraphic sleep measures with effective sample sizes up to 452,633.

Results

Our best-fitting sleep health model had 6 correlated genetic factors pertaining to 6 sleep health domains: circadian preference, efficiency, alertness, duration, noninsomnia, and regularity. All sleep health factors were significantly correlated (|rgs| = 0.11-0.51), except for the circadian preference factor with duration and noninsomnia. Better sleep health was generally significantly associated with lower genetic liability for psychopathology (|rgs| = 0.05-0.48), yet the 6 sleep health factors showed divergent patterns of associations with different psychopathology factors, especially when controlling for covariance among the sleep health factors.

Conclusions

These results provide evidence for genetic separability of sleep health constructs and their differentiation with respect to associations with mental health.

Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and implications for science and practice

A strong and specific link between obsessive-compulsive disorder or symptoms (OCD/S) and a tendency for dissociative experiences (e.g., depersonalization-derealization, absorption and imaginative involvement) cannot be explained by trauma and is poorly understood. The present theoretical formulation proposes five different models conceptualizing the relationship. According to Model 1, dissociative experiences result from OCD/S through inward-focused attention and repetition. According to Model 2, dissociative absorption causally brings about both OCD/S and associated cognitive risk factors, such as thought-action fusion, partly through impoverished sense of agency. The remaining models highlight common underlying causal mechanisms: temporo-parietal abnormalities impairing embodiment and sensory integration (Model 3); sleep alterations causing sleepiness and dreamlike thought or mixed sleep-wake states (Model 4); and a hyperactive, intrusive imagery system with a tendency for pictorial thinking (Model 5). The latter model relates to Maladaptive Daydreaming, a suggested dissociative syndrome with strong ties to the obsessive-compulsive spectrum. These five models point to potential directions for future research, as these theoretical accounts may aid the two fields in interacting with each other, to the benefit of both. Finally, several dissociation-informed paths for further developing clinical intervention in OCD are identified.

Examining subjective sleep quality in adults with hoarding disorder

Hoarding disorder (HD), characterized by difficulty parting with possessions and functionally impairing clutter, affects 2-6% of the population. Originally considered part of Obsessive-Compulsive Disorder (OCD), HD became a distinct diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. While sleep impacts OCD, little is known about sleep in HD. As HD patients often report poor sleep in clinical settings, understanding global subjective sleep quality and disturbances may lead to novel therapeutic targets. To address this gap, the authors used a sample of convenience: an existing data set designed to screen research study eligibility and explore the psychopathology and phenomenology of OCD and HD. The data set included information collected from individuals with HD (n = 38), OCD (n = 26), and healthy participants (n = 22) about insomnia, sleep quality, and mood using interviews and structured instruments including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Depression Anxiety Stress Scales (DASS). In this data set, HD and OCD groups reported significantly greater insomnia symptoms and poorer sleep quality compared with healthy controls while controlling for depression, age, and gender. A sizable minority of HD and OCD individuals met criteria for comorbid sleep disorders. OCD and HD groups differed in delayed sleep phase prevalence. To our knowledge, this is the first study examining subjective sleep quality and insomnia in HD as compared to healthy individuals and those with OCD, while controlling for relevant clinical characteristics. Given that there are evidence-based treatments for insomnia and other sleep disorders, our study raises the possibility that treatment interventions targeting sleep may improve HD outcomes.

Sleep quality and its clinical associations in trichotillomania and skin picking disorder

BACKGROUND

Trichotillomania (TTM) is characterized by recurrent hair pulling and associated hair loss. Skin picking disorder (SPD) is characterized by recurrent skin picking and associated scarring or tissue damage. Both disorders are also accompanied by psychological distress and poor sleep. Very little, however, is known about lifestyle variables that may contribute to symptom severity in these disorders.

METHODS

We recruited 87 adults as part of a cross-sectional study of 3 groups (TTM, SPD, and non-affected). Clinical subjects (n=69) were compared with controls (n=18) on sleep quality as measured by Pittsburgh Sleep Quality Index (PSQI). We used partial least squares regression to identify which variables were significantly associated with poor sleep quality among those participants with TTM or SPD.

RESULTS

Clinical subjects had significantly poorer sleep quality than controls. Sleep quality was significantly related to older age, worse perceived stress, lower distress tolerance and greater impulsivity in adults with BFRBs. Poor sleep quality was associated with worse hair pulling symptom severity but not skin picking severity. Higher levels of comorbid mental disorders was also associated with worse sleep, above and beyond the impact of these other variables.

