Bryony Sheaves

The role of sleep dysfunction in the occurrence of delusions and hallucinations: A systematic review.

Background Sleep dysfunction is extremely common in patients with schizophrenia. Recent research indicates that sleep dysfunction may contribute to psychotic experiences such as delusions and hallucinations. Objectives The review aims to evaluate the evidence for a relationship between sleep dysfunction and individual psychotic experiences, make links between the theoretical understanding of each, and highlight areas for future research. Method A systematic search was conducted to identify studies investigating sleep and psychotic experiences across clinical and non-clinical populations. Results 66 papers were identified. This literature robustly supports the co-occurrence of sleep dysfunction and psychotic experiences, particularly insomnia with paranoia. Sleep dysfunction predicting subsequent psychotic experiences receives support from epidemiological surveys, research on the transition to psychosis, and relapse studies. There is also evidence that reducing sleep elicits psychotic experiences in non-clinical individuals, and that improving sleep in individuals with psychosis may lessen psychotic experiences. Anxiety and depression consistently arise as (partial) mediators of the sleep and psychosis relationship. Conclusion Studies are needed that: determine the types of sleep dysfunction linked to individual psychotic experiences; establish a causal connection between sleep and psychotic experiences; and assess treatments for sleep dysfunction in patients with non-affective psychotic disorders such as schizophrenia.

An early Phase II randomised controlled trial testing the effect on persecutory delusions of using CBT to reduce negative cognitions about the self: the potential benefits of enhancing self confidence.

Background Research has shown that paranoia may directly build on negative ideas about the self. Feeling inferior can lead to ideas of vulnerability. The clinical prediction is that decreasing negative self cognitions will reduce paranoia. Method Thirty patients with persistent persecutory delusions were randomised to receive brief CBT in addition to standard care or to standard care (ISRCTN06118265). The six session intervention was designed to decrease negative, and increase positive, self cognitions. Assessments at baseline, 8 weeks (posttreatment) and 12 weeks were carried out by a rater blind to allocation. The primary outcomes were posttreatment scores for negative self beliefs and paranoia. Secondary outcomes were psychological well-being, positive beliefs about the self, persecutory delusions, social comparison, self-esteem, anxiety, and depression. Results Trial recruitment and retention were feasible and the intervention highly acceptable to the patients. All patients provided follow-up data. Posttreatment there was a small reduction in negative self beliefs (Cohens d = 0.24) and a moderate reduction in paranoia (d = 0.59), but these were not statistically significant. There were statistically significant improvements in psychological well-being (d = 1.16), positive beliefs about the self (d = 1.00), negative social comparison (d = 0.88), self-esteem (d = 0.62), and depression (d = 0.68). No improvements were maintained. No adverse events were associated with the intervention. Conclusions The intervention produced short-term gains consistent with the prediction that improving cognitions about the self will reduce persecutory delusions. The improvement in psychological well-being is important in its own right. We recommend that the different elements of the intervention are tested separately and that the treatment is lengthened.

Virtual reality in the treatment of persecutory delusions: Randomised controlled experimental study testing how to reduce delusional conviction

Background Persecutory delusions may be unfounded threat beliefs maintained by safety-seeking behaviours that prevent disconfirmatory evidence being successfully processed. Use of virtual reality could facilitate new learning. Aims To test the hypothesis that enabling patients to test the threat predictions of persecutory delusions in virtual reality social environments with the dropping of safety-seeking behaviours (virtual reality cognitive therapy) would lead to greater delusion reduction than exposure alone (virtual reality exposure). Method Conviction in delusions and distress in a real-world situation were assessed in 30 patients with persecutory delusions. Patients were then randomised to virtual reality cognitive therapy or virtual reality exposure, both with 30 min in graded virtual reality social environments. Delusion conviction and real-world distress were then reassessed. Results In comparison with exposure, virtual reality cognitive therapy led to large reductions in delusional conviction (reduction 22.0%, P = 0.024, Cohens d = 1.3) and real-world distress (reduction 19.6%, P = 0.020, Cohens d = 0.8). Conclusion Cognitive therapy using virtual reality could prove highly effective in treating delusions.

Using Metrics to Describe the Participative Stances of Members Within Discussion Forums

Background Researchers using forums and online focus groups need to ensure they are safe and need tools to make best use of the data. We explored the use of metrics that would allow better forum management and more effective analysis of participant contributions. Objective To report retrospectively calculated metrics from self-harm discussion forums and to assess whether metrics add to other methods such as discourse analysis. We asked (1) which metrics are most useful to compare and manage forums, and (2) how metrics can be used to identify the participative stances of members to help manage discussion forums. Methods We studied the use of metrics in discussion forums on self-harm. SharpTalk comprised five discussion forums, all using the same software but with different forum compositions. SharpTalk forums were similar to most moderated forums but combined support and general social chat with online focus groups discussing issues on self-harm. Routinely recorded time-stamp data were used to derive metrics of episodes, time online, pages read, and postings. We compared metrics from the forums with views from discussion threads and from moderators. We identified patterns of participants’ online behavior by plotting scattergrams and identifying outliers and clusters within different metrics. Results In comparing forums, important metrics seem to be number of participants, number of active participants, total time of all participants logged on in each 24 hours, and total number of postings by all participants in 24 hours. In examining participative stances, the important metrics were individuals’ time logged per 24 hours, number of episodes, mean length of episodes, number of postings per 24 hours, and location within the forum of those postings. Metric scattergrams identified several participative stances: (1) the “caretaker,” who was “always around,” logged on for a much greater time than most other participants, posting but mainly in response to others and rarely initiating threads, (2) the “butterfly,” who “flitted in and out,” had a large number of short episodes, (3) two “discussants,” who initiated many more discussion threads than anybody else and posted proportionately less in the support room, (4) “here for you,” who posted frequently in the support room in response to other participants’ threads, and (5) seven “people in distress,” who posted many comments in the support room in comparison with their total postings and tended to post on their own threads. Conclusions Real-time metrics may be useful: (1) by offering additional ways of comparing different discussion forums helping with their management, and (2) by identifying participative stances of individuals so allowing better moderation and support of forums, and more effective use of the data collected. For this to happen, researchers need to publish metrics for their discussion forums and software developers need to offer more real-time metrics facilities.

Insomnia, Nightmares, