Sleep in obsessive–compulsive disorder: a systematic review and meta-analysis

Predictors of Health-Related Quality of Life in Neurodivergent Children: A Systematic Review

Health-related Quality of Life (HRQoL) is a multi-faceted construct influenced by a myriad of environmental, demographic, and individual characteristics. Our understanding of these influencers remains highly limited in neurodevelopmental conditions. Existing research in this area is sparse, highly siloed by diagnosis labels, and focused on symptoms. This review synthesized the evidence in this area using a multi-dimensional model of HRQoL and trans-diagnostically across neurodevelopmental conditions. The systematic review, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist, was completed in June 2023 using Medline, PsycInfo, Embase, PubMed, and Cochrane Library. Our search revealed 78 studies that examined predictors of HRQoL in neurodevelopmental conditions. The majority of these studies focused on autism and ADHD with a paucity of literature in other conditions. Cross-diagnosis investigations were limited despite the fact that many of the examined predictors transcend diagnostic boundaries. Significant gaps were revealed in domains of biology/physiology, functioning, health perceptions, and environmental factors. Very preliminary evidence suggested potentially shared predictors of HRQoL across conditions including positive associations between HRQoL and adaptive functioning, male sex/gender, positive self-perception, physical activity, resources, and positive family context, and negative associations with diagnostic features and mental health symptoms. Studies of transdiagnostic predictors across neurodevelopmental conditions are critically needed to enable care models that address shared needs of neurodivergent individuals beyond diagnostic boundaries. Further understanding of HRQoL from the perspective of neurodivergent communities is a critical area of future work.

The Oxidative Status and Na+/K+-ATPase Activity in Obsessive-Compulsive Disorder: A Case Control Study

Background

Oxidative stress is involved in pathogenesis of some psychiatric disorders. To examine the role of oxidative stress in the etiopathogenesis of obsessive-compulsive disorder (OCD), we aimed to determine oxidative stress indices, including malondialdehyde (MDA) levels in serum and red blood cells (RBC) membrane, total antioxidant capacity (TAC), serum glutathione (GSH) levels, serum antioxidant vitamins (A and E), and Na+/K+-ATPase activity, in patients with the mentioned disorder vs. healthy controls.

Method

39 OCD patients diagnosed based on Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and 39 volunteer healthy subjects were included in this study. MDA levels in serum and RBC membrane were measured using fluorometric method. Serum TAC level, serum GSH level, and Na+/K+-ATPase activity were also measured using spectrophotometric methods. Serum levels of vitamins were calculated by reversed-phase high-performance liquid chromatography (RP-HPLC).

Result

There was a significantly higher MDA level in serum (p < 0.0001) and RBC membrane (p = 0.002) of OCD patients compared with those in controls. A significant reduction in vitamin A (p = 0.001) and vitamin E (p = 0.024) levels was found in OCD patients vs. controls. There was significantly lower activity of erythrocyte membrane Na+/K+-ATPase in RBC membrane of OCD patients vs. controls (p < 0.0001).

Conclusion

Our findings indicate significantly higher levels MDA in both serum and RBC membrane, lower levels of serum vitamins A and E, and lower activity of membrane Na+/K+-ATPase in OCD patients compared to controls. These suggest an imbalance between oxidant and antioxidant factors in OCD patients that might play a fundamental role in the etiopathogenesis of OCD.

General somatic health and lifestyle habits in individuals with obsessive- compulsive disorder: an international survey

BACKGROUND

Obsessive-compulsive disorder (OCD) has been associated with a broad range of health-related issues. Unhealthy lifestyle habits such as physical inactivity, an unhealthy diet, smoking, and alcohol consumption are hypothesized to contribute to this association. However, the lifestyle habits of individuals with OCD have been scarcely investigated. In this international survey, we explored the physical health and lifestyle habits of adults with a self-reported diagnosis of OCD.

METHODS

An online global survey available in seven languages was disseminated through interest organizations and social media between July 2021 and March 2022. The survey included questions relating to socio-demographic variables and clinical characteristics (including OCD symptom severity - as measured with the 12-item self-report scale Obsessive-Compulsive Inventory [OCI-12] - and psychotropic medication), physical health, and lifestyle habits. Frequencies and percentages, or means and standard deviations, as appropriate, were calculated. Subgroup analyses by OCD symptom severity, gender, and age group were performed.

RESULTS

A total of 496 individuals with OCD completed the survey and were included in the analyses (mean age = 36.0 years, SD = 12.5, range 18-79; 78.8% women). Most participants were from Europe (n = 245, 49.4%) and North America (n = 187, 37.7%). OCD symptom severity scores were on the moderate range (OCI-12 mean score = 21.2, SD = 9.1). A majority (n = 354, 71.4%) reported having comorbid somatic health issues, mainly allergies, gastrointestinal conditions, and cardiometabolic conditions. Nearly half of the sample (n = 236, 47.6%) reported a body mass index ≥ 25, corresponding to at least overweight. A significant proportion of the participants reported low physical activity (n = 271, 55.0%), unhealthy dietary habits (n = 182, 36.7%), risk consumption of alcohol (n = 111, 22.3%), and non-restorative sleep (n = 268, 54.0%). Subgroup analyses showed overall similar results across groups, with some exceptions.

CONCLUSIONS

In this sample, individuals with OCD self-reported a range of health-related issues and a number of unhealthy lifestyle behaviors, most prominently a lack of physical activity. Interventions aimed at modifying unhealthy lifestyles to prevent or improve health conditions beyond the psychiatric symptoms should be considered.

Considerations for the treatment of obsessive-compulsive disorder in patients who have comorbid major depression

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder that affects a significant number of individuals worldwide. Major depressive disorder (MDD) is among the most common comorbidities reported in people with OCD. The emergence of MDD in individuals with OCD can be attributed to the increased severity of OCD symptoms and their profound impact on daily functioning. Depressive symptoms can also modify the course of OCD.

AREAS COVERED

In this review, the authors explore potential shared neurobiological mechanisms that may underlie both OCD and MDD, such as disturbed sleep patterns, immunological dysregulations, and neuroendocrine changes. Furthermore, they address the challenges clinicians face when managing comorbid OCD and MDD. The authors also discuss a range of treatment options for OCD associated with MDD, including augmentation strategies for serotonin reuptake inhibitors (e.g. aripiprazole), psychotherapy (especially CBT/EPR), transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and deep brain stimulation (DBS).

EXPERT OPINION

Although there is no 'rule of thumb' or universally acceptable strategy in the treatment of OCD comorbid with MDD, many clinicians, including the authors, tend to adopt a unique transdiagnostic approach to the treatment of OCD and related disorders, focusing on strategies known to be effective across diagnoses. Nevertheless, the existing 'cisdiagnostic approaches' still retain importance, i.e. specific therapeutic strategies tailored for more severe forms of individual disorders.

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.

A systematic review of sleep problems in children and adolescents with obsessive compulsive disorder

There is growing interest in the relationship between obsessive-compulsive disorder (OCD) and sleep problems in youth, including the development of a theoretical model proposing how these disorders maintain each other. The model suggests that OCD symptoms are proposed to interfere with sleep duration (e.g., via increased arousal and delayed bedtime), which compounds OCD symptom severity during the daytime and into the evening, feeding back into the model. Whether the recent influx of research on sleep problems in youth with OCD supports this model is unknown. The primary aim of this systematic review was to characterize sleep problems in youth with OCD and evaluate whether current research supports previous theoretical inferences. Findings across 20 studies revealed a high prevalence of sleep problems among youth with OCD and support a bidirectional relationship. Studies largely did not assess hypothesized relationships proposed by the model; support for the model is therefore preliminary. A secondary aim was to assess the impacts of comorbidity and developmental stage. Findings suggest that in childhood, comorbid anxiety disorders may initially predate sleep problems, but they become mutually maintained over time; the role of comorbid depression appears to increase with age. Limitations, future directions, and clinical implications are discussed.

Morbidity and mortality in obsessive-compulsive disorder: A narrative review

Current knowledge on the general somatic health of individuals with obsessive-compulsive disorder (OCD) is very limited. Here, we critically review the emerging literature on the topic. Rapidly accumulating evidence indicates an association between OCD and autoimmune diseases, which is not limited to streptococcus-related conditions. Similarly, an association with metabolic and circulatory system diseases has been reported, which is at least partially independent from psychiatric comorbidities and familial confounders. Preliminary results also suggest potential links with dementia, insomnia, respiratory diseases, gastrointestinal diseases, migraine, and chronic pain, but replication is warranted. The risk of death by suicide in OCD is now well established. OCD has also been associated to increased mortality due to natural causes, but more research on specific causes of death is needed. Clarification of the mechanisms behind the observed associations will be critical to inform the rational design of prevention efforts. In the meantime, while OCD symptom reduction remains a priority, clinicians should also focus on monitoring the general health and promoting healthy lifestyles of persons with OCD.

