Insomnia and Perfectionism for MCQs.docx

Insomnia and Perfectionism Susie Oh: Perfect enough to sleep? Perfectionism and Actigraphy Markers of Insomnia (PhD thesis) Insomnia Insomnia: Prevalence “Insomnia”: difficulty initiating and/or maintaining sleep and waking earlier than intended despite adequate opportunity AND impairment or dysfun...

Insomnia and Perfectionism Susie Oh: Perfect enough to sleep? Perfectionism and Actigraphy Markers of Insomnia (PhD thesis) Insomnia Insomnia: Prevalence “Insomnia”: difficulty initiating and/or maintaining sleep and waking earlier than intended despite adequate opportunity AND impairment or dysfunction (American Psychiatric Association, APA, 2013) Note: Reynolds et al., 2019 – Chronic insomnia disorder in Australia. A report to the Sleep Health Foundation. Affects ~ 5.6 – 33% of adult Australians - i.e., is a common condition (Adams et al., 2016; Bartlett et al., 2008; Bin et al., 2012; Cunnington et al, 2013). Prevalence lower if defined by established diagnostic criteria and higher if based on broader definition relating to difficulties getting to or maintaining sleep. Insomnia: Significance Common and burdensome > significant personal and economic costs Transdiagnostic factor i.e., it tends to contribute on onset, maintenance, and relapse of mental health disorders. (Dolsen et al., 2015; Harvey, 2008; Harvey et al., 2014; Hertenstein et al., 2019) 41-53% comorbidity (Harvey, 2008) Contributes to onset, maintenance and relapse of mental health disorders Is a risk and maintenance factor for Depression, GAD, BPD, PTSD, Schizophrenia (Dolsen et al., 2015) Poor sleep in DSMV (DSM5; APA, 2013) Distinct condition – “insomnia disorder” Poor sleep is a diagnostic criterion for other disorders: Sleep disturbance – difficulty falling or staying asleep, unsatisfying or restless sleep Anxiety disorders, depressive disorders, Bipolar disorders, PTSD, etc. Perfectionism “Complex multidimensional construct: excessively high personal standards + overly self-critical (Frost et al., 1990) “ Often measured by 2 Multidimensional Perfectionism Scales Frost MPS (F-MPS) (Frost et al., 1990): CDPPPO – cd3po Proposed that perfectionistic people may be characterised by six dimensions (summarised by Schmidt et al 2019): Concern over mistakes (CM) – tendency to react negatively to mistakes and to perceive failures as mistakes, Doubts about action (DA) – tendency to doubt the quality of one’s own performance Parental expectations(PE) - tendency to perceive parents as setting high standards Parental criticism (PC) - tendency to perceive parents as being very critical Personal standards (PS) – tendency to set high standards and Organisation (ORG) - preference for precision, order, organisation Hewitt-Flett MPS (HF-MPS) (Hewitt et al., 1991) Self-oriented perfectionism (SOP)- having exacting and unrealistic standards for oneself and being highly self-critical for not meeting the standards Other-oriented perfectionism (OOP) – tendency to have unrealistically high standards for other people - expectation that others can and should meet high unrealistic standards Socially prescribed perfectionism (SPP) – tendency to believe that others hold unrealistically high standards for oneself F-MPS and HF-MPS interrelated (Frost et al., 1993) but they also capture distinct aspects of perfectionism: Personal Standards (PS) ~ Self-oriented perfectionism (SOP) Concern over Mistakes (CM), Parental Expectations (PE)+ Parental Criticism (PC) ~ Socially Prescribed perfectionism (SPP) Perfectionism: Significance adaptive (motivating; relating to more personal orientated perfectionism or high organisation) vs maladaptive perfectionism (tends to relate to relate to parental criticism or socially prescribed perfectionism; Frost et al., 1993) Maladaptive perfectionism: CM, PC, PE, DA + SPP Adaptive perfectionism: PS, ORG + SOP Transdiagnostic process > risk factor and therefore a predictor of mental health disorders Eating disorders, anxiety, depression (Egan et al., 2011; Limburg et al., 2016) Both Perfectionism and Insomnia are transdiagnostic Is perfectionism