The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: An exploratory study
Introduction
The diagnosis of breast cancer, the most common type of cancer among American women, elicits greater distress than any other diagnosis regardless of prognosis [1]. The literature has focused immensely on the effects of this distress on depression, anxiety, nausea, and pain [2], [3], [4], [5], [6]; however, the relationship between distress and sleep disturbance has received little attention. This is an important omission considering that sleep difficulties are among the most frequent consequences of cancer [7]. The literature indicates that between 31% and 54% of cancer patients report sleep difficulties [8], [9]. Further, these difficulties continue several years after the diagnosis for a significant portion of breast cancer patients (i.e., 23% and 44%) [10], [11].
There is a large literature on the relationship between stress and sleep disturbance. Important life events, such as the death of a loved one, retirement, and persistent health problems, have been shown to be related to sleep complaints [12]. Similarly, the literature on sleep disturbances following traumatic events, such as rape, war, fires, and hurricanes, has found that sleep disturbances are part and parcel of the posttraumatic symptoms [13]. Often the subjective sleep complaints are more severe and persistent than objective, sleep assessments.
Stress management interventions, including meditation, relaxation training, biofeedback, and multicomponent treatments have been shown to produce improvement in sleep complaints [14]. The present intervention was designed to help manage stress and thereby decrease concomitant sleep complaints. Mindfulness-based stress reduction (MBSR) was selected because of prior evidence of its effectiveness in reducing stress in a number of different populations, including patients with chronic pain [15], anxiety [16], [17], and depression [18], and because of pilot research by the first two authors on its effectiveness in reducing stress, including worry and cognitive rumination, in insomniacs.
The current study is part of a larger research project,1 which examined the psychological, immunological, and sleep effects of a MBSR intervention for women with Stage II breast cancer as compared to a self-monitoring “control” condition. This article reports only the data on sleep. We hypothesized that MBSR would help reduce psychological distress, increase ability to monitor negative cognitions, and thereby decrease sleep disturbance. The specific hypotheses of the study were: (1) sleep complaints would be associated with psychological distress; (2) participants in the MBSR condition would demonstrate significantly greater reported sleep quality and efficiency as compared to the free choice (FC) control condition; and (3) within the MBSR group, improvement would be significantly associated with amount of mindfulness practice. Mindfulness is a skill, which is learned through practice. It makes sense, therefore, that the more one practices, the more adept s/he will become at using the mindfulness techniques, and the more she will benefit. There is a large literature that treatment adherence effects treatment outcome [19].
Section snippets
Method
Participants were recruited from the practices of all medical oncologists in the Tucson community. Inclusion criteria were (a) female, (b) age 18–80, (c) fluent in English, (d) no current diagnosis of mental illness,2 (e) have a history of Stage II breast cancer,3
Participant attrition and adherence
Sixty-three women were randomized to either the MBSR or the FC condition (32 FC, 31 MBSR). One woman dropped from the FC condition before baseline assessment and before the study period began due to family constraints. One woman dropped from the MBSR condition before the study period began due to recurrence of her cancer. Fifty-four (86%) of the participants completed post-assessment data (28 FC, 26 MBSR). Forty-one (65%) completed the 3-month follow-up assessment (23 FC, 18 MBSR). Forty-nine
Discussion
The three principle hypothesis of the current study predicted that (1) sleep functioning would be associated with psychological distress; (2) participants in the MBSR condition would demonstrate enhanced sleep functioning compared to the FC control condition; and (3) participants who practiced mindfulness meditation more would demonstrate significantly greater improvement. Our first hypothesis was confirmed. The data indicated that regardless of experimental condition, participants with greater
Acknowledgements
Our greatest appreciation is extended to the women participating in the study. We also thank Jon Kabat-Zinn, Saki Santorelli, Elana Rosenbaum, Ferris Urbanowski, and the staff of the Center of Mindfulness in Medicine, Health Care, and Society, University of Massachusetts Medical Center for invaluable guidance and support. The research reported was supported by the National Institute of Health, National Cancer Institute, Bethesda, MD (Grant Number: 1 RO3 CA83342-01).
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