CONCLSUIONS

Poor sleep quality appears to be related to multiple variables. Further research is needed to determine causality and to tailor treatment to specific patient needs.

Linking insomnia and OCD symptoms during the coronavirus pandemic: Examination of prospective associations

There is considerable concern in the mental health community about the psychological consequences of the coronavirus pandemic and who may be most vulnerable. Obsessive-compulsive disorder (OCD) symptoms may be particularly sensitive to the context of the pandemic. Previous research suggests insomnia symptoms may contribute to increased OCD symptoms over time, particularly during times of stress, such as the pandemic. The present study examined pre-coronavirus outbreak insomnia symptoms as a predictor of post-coronavirus outbreak OCD symptoms in a sample of community adults who completed a 2016 survey study and were re-contacted on April 1, 2020 (N = 369). Results revealed a small significant increase in OCD symptoms following the coronavirus outbreak and a small significant decrease in insomnia symptoms. Pre-coronavirus outbreak insomnia symptoms significantly predicted increases in post-coronavirus outbreak OCD symptoms. Similar results were found for specific OCD symptom facets with the exception of washing and hoarding symptoms, which were unrelated to pre-coronavirus insomnia symptoms. There was no evidence for a reverse effect of prior OCD symptoms on insomnia symptoms during the pandemic. These findings suggest those with insomnia symptoms prior to the coronavirus pandemic may be vulnerable to increases in some OCD symptoms during the pandemic. The implications for preventing adverse psychological responses during the coronavirus pandemic are discussed.

Delayed sleep timing and circadian rhythms in pregnancy and transdiagnostic symptoms associated with postpartum depression

Later sleep timing, circadian preference, and circadian rhythm timing predict worse outcomes across multiple domains, including mood disorders, substance use, impulse control, and cognitive function. Disturbed sleep is common among pregnant and postpartum women. We examined whether sleep timing during third trimester of pregnancy predicted postpartum symptoms of mania, depression, and obsessive-compulsive disorder (OCD). Fifty-one women with a previous, but not active, episode of unipolar or bipolar depression had symptoms evaluated and sleep recorded with wrist actigraphy at 33 weeks of gestation and 2, 6, and 16 weeks postpartum. Circadian phase was measured in a subset of women using salivary dim light melatonin onset (DLMO). We divided the sample into "early sleep" and "late sleep" groups using average sleep onset time at 33 weeks of gestation, defined by the median-split time of 11:27 p.m. The "late sleep" group reported significantly more manic and depressive symptoms at postpartum week 2. Longer phase angle between DLMO and sleep onset at 33 weeks was associated with more manic symptoms at postpartum week 2 and more obsessive-compulsive symptoms at week 6. Delayed sleep timing in this sample of at-risk women was associated with more symptoms of mania, depression, and OCD in the postpartum period. Sleep timing may be a modifiable risk factor for postpartum depression.

Pre- to post-inpatient treatment of subjective sleep quality in 5,481 patients with mental disorders: A longitudinal analysis

There is only limited evidence of the course of sleep quality and sleep disturbances during acute inpatient treatment and the prediction of/association with treatment outcome in mental disorders. Within this naturalistic study, 5,481 consecutively admitted inpatients completed the Pittsburgh Sleep Quality Index (PSQI) and the Beck Depression Inventory (BDI-II) at admission and at discharge. Treatment included both individual and group psychotherapy (but no specific interventions for sleep disturbances) and pharmacotherapy based on current national treatment guidelines. Correlation analyses, analyses of variance and linear models were calculated to analyse the datasets. The PSQI improved significantly (p < 0.001) from admission (mean score 9.51 [±4.11]) to discharge (mean score 8.08 [±4.20]) in all diagnostic subgroups. Despite this improvement, 47% of the patients still showed elevated PSQI scores (>5) at discharge. Patients with post-traumatic stress disorder showed the largest sleep disturbances at both time-points; patients with obsessive-compulsive disorder were the least impaired. An improvement of the PSQI was found to be significantly correlated (p < 0.001) to the change of BDI-II values (without the sleep item) during treatment. The likelihood of achieving remission of depressive symptoms (BDI-II total score <14) was significantly associated with less sleep disturbances at admission. The results suggest that almost half of inpatients with mental disorders treated successfully with state-of-the art specific psychotherapy and pharmacotherapy do not have remission of their sleep problems. Therefore, specific treatment programmes for insomnia should be evaluated and implemented in daily clinical routines.

Obsessive-Compulsive Symptom Dimensions and Insomnia: Associations Among a Treatment-Seeking Veteran Sample

Sleep disturbances are a prevalent and pernicious correlate of most emotional disorders. A growing body of literature has recently found evidence for an association between sleep disturbances and obsessive-compulsive disorder (OCD). Though informative, this link has yet to be explored in a veteran population. Further, the degree to which this relationship is accounted for by relevant third variables is limited. The current study investigated the relationship between self-reported insomnia and OCD symptoms after controlling for probable depression and posttraumatic stress disorder (PTSD) using an unselected sample of veterans (N = 57). Most of the sample reported clinically significant OCD (61%) and insomnia symptoms (58%). Results revealed associations between insomnia and OCD unacceptable thoughts/neutralizing compulsions, but not contamination obsessions/washing compulsions, responsibility for harm obsessions/checking compulsions, or symmetry obsessions/ordering compulsions. Findings highlight the need for more research on OCD and sleep problems and clinical work focused on sleep for patients reporting increased OCD symptoms, particularly veterans.

Insomnia in pediatric obsessive-compulsive disorder: prevalence and association with multimodal treatment outcomes in a naturalistic clinical setting

OBJECTIVE

Little is known about the prevalence and impact of insomnia on clinical outcomes in youth with obsessive-compulsive disorder (OCD). This study aimed to investigate this subject.

PATIENTS/METHODS

A total of 193 patients from a specialist pediatric OCD clinic completed a range of diagnostic and clinical measures, including the Insomnia Severity Index (ISI). Patients scoring above a previously validated cut-off on the ISI (score ≥9) were compared to the rest of the sample on sociodemographic and clinical characteristics. In a subsample of 143 (from the initial 193) patients who were treated at the clinic, a mixed-model analysis of variance (ANOVA) was used to compare the outcomes of multimodal OCD treatment in the insomnia (N = 60) vs no insomnia (N = 83) groups. The primary outcome measure was the clinician-administered Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at post-treatment and at three-month follow-up.

RESULTS

The psychometric properties of the ISI in our sample were excellent. At baseline, 42% (81/193) of the sample scored above the ISI cut-off for clinical insomnia. These participants had significantly higher OCD severity, higher rates of psychiatric comorbidities, more severe depressive symptoms, poorer general functioning, and were more likely to take sleep medications, compared to those who scored below the ISI cut-off. In the treated subsample, while the insomnia group remained more severely affected through the three time-points, both groups improved similarly on the CY-BOCS at post-treatment and at three-month follow-up.

CONCLUSION

Insomnia is relatively common in pediatric OCD and is associated with more severe psychopathology. However, with adequate multimodal, evidence-based treatment, these patients can improve as much as those without insomnia.

The role of eveningness in obsessive-compulsive symptoms: Cross-sectional and prospective approaches

BACKGROUND

Eveningness may be defined as the tendency to be most active and alert during the evening. Previous research has linked eveningness with maladaptive psychological outcomes, and recent evidence has highlighted circadian dysregulation as a novel factor in psychopathology, including obsessive-compulsive disorder (OCD). However, limited research has examined the unique relationship between eveningness and OC symptoms. Two studies were conducted to thoroughly examine the links between eveningness and OC symptoms, while also considering the role of depression symptoms and sleep-related factors.

METHODS

Using a cross-sectional approach, Study 1 examined the association between eveningness and OC symptoms when controlling for depression symptoms. Study 2 then employed a prospective approach to examine the extent to which the relationship between eveningness and change in OC symptoms over 4 months is mediated by change in sleep disturbance and total sleep time when controlling for depression symptoms.

RESULTS

Results indicated that depression better accounts for the cross-sectional association between eveningness and OC symptoms. However, eveningness was found to be a more robust prospective predictor of change in OC symptoms in Study 2. Furthermore, sleep disturbance, but not total sleep time, partially mediated the relationship between eveningness and OC symptoms.

LIMITATIONS

Single-method self-report approach, unselected sample, and lack of experimental manipulation.

CONCLUSIONS

These findings suggest that eveningness may contribute to the development of OC symptoms over time, in part due to its effect on sleep disturbance. Future research examining the role of circadian dysregulation in OCD may uncover novel physiological mechanisms.

Eveningness is associated with poor sleep quality and negative affect in obsessive-compulsive disorder

Background Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts and repetitive behaviors that severely encumber daily functioning. OCD patients seem to exhibit sleep disturbances, especially delayed bedtimes that reflect disrupted circadian rhythmicity. Morningness-eveningness is a fundamental factor reflecting individual variations in diurnal preferences related to sleep and waking activities. Eveningness reflecting a delayed sleep-wake timing has repeatedly been associated with sleep problems and negative affect (NA). Therefore, the aim of this study was to examine the associations between morningness-eveningness, sleep complaints, and symptom severity in OCD patients and compared with a mixed psychiatric control group. Materials and methods The data of 49 OCD and 49 mixed psychiatric inpatients (with unipolar depression and anxiety disorders) were analyzed. Patients completed questionnaires regarding morningness-eveningness, sleep quality, nightmare frequency, depression, anxiety, and affective states. Obsessive and compulsive symptom severity was also assessed within the OCD group by clinician-rated scales. Results Eveningness preference was associated with impaired sleep quality and higher NA in OCD patients. In addition, impaired sleep quality showed a moderate correlation with anxiety and strong correlations with depressive symptoms and NA. Interestingly, in the mixed psychiatric group, eveningness was not linked to NA, and sleep quality also showed weaker associations with depressive symptoms and NA. Within the OCD group, eveningness preference was predictive of poorer sleep quality regardless the influence of depressive symptoms. Conclusion Our findings suggest that eveningness and sleep complaints are predictive of affective dysfunctions, and should be carefully considered in the evaluation and treatment of OCD patients.

Sleep disturbances in treatment-seeking OCD-patients: Changes after concentrated exposure treatment

Research indicates that patients with Obsessive Compulsive Disorder (OCD) frequently suffer from comorbid sleep difficulties, and that these difficulties often are not clinically recognized and diagnosed. There has been limited research investigating if comorbid sleep difficulties impair treatment outcome for OCD and if the sleep difficulties change following OCD-treatment. Thirty-six patients with obsessive compulsive disorder underwent concentrated exposure treatment delivered in a group over four consecutive days and were assessed with measures of OCD, depressive symptoms and sleep disturbance at three different time points (pre, post and 6 months follow-up). The sample was characterized by a high degree of comorbidity with other psychiatric disorders. At pre-treatment nearly 70% of the patients reported sleep difficulties indicative of primary insomnia. The results showed that patients had large reductions of OCD-symptoms as well as significant improvements in sleep disturbance assessed after treatment, and that these improvements were maintained at follow-up. Sleep disturbance did not impair treatment outcome, on the contrary patients with higher degree of sleep disturbance at pre-treatment had better outcome on OCD-symptoms after treatment. The results indicated that the majority of the OCD sample suffered from sleep disturbances and that these sleep disturbances were significantly reduced following adequate treatment of OCD without specific sleep interventions. However, a proportion of the patients suffered from residual symptoms of insomnia after treatment.

Sleep disturbances in obsessive-compulsive disorder: Association with non-response to repetitive transcranial magnetic stimulation (rTMS)

Background Repetitive transcranial magnetic stimulation (rTMS) is a promising augmentation strategy for treatment-refractory OCD. However, a substantial group still fails to respond. Sleep disorders, e.g. circadian rhythm sleep disorders (CRSD), are highly prevalent in OCD and might mediate treatment response. The aims of the current study were to compare sleep disturbances between OCD patients and healthy subjects as well as between rTMS responders and non-responders, and most importantly to determine sleep-related predictors of rTMS non-response. Methods 22 OCD patients received at least 10 sessions rTMS combined with psychotherapy. Sleep disturbances were measured using questionnaires and actigraphy. Sleep in patients was compared to healthy subjects. Treatment response was defined as >35% reduction on YBOCS. Treatment response prediction models were based on measures of CRSD and insomnia. Results Sleep disturbances were more prevalent in OCD patients than healthy subjects. The OCD group consisted of 12 responders and 10 non-responders. The CRSD model could accurately predict non-response with 83% sensitivity and 63% specificity, whereas the insomnia model could not. Conclusions CRSD is more prevalent in OCD patients than healthy subjects, specifically in rTMS non-responders. Therefore, CRSD may serve as a biomarker for different subtypes of OCD corresponding with response to specific treatment approaches.