a predisposing factor for insomnia? Three different models: Attention-intention-effort pathway (Espie et al., 2006): attention bias and preoccupation towards sleep intention to avoid sleeplessness disrupts the automatic process of sleep which can lead to insomnia Hyperarousal model of insomnia (Riemann et al., 2010) People who focus on sleep problems tend to engage in rumination and worry which heightens arousal and makes hard to fall asleep Cognitive/Cognitive-behavioural model of insomnia (Espie et al, 2006; Lundh & Broman, 2000; Lundh et al., 1994; Riemann et al., 2010; van de Laar, Verbeek et al., 2010) High perfectionism tendency to focus on negative aspects of performance during the day – even for small perceived flaws. Constantly think repetitively about and monitor about their presentation. High perfectionism + stressful life events > then start to worry about sleep + worry about daytime performance > hyperarousal > acute insomnia > worry about sleep > chronic insomnia. Clinical implications: If perfectionism is a risk factor for insomnia it might be used to improve efficacy of CBT-Insomnia (CBT-I) i.e., incorporating perfectionism in CBT-I may benefit highly perfectionistic insomniacs and improve efficacy (Johann et al., 2018). Research Findings So Far ... So far only about 16 studies in the area have found evidence of a relationship between perfectionism and insomnia. Is evidence of an existing relationship between perfectionism + insomnia Concern over mistakes (CM), doubts about actions (DA) + socially prescribed perfectionism (SPP) positively associated with insomnia symptoms + severity Akram et al., 2017; Akram et al., 2019; Azevedo et al., 2010; Azevedo et al., 2009; Brand et al., 2015; Frost et al., 1993; Johann et al., 2017; Lundh et al., 1994; Schmidt et al., 2018; Vincent & Walker, 2000) Organisation (ORG) found to be negatively associated with insomnia parental criticism (PC) higher in chronic insomniacs compared to healthy controls, also positively associated with high sleep onset latency (SOL i.e., trouble getting to sleep) Vincent & Walker, 2000 – FMPS and HFMPS 32 adults with chronic insomnia and 26 healthy controls Low ORG associated with high Insomnia symptoms Schmidt et al., 2018; Akrametal.,2019 Personal Standards (PS) positively associated with nocturnal awakenings Johann et al., 2017 Earlier arrival (a proxy for perfectionism) associated with reduced sleep duration Spiegelhalder et al., 2012) Concern over mistakes (CM), doubts about action (DA) + Parental Criticism (PC): insomniacs > controls Akram et al., 2017 Adolescents: Maladaptive perfectionism associated with poor sleep quality Linetal.,2017 These relationships are also found in longitudinal studies. 1 year follow-up: Baseline insomnia associated with future DA + future Parental Criticism (Akram et al., 2015) 1 year follow up: Concern over mistakes (CM) associated with pre-existing + future insomnia (Jansson-Fröjmark & Linton, 2007) BUT relationship may be weak due to mediating factors ... Relationship between insomnia and perfectionism seems to be mediated by stress, anxiety and/or depression Brand et al., 2015 (346 university students) found insomnia was associated with higher scores on CM, DA PE, PC and PS – structural equation modelling (SEM) analysis indicated these associations were mediated by perceived stress, stress coping, emotional regulation, and mental toughness. Other studies have found facets of perfectionism and insomnia to be partially mediated by symptoms of anxiety (Akram et al. 2017); explains the relationship and allows for the identification of the mechanisms or processes underlying it. Suggests anxiety and/or depression, stress, stress coping, emotional regulation, and mental toughness may be the mechanisms underlying the relationship between Perfectionism and Insomnia Longitudinal studies (general population and young student samples): Jansson-Frojmark & Linton (2007): baseline CM ~ future insomnia mediated by anxiety Akram et al.(2015): Baseline insomnia ~ future DA + future PC mediated by anxiety + concurrent insomnia > Insomnia symptoms predicted higher perfectionism thinking Baseline insomnia ~ future PC mediated by anxiety ... more mediating factors: sleep-related cognitions: counterfactual processing (Schmidt et al, 2018) dysfunctional sleep beliefs (Akram et al., 2020) rumination and worry (Lin et al., 2019) Some Studies Conducted So Far ... Most studies have used general population, adolescent, and student samples with few using clinical samples: Akram et al, 2017; Vincent & Walker, 2000; Lundh et al., 1994 Most studies use subjective measures of sleep. Insomnia diagnosis based on subjective measures of sleep (i.e., self-report) but we know there can be differences between subjective and objective measures Objective vs subjective measures of sleep – IS A DIFFERENCE subjective measures (self-report): insomniacs tend to underestimate total sleep time and overestimate sleep onset latency (Fernandez-Mendoza et al., 2012; Harvey & Tang, 2012; Means et al., 2003) Objective measures may improve our understanding the perfectionism-insomnia relationship. Only ONE study by Johann et al. (2017) used objective sleep measures 2-night polysomnography (PSG) study: High Perfectionism associated with PSG-determined markers of poor sleep on first night particularly the number of nocturnal awakenings, few significant associations on second night Total F-MPS score ~ nocturnal awakenings, statistical trends (not significant) between total F-MPS score + TST, arousal index, WASO, REM CM + PS ~ TST, nocturnal awakenings; PE + PC ~ nocturnal awakenings; PS ~ WASO Gaps in the Literature Lack of studies using objective measures of sleep. No study has utilised actigraphy as an objective measure of sleep. Wrist actigraphy: Sleep data is collected based on physical movements (proxy) i.e., sleep is proxy based on movement. Advantages Ecological: collect data in natural sleep environment (Martin & Hakim, 2011) Harder if doing a PSG (polysomnography) study as requires extensive wiring – tends to be shorter – 1-3 nights in sleep lab) Actigraphy typically allows for a longer study period: usually 10-14 days Lower cost: just need participant to wear a watch Disadvantages Not gold standard Is only a proxy measure for when asleep based on movement - if awake but not moving watch will record as if asleep Don’t get data like sleep architecture No study on intraindividual variability: if have an individual mean for both sleep and perfectionism over 14 days. If have higher perfectionism on a particular day does the marker for poor sleep also change? What is the within person variability of this relationship? Processes/pathways of how perfectionism may influence sleep remain largely under explored. Research Aims Explore the relationship between perfectionism and insomnia using objective sleep parameters obtained from actigraphy. Investigate the association between facets of multidimensional parts of perfectionism and sleep disturbances. Explore pathways whereby perfectionism may influence sleep through anxiety, stress, depression, and sleep-related cognitions. Whether any supported relationships remain after accounting for those mediating factors Explore the associations between intraindividual variability of perfectionism and insomnia, and pathways of mediation through anxiety, stress, depression, and sleep- related cognitions. Study 1: Testing for Associations Using R to test for associations using Pearson’s bivariate correlations between: (looking at both objective and subjective measures) Perfectionism and insomnia, and Facets of perfectionism and insomnia Hypotheses: High Perfectionism will be associated with Higher Actigraphy markers of poor sleep Sleep is measured by total sleep time, sleep efficiency, wake after sleep onset, sleep onset latency Inconsistent evidence on facets of perfectionism related to insomnia so no a priori hypotheses. Run analysis and see what is found Study 2: Testing for Mediating Effects Using R to test for indirect pathways of perfectionism on insomnia via mediation analysis. Significant relationship between perfectionism and insomnia will be examined with sequential logistic