It's About Time: The Circadian Network as Time-Keeper for Cognitive Functioning, Locomotor Activity and Mental Health

A variety of organisms including mammals have evolved a 24h, self-sustained timekeeping machinery known as the circadian clock (biological clock), which enables to anticipate, respond, and adapt to environmental influences such as the daily light and dark cycles. Proper functioning of the clock plays a pivotal role in the temporal regulation of a wide range of cellular, physiological, and behavioural processes. The disruption of circadian rhythms was found to be associated with the onset and progression of several pathologies including sleep and mental disorders, cancer, and neurodegeneration. Thus, the role of the circadian clock in health and disease, and its clinical applications, have gained increasing attention, but the exact mechanisms underlying temporal regulation require further work and the integration of evidence from different research fields. In this review, we address the current knowledge regarding the functioning of molecular circuits as generators of circadian rhythms and the essential role of circadian synchrony in a healthy organism. In particular, we discuss the role of circadian regulation in the context of behaviour and cognitive functioning, delineating how the loss of this tight interplay is linked to pathological development with a focus on mental disorders and neurodegeneration. We further describe emerging new aspects on the link between the circadian clock and physical exercise-induced cognitive functioning, and its current usage as circadian activator with a positive impact in delaying the progression of certain pathologies including neurodegeneration and brain-related disorders. Finally, we discuss recent epidemiological evidence pointing to an important role of the circadian clock in mental health.

Waxing and waning: The roles of chronotype and time of day in predicting symptom fluctuations in obsessive-compulsive disorder using a daily-monitoring design

Obsessive-compulsive disorder (OCD) symptoms fluctuate throughout the day, but scientists are not sure what underlies these fluctuations. One factor which may explain how OCD symptoms wax and wane throughout the day is alertness. Increased alertness is associated with greater inhibitory control, a factor which plays a significant role in patients' ability to overcome their OCD symptoms. The current study examined the relationship between chronotype (morningness/eveningness preference, a measure of alertness) and within-day OCD symptom severity fluctuations. We hypothesized that increased alertness leads to better inhibitory abilities and, therefore, reduced OCD symptoms. OCD Symptoms were measured through 7-days of monitoring in which participants were asked to retrospectively rate their symptoms at several timepoints throughout the day. Chronotype was measured using the Morningness/Eveningness Questionnaire (MEQ). Consistent with our hypotheses, results revealed an interaction between chronotype and time of day, such that those with an eveningness preference tended to have worse symptoms in the morning, and vice versa. In addition, we also report novel findings regarding the effect of bedtime, sleep duration, and sleep quality on symptom severity the next day. Taken together, these findings suggest that alertness may modulate OCD symptom severity throughout the day such that individuals experience more severe symptoms during times of low alertness. The clinical and theoretical implications of these findings are discussed.

Atypical interoception as a common risk factor for psychopathology: A review

The inadequacy of a categorial approach to mental health diagnosis is now well-recognised, with many authors, diagnostic manuals and funding bodies advocating a dimensional, trans-diagnostic approach to mental health research. Variance in interoception, the ability to perceive one's internal bodily state, is reported across diagnostic boundaries, and is associated with atypical functioning across symptom categories. Drawing on behavioural and neuroscientific evidence, we outline current research on the contribution of interoception to numerous cognitive and affective abilities (in both typical and clinical populations), and describe the interoceptive atypicalities seen in a range of psychiatric conditions. We discuss the role that interoception may play in the development and maintenance of psychopathology, as well as the ways in which interoception may differ across clinical presentations. A number of important areas for further research on the role of interoception in psychopathology are highlighted.

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 disturbances in obsessive-compulsive disorder: influence of depression symptoms and trait anxiety

BACKGROUND

Sleep disturbances have been reported in obsessive-compulsive disorder (OCD) patients, with heterogeneous results. The aim of our study was to assess sleep function in OCD and to investigate the relationship between sleep and the severity of obsessive-compulsive (OC) symptoms, depressive symptoms and trait anxiety.

