An investigation of monitoring for sleep-related threat in primary insomnia
Introduction
In the clinical psychology literature, attentional processes have been implicated in the maintenance of a range of psychological disorders (e.g. Clark, 1999, Ehlers and Clark, 2000, Fairburn, Shafran and Cooper, 1999, Williams, Watts, MacLeod and Mathews, 1997 for review). Selective attention toward salient internal and external threat cues is also known as monitoring (Miller and Mangan, 1983, Pennebaker, 1982) and has recently been highlighted in several studies of primary insomnia. For example, Watts, Coyle and East (1994) identified ‘somatic preoccupations’ as one of six factors explaining a significant amount of the variance in sleep-interfering thoughts during the pre-sleep period. Wicklow and Espie (2000) asked individuals with insomnia to verbalise their thoughts when trying to fall asleep on three consecutive nights. A factor analysis of the voice-activated recordings elucidated ‘environmental reactivity’ and ‘present state monitoring’ as key factors contributing to sleep-onset difficulty. Harvey (2000) found that participants with insomnia were more likely to monitor the time and the environment during the pre-sleep period compared to good sleepers. Finally, in a study of daytime processes, people with insomnia were found to be more likely than good sleepers to be preoccupied with themselves (Marchini, Coates, Magistad, & Waldum, 1983).
Drawing on this research, we have proposed that monitoring for sleep-related threat contributes to a vicious cycle of cognitive processes that operates at night and during the day to maintain insomnia (Harvey, 2002a). Based on clinical practice, we have suggested that during the night people with insomnia monitor: (a) the clock to calculate how much sleep will be obtained; (b) the clock to check how long it is taking to fall asleep; (c) their body sensations for signs consistent with falling asleep (e.g. physical signs of drifting off such as slowing heart rate, loss of muscle tone), (d) their body sensations for signs inconsistent with falling asleep (e.g. heart pounding quickly, muscle tension); and (e) the environment for signs of not falling asleep (e.g. noises outside and inside the house). During the day, it is suggested that individuals with insomnia monitor: (a) the clock on waking to calculate how many hours of sleep were obtained; (b) their body sensations on waking for signs of poor sleep (e.g. heavy feeling in the head, heavy or tired eyes); and (c) their body sensations throughout the day for signs of fatigue (e.g. heavy legs, sore shoulders) (Harvey, 2002a).
How does monitoring contribute to the maintenance of insomnia? The clinical psychology literature has shown that attention toward threat is associated with increased negative thoughts and perception of threat (e.g. Breitholtz, Westling and Ost, 1998, Clark, Salkovskis, Ost, Breitholtz, Koehler, Westling, Jeavons and Gelder, 1997, Harvey and McGuire, 2000), and with avoidance of, or withdrawal from, threatening situations (e.g. Carver, Blaney and Scheier, 1979, Scheier, Carver and Gibbons, 1981). Salkovskis, 1989, Salkovskis, 1991) has used the term ‘safety behaviour’ to refer to the behaviours and mental processes used in an attempt to reduce, avoid, escape, or alleviate threat and fear. He argues that safety behaviours contribute to the persistence of disorders by (a) preventing disconfirmation of unhelpful beliefs and (b) increasing the risk of the feared outcome actually occurring. On the basis of these findings, we have suggested that monitoring at night (e.g. calculating the time at night to determine how much sleep will be obtained) and during the day (e.g. noticing heavy eyes on waking) triggers excessively worrisome negative thoughts (e.g. “I’ll never be able to cope”, “I won’t be productive at all”) which increases the tendency to engage in safety behaviours (e.g. taking it easy, napping during the day) (Harvey, 2002a). These hypotheses extend earlier suggestions that insomnia is fuelled by cognitive arousal, and that this can instigate the use of maladaptive behaviours in an attempt to cope with/reduce the unwanted arousal (e.g. Espie, 1991, Espie, 2002, Fichten, Libman, Creti, Amsel, Sabourin, Brender and Bailes, 2001, Lundh, 2000, Morin, 1993).
In this paper, we report two studies that were designed to test the proposal that monitoring for sleep-related threat is involved in the maintenance of primary insomnia. Study 1 aimed to provide the first systematic investigation of the role of monitoring, at night and during the day, in primary insomnia. The first hypothesis tested was that individuals with insomnia would engage in monitoring for sleep-related threat, at night and during the day, more frequently than good sleepers. This hypothesis was based on the finding that many psychological disorders are characterised by attention toward threat (e.g. Williams et al., 1997) and previous research highlighting a relationship between monitoring and insomnia (e.g. Harvey, 2000, Marchini, Coates, Magistad and Waldum, 1983). Based on the association between monitoring and increased negative thoughts and perception of threat noted in studies based on other psychological disorders (e.g. Breitholtz, Westling and Ost, 1998, Harvey and McGuire, 2000), the second hypothesis was that monitoring would be associated with increased negative thinking in individuals with insomnia relative to good sleepers. Safety behaviours have been linked with monitoring in psychological disorders (e.g. Carver, Blaney and Scheier, 1979, Scheier, Carver and Gibbons, 1981) and there is evidence to support their use in insomnia (e.g. Harvey, 2002b, Libman, Creti, Amsel, Brender and Fichten, 1997, Lundh, Lundqvist, Broman and Hetta, 1991). As such, the third hypothesis was that individuals with insomnia would report the use of more safety behaviours in association with monitoring compared to good sleepers. Finally, based on a recent cognitive model of insomnia (Harvey, 2002a), an analysis was conducted to test the predicted pathway that monitoring for sleep-related threat is associated with increased negative thoughts, which in turn, is related to an increase in the use of safety behaviours.
Section snippets
Participants
A sample of individuals meeting diagnostic criteria for primary insomnia and a comparison group of good sleepers were recruited from the University of Oxford and Oxford Brookes University. A screening questionnaire was left in personal mailboxes and distributed personally in a university cafeteria. Of 303 responses to this questionnaire, 229 individuals were invited to participate. Invitees were selected for the good sleeper group on the basis that they: (a) indicated sleeping “very well”; (b)
Participant characteristics
Table 1 presents the mean values for participant characteristics. A Chi-square analysis showed that there was no difference between the groups for gender distribution. t-test comparisons showed that the groups did not differ for age. For self-reported sleep on a typical night in the past month (obtained from the PSQI), individuals with insomnia had significantly longer mean sleep onset latency and significantly shorter total sleep time compared to good sleepers. Individuals with insomnia also
Summary
Study 1 was conducted to explore the role of monitoring for sleep-related threat, at night and during the day, in primary insomnia. The first hypothesis tested was that individuals with insomnia would engage in monitoring for sleep-related threat more frequently, both at night and during the day, compared to good sleepers. The results indicated support for this hypothesis, in that the insomnia group reported higher Nighttime Monitoring Frequency Scores and Daytime Monitoring Frequency Scores
Participants
A sample of participants meeting diagnostic criteria for primary insomnia was recruited from the community. Posters placed in local physician surgeries and a newspaper advertisement requested that individuals aged 18–60 years who were concerned about regular problems with their sleep contact the experimenter by telephone or e-mail. A total of 43 individuals responded. Of these respondents, 27 met the initial criteria for insomnia (described in Study 1) and were invited to participate.
Participant characteristics
The mean age of the participants was 40.9 years (SD=10.6) and the mean duration of their sleep problems was 10.6 years (SD=7.1). For self-reports of a typical night in the past month, the mean sleep onset latency was 38.8 min (SD=33.3) and the mean total sleep time was 5.5 h (SD=1.2). For the questionnaires, the mean scores were: 11.6 (SD=2.5) for the global score on the PSQI; 13.3 (SD=8.7) for the BDI; 42.7 (SD=14.0) for the STAI-S; 46.0 (SD=14.4) for the STAI-T; and 51.3 (SD=16.1) for the
Summary
The objective of Study 2 was to examine whether the findings reported in Study 1 were generalisable to a clinical sample of individuals with insomnia. The hypothesis tested was that the clinical sample would monitor more frequently and report more negative thoughts and safety behaviours in association with monitoring, at night and during the day, relative to the university insomnia sample included in Study 1. The assumption that the clinical sample would be more severe than the university
General discussion
Studies 1 and 2 aimed to provide the first systematic investigation of monitoring for sleep-related threat at night and during the day in primary insomnia. The results of Study 1 showed that, in a university sample, individuals with insomnia monitored more frequently at night and during the day than good sleepers. In addition, individuals with insomnia reported more negative thoughts associated with monitoring at night and during the day, and the use of more safety behaviours associated with
Acknowledgements
This investigation was supported by funding from the Wellcome Trust (Grant No. 065913) and the Social Sciences and Humanities Research Council of Canada. The authors are grateful to Julia Nelson for assistance with the blind ratings.
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