regression analyses as per Hayes (2013) multiple mediation method with 1000 bootstrapping samples to determine indirect effects of perfectionism on insomnia via the following mediators through Sobel test: Study 2a: Anxiety, stress, and depression Study 2b: Sleep related cognitions. Hypotheses: Direct associations between perfectionism and insomnia symptoms Significant associations between perfectionism and insomnia will be mediated by perceived stress, anxiety, and depression. Significant associations between perfectionism and insomnia will be mediated by sleep- related cognitions. Study 2a: Mood-Related Measures Mood-related mediators measured by: Daily Stress Inventory (DSI): lists about 58 common life stressors and participants fills it out every day (e.g., “someone was rude to me today” then say how stressed that made them feel on a scale of 1-10) Perceived Stress Scale (PSS) Depression Anxiety and Stress Scale 21 (DASS21) Ford Insomnia Response to Stress Test (FIRST) Hyperarousal Scale Pre-Sleep Arousal Scale (PSAS) Arousal Predisposition Scale (APS): measures how aroused before sleep; some think about or worry about whether will be able to get to sleep) Study 2b: Sleep-Related Cognitions Sleep-related beliefs as mediators measured by: Dysfunctional Beliefs About Sleep (DBAS) - the key one – are about 10-15 statements (e.g., “I can’t function if U don’t get my sleep” – is a belief about sleep but it is a dysfunctional belief if rate it highly) Sleep Self-Efficacy Scale (SSES) - how well you think you can sleep Anxiety and Preoccupation about Sleep Questionnaire (APSQ) - measures how are thinking about sleep Sense of Control Questionnaire (SCQ) – whether feel in control of their life in general (she doesn’t remember why they threw that in) Study 3: Intraindividual Variability: 1st time studied Exploring associations between daily levels of perfectionism and insomnia symptoms: (e.g., if have a stressful day because performed badly will this impact how study that night?), and their potential mediating pathways through stress, anxiety, depression, and sleep-related cognitions. Intraindividual analysis conducted in R using Varian as per Wiley et al. (2014) Bayesian intraindividual variability model with tolerance for missing data Missing data tolerance for 14-day data points: not exceeding 50% as per SEMA3 recommendation. Hypotheses: Direct associations between mean levels of Concern over Mistakes (CM), Doubt about Action (DA), Socially Prescribed Perfectionism (SPP) and scores on the Multidimensional Perfectionism Cognitions Inventory (MPCI-E) and insomnia symptoms Higher variable perfectionism (beyond individual mean values) will be associated with poor measures of sleep; and Stress, anxiety, depression, and sleep-cognitions will mediate any significant relationships. Recruitment UoM REP, postgraduate pool, the Melbourne Sleep Disorder Centre, social media, snowball, and word of mouth. Minimum target of 51 for power purpose relating to study 3 (EMA study). Ecological Momentary Assessment Study – send surveys to P’s every day, several times a day and collect data as go along Inclusion criteria: Participants ranging from normal to abnormal sleepers with insomnia. Abnormal sleepers with insomnia ISI (Insomnia Severity index) > 7 + PSQI (Pittsburgh Sleep Quality Index) > 5 Screened out with other sleep disorders (to exclude narcolepsy, sleep apnea, restless leg syndrome, circadian rhythm sleep disorder and parasomnia) Normal sleepers with no history of insomnia Exclusion criteria: Current diagnosis of psychosis bipolar affective disorder, substance use disorder, central nervous system disorder, prior head injury and shift work. Medication use (including sedatives, hypnotics, and antidepressants) that may affect sleep were eligible if usage pattern was stable for at least the past 3 months. Procedure Screening for Eligibility Initial screening via Qualtrics Informed consent Demographics Eligibility screening: Medication use, shift work, excluded dx Brief Insomnia Questionnaire (BIQ) Insomnia Severity Index (ISI) Pittsburgh Sleep Quality Index (PSQI) Sleep Timing Questionnaire (STQ) Sleep Algorithm: allows to screen out people who potentially have sleep disorders other than insomnia Pre-Actigraphy Study Qualtrics survey at the start of 14-day actigraphy study F-MPS: perfectionist scale HF-MPS: perfectionist scale “Morningness” – “Eveningness” Questionnaire (MEQ) Pre-Sleep Arousal Scale (PSAS) Dysfunctional Beliefs (DBAS) Attitudes about Sleep Sense of Control Questionnaire (SCQ) Sleep Self-Efficacy Scale (SSES) 14-Day Actigraphy Study Participants wore an actigraphy watch 24 hours a day for 14 days Surveys sent using SEMA3 during 14-day actigraphy study: Daily: Pittsburgh Sleep Diary(PSD) (when went to sleep Daily Stress Inventory(DSI) Positive and Negative Affect Scales(PANAS) 3 broad questions on CM, DA and SPP rated on a scale of 1 (never) to 5( always – previous research had shown these to be quite consistently associated with insomnia) I was concerned about mistake(s) I made today I had doubts about how well I did things today Others had high expectations of me today Day 7 and 14 Multidimensional Perfectionism Cognitions Inventory-English(MPCI-E) Post-Actigraphy Study Qualtrics survey after 14-day actigraphy study: Depression Anxiety and Stress Scale 21 (DASS21) Perceived Stress Scale (PSS) ISI PSQI Anxiety and Preoccupation about Sleep Questionnaire (APSQ) Ford Insomnia Response to Stress Test (FIRST) Hyperarousal Scale Arousal Predisposition Scale (APS) DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure McLean Screening Instrument for Borderline Personality Disorder Ethical & Cost Considerations Low risk Participants debrief: Information on where to obtain help if concerned about sleep after participation. Ethics approval obtained in 2021 Recruitment began in April 2021 and completed in August 2022 COVID delays Total project costs = $2,120.60 A$25 voucher per participant x 64 participants = $1600 Postage cost = $520.60 Current Project Status 1132 responses > 246 left contact details and eligible > 212 invited > 65 participants 31 identified as insomniacs using ISI and PSQI 28 normal sleepers  6 unclear - inconsistent ISI and PSQI scores Data collection completed: 2 participants’ actigraphy watches did not register any data > watch error, insufficient wear? 1 participant did not complete post-study survey. 4 participants did not meet 50% response threshold. Data cleansing is underway with data analysis to begin in R in 2 weeks. References Key terms – Sleep and Perfectionism Actigraphy: a device that records movement used as an objective measure of sleep. Sleep data is collected based on physical movements (proxy) i.e., sleep is proxy based on movement. Adaptive perfectionism: PS, ORG + SOP (Frost et al 1993) F-MPS: Frost Multidimensional Perfectionism Scale (Frost et al., 1990) - a subjective measure of 6 facets of perfectionism: CM, DA, PS, PE, PC, ORG (p39) HF-MPS: Hewitt-Flett MPS (Hewitt et al., 1991) – another subjective measure of perfectionism which distinguishes between three dimensions of perfectionism: self-orientated perfectionism (SOP) other-orientated perfectionism (OOP) and socially-prescribed perfectionism (SPP) Perfectionism: a complex multidimensional construct characterised by excessively high personal standards and overly self-critical (Frost et al 1990) Maladaptive perfectionism: CM, PC, PE, DA + SPP (Frost et al 1993) CBT-I: Cognitive Behaviour Therapy – Insomnia Possible Exam Questions Is perfectionism a predisposing factor for insomnia? 3 models: attention-inattention-effort pathway (Espie et al., 2016); hyperarousal model of insomnia (Reimann et al 2010); cognitive behavioural model of insomnia (eg Verbeek et al 2010) Didn’t go into much detail on this What is known about the mechanisms underlying the relationship between insomnia and perfectionism? What are the main gaps in the published literature regarding the relationship between insomnia and perfectionism? Discuss possible methods for addressing these gaps What were the main gaps in the literature that Oh and colleagues are aiming to address in their current study? What are their predictions and why?