METHODS

Sleep quality was measured in 61 OCD patients and 100 healthy controls (HCs) using the Pittsburgh Sleep Quality Index (PSQI). Multiple linear regression was conducted to explore the association between sleep and psychopathological measures; a mediation analysis was also performed.

RESULTS

OCD patients showed poor sleep quality and more sleep disturbances compared to HCs. The severity of depression, trait anxiety and OC symptomatology were correlated with poor sleep quality. Multiple linear regression analyses controlling for potential confounders revealed that the severity of depression and trait anxiety were independently related to poor sleep quality in OCD. A mediation analysis showed that both the severity of trait anxiety and depression mediate the relationship between the severity of OC symptoms and poor sleep quality among patients with OCD.

CONCLUSIONS

Our findings support the existence of sleep disturbances in OCD. Trait anxiety and depression play a key role in sleep quality among OCD patients.

Sleep duration and timing in obsessive-compulsive disorder (OCD): evidence for circadian phase delay

OBJECTIVES

To investigate potential delays in endogenous melatonin in individuals with obsessive-compulsive disorder (OCD).

METHODS

First, data are presented for 15 individuals with OCD and matched healthy controls. Next, nine additional participants with OCD who did not have matched controls were added, resulting in a sample of 24 individuals with OCD. All participants were assessed for sleep and circadian rhythm disturbance. Dim light melatonin onset (DLMO) was derived from salivary melatonin and was used in conjunction with sleep diaries, interview measures, and questionnaires. A subset of the OCD group (n = 16) also used actigraphy.

RESULTS

In sum, 42% percent (10/24) of the patients with OCD met the criteria for delayed sleep-wake phase disorder (DSWPD) in comparison to 0% in the control sample. DLMO was significantly later in individuals with OCD compared to controls. DLMO and bedtime were not significantly associated with the severity of obsessive-compulsive symptoms or negative affect.

CONCLUSIONS

Replication of the findings presented herein, particularly the DLMO results, is warranted. Further, there are now three studies showing that nearly ½ of individuals with OCD meet criteria for a DSWPD. Future studies can explore the mechanisms underlying these connections and the implications of this comorbidity. These findings may increase our understanding of OCD and inform future interventions.

Prevalence and Characteristics of Obsessive-Compulsive Disorder Among Urban Residents in Wuhan During the Stage of Regular Control of Coronavirus Disease-19 Epidemic

Background: Coronavirus disease-19 (Covid-19) is one of the most devastating epidemics in the 21st century, which has caused considerable damage to the physical and mental health of human beings. Despite a few regions like China having controlled the epidemic trends, most countries are still under siege of COVID-19. As the emphasis on cleaning and hygiene has been increasing, the problems related to obsessive-compulsive disorder (OCD) may appear. Objective: This study was designed to investigate the prevalence of OCD in the urban population in Wuhan during the stage of regular epidemic control and prevention. Meanwhile, characteristics and risk factors for OCD were also explored. Method: Five-hundred and seventy residents in urban areas of Wuhan were recruited using the snowball sampling method to complete questionnaires and an online interview from July 9 to July 19, 2020. Collected information encompassed socio-demographics, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores, Social Support Rating Scale (SSRS) scores and Pittsburgh Sleep Quality Index(PSQI) values. Results: Three months after lifting the quarantine in Wuhan, the prevalence of OCD was 17.93%. About 89% of OCD patients had both obsessions and compulsions, while 8% had only obsessions and 3% had only compulsions. Top 3 common dimensions of obsessions were miscellaneous (84.0%), aggressive (76.6%), and contamination (48.9%), and of compulsions were miscellaneous (64%), checking (51.7%), and cleaning/washing/repeating (31.5%). The unmarried were more vulnerable to OCD than the married (p < 0.05, odds ration = 1.836). Students had 2.103 times the risk of developing OCD than health care workers (p < 0.05). Those with positive family history of OCD and other mental disorders (p < 0.05, odds ration = 2.497) and presence of psychiatric comorbidity (p < 0.05, odds ration = 4.213) were also at higher risk. Each level increase in sleep latency increased the risk of OCD to 1.646 times (p < 0.05). Conclusion: In the background of regular epidemic control, the prevalence of OCD was high, and the symptoms were widely distributed. Obsessions often accompanied compulsions. Being single and a student, positive family history of OCD and other mental disorders, presence of psychiatric comorbidity, and longer sleep latency were predictors of OCD. Early recognition and detection of these issues may help to intervene in OCD.

Association between Obsessive-Compulsive Symptoms and Long-Term Cardiac Outcomes in Patients with Acute Coronary Syndrome: Effects of Depression Comorbidity and Treatment

OBJECTIVE

The role of obsessive-compulsive symptoms (OCS) in patients with acute coronary syndrome (ACS) is not well elucidated. This study investigated the association between OCS and the long-term prognosis of ACS in tandem with depression comorbidity and treatment.

METHODS

A cross-sectional baseline study and a nested 24-week double-blind escitalopram-placebo controlled trial were carried out between May 2007 and March 2013, and then a 5-12-year follow-up for major adverse cardiac events (MACE) was conducted. A total of 1,152 patients with ACS were stratified by baseline depression comorbidity and treatment allocation into four groups: no depression (706 patients), depression and taking escitalopram (149 patients), depression and taking a placebo (151 patients), and depression and receiving medical care as usual (CAU; 146 patients). OCS were evaluated using the Symptom Checklist-90-Revised Obsessive-Compulsive symptom domain. During the follow-up, Kaplan-Meier event rates for MACE outcomes were calculated, and hazard ratios were estimated using Cox regression models after adjusting for a range of covariates.

RESULTS

A higher OCS score at baseline was associated with a worse ACS prognosis after adjusting for relevant covariates and across MACE outcomes. This association varied according to the depression comorbidity. The association was significant in patients without depression and depressive patients receiving placebos and CAU, but not in depressive patients on escitalopram.

CONCLUSION

Evaluating OCS and depression is recommended during the early phase of ACS. Treatment for OCS may improve the longterm cardiac outcomes of patients with ACS.

A Psycho-Behavioral Perspective on Modelling Obsessive-Compulsive Disorder (OCD) in Animals: The Role of Context

Obsessive-compulsive disorder is a heterogeneous and debilitating condition, characterized by intrusive thoughts and compulsive repetition. Animal models of OCD are important tools that have the potential to contribute significantly to our understanding of the condition. Although there is consensus that pre-clinical models are valuable in elucidating the underlying neurobiology in psychiatric disorders, the current paper attempts to prompt ideas on how interpretation of animal behavior can be expanded upon to more effectively converge with the human disorder. Successful outcomes in psychopharmacology involve rational design and synthesis of novel compounds and their testing in well-designed animal models. As part of a special journal issue on OCD, this paper will 1) review the psychobehavioral aspects of OCD that are of importance on how the above ideas can be articulated, 2) briefly elaborate on general issues that are important for the development of animal models of OCD, with a particular focus on the role and importance of context, 3) propose why translational progress may often be less than ideal, 4) highlight some of the significant contributions afforded by animal models to advance understanding, and 5) conclude by identifying novel behavioral constructs for future investigations that may contribute to the face, predictive and construct validity of OCD animal models. We base these targets on an integrative approach to face and construct validity, and note that the issue of treatment-resistance in the clinical context should receive attention in current animal models of OCD.

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.

Does improving sleep lead to better mental health? A protocol for a meta-analytic review of randomised controlled trials

INTRODUCTION

Sleep and mental health go hand-in-hand, with many, if not all, mental health problems being associated with problems sleeping. Although sleep has been traditionally conceptualised as a secondary consequence of mental health problems, contemporary views prescribe a more influential, causal role of sleep in the formation and maintenance of mental health problems. One way to evaluate this assertion is to examine the extent to which interventions that improve sleep also improve mental health.

METHOD AND ANALYSIS

Randomised controlled trials (RCTs) describing the effects of interventions designed to improve sleep on mental health will be identified via a systematic search of four bibliographic databases (in addition to a search for unpublished literature). Hedges' g and associated 95% CIs will be computed from means and SDs where possible. Following this, meta-analysis will be used to synthesise the effect sizes from the primary studies and investigate the impact of variables that could potentially moderate the effects. The Jadad scale for reporting RCTs will be used to assess study quality and publication bias will be assessed via visual inspection of a funnel plot and Egger's test alongside Orwin's fail-safe n. Finally, mediation analysis will be used to investigate the extent to which changes in outcomes relating to mental health can be attributed to changes in sleep quality.

ETHICS AND DISSEMINATION

This study requires no ethical approval. The findings will be submitted for publication in a peer-reviewed journal and promoted to relevant stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42017055450.

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.

Arousal in Nocturnal Consciousness: How Dream- and Sleep-Experiences May Inform Us of Poor Sleep Quality, Stress, and Psychopathology

The term "sleep experiences," coined by Watson (2001), denotes an array of unusual nocturnal consciousness phenomena; for example, nightmares, vivid or recurrent dreams, hypnagogic hallucinations, dreams of falling or flying, confusional arousals, and lucid dreams. Excluding the latter, these experiences reflect a single factor of atypical oneiric cognitions ("general sleep experiences"). The current study is an opinionated mini-review on the associations of this factor-measured with the Iowa sleep experiences survey (ISES, Watson, 2001)-with psychopathological symptoms and stress. Findings support a strong relation between psychological distress and general sleep experiences. It is suggested that that they should be viewed as a sleep disturbance; they seem to represent involuntary intrusions of wakefulness into sleep, resulting in aroused sleep. These intrusions may stem from excessively thin boundaries between consciousness states (e.g., "transliminality"), or, conversely, they may follow an attempt at disconnecting mental elements (e.g., dissociation), which paradoxically results in a "rebound effect." The extent to which unusual dreaming is experienced as intrusive, rather than controlled, may explain why general sleep experiences are related to psychopathology, whereas lucid dreams are related to psychological resilience. In conclusion, the exploration of the interplay between psychopathology and sleep should be expanded from focusing almost exclusively on quantitative aspects (e.g., sleep efficiency, latency) to including qualitative conscious experiences which may reflect poor sleep quality. Taking into account nocturnal consciousness-including unusual dreaming and permeable sleep-wake boundaries-may unveil rich information on night-time emotional states and broaden our definition of poor sleep quality.

Sleep Characteristics in Children with Attention Deficit Hyperactivity Disorder: Systematic Review and Meta-Analyses

STUDY OBJECTIVES

Sleep disturbances have been associated with attention deficit hyperactivity disorder (ADHD), but such relationship is still unclear. The results from the studies conducted do not provide enough evidence to support a sleep physiology inherent to ADHD. This study tries to determine if that sleep physiology really exists by comparing children with ADHD and control children in some sleep parameters.

METHODS

A search was conducted in several databases (Web of Science, Scopus, Pubmed and PsycINFO), and a manual search, to retrieve all the articles available from 1987 until March 2014. Of 8,678 non-duplicate studies retrieved, 11 studies met the inclusion and methodological quality criteria. Two meta-analyses were performed with eight of those studies, depending on data provided by them: polysomnographic or actigraphic. A fixed-effects model, and the standardized mean difference (SMD) as the index of effect size, were used in both meta-analyses.

RESULTS

Significant differences were found only in the meta-analysis with polysomnography as outcome. Children with ADHD were found to spend more time in stage 1 sleep than controls (pooled SMD = 0.32, 95% CI = 0.08-0.55, p value = 0.009).

CONCLUSIONS

Although few differences in sleep between children with ADHD and controls have been found in this review, further studies are required on this matter. Those studies should consider some variables discussed in this review, in order to obtain useful and reliable conclusions for research and clinical practice. Particularly, the influence of assessment criteria and ADHD subtypes in the sleep characteristics of children with ADHD should be addressed.

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

A small body of developing research has found evidence for sleep disturbance in obsessive-compulsive disorder (OCD) and links between sleep disturbance and obsessive-compulsive symptoms (OCS) in unselected samples. However, the link between sleep disturbance and OCS is yet to be examined in a nationally representative sample. Furthermore, the extent to which the link between sleep disturbance and OCS is accounted for by symptoms of depression remains unclear. To address this gap in the literature, the present study examined the relationship between sleep disturbance and OCS in a nationally representative sample. Participants were assessed in the National Comorbidity Survey Replication (NCS-R; n = 2073). Consistent with predictions, results revealed that individuals with sleep disturbance reported increased OCS severity compared to individuals without sleep disturbance. Further, sleep disturbance severity was associated with OCS severity, even when controlling for depression (and other anxiety-related disorders). This study is the first to link sleep disturbance and OCS in a nationally representative sample, and these findings highlight the unique role of sleep disturbance in the experience of OCS. Future research is necessary to delineate specific mechanisms that may account for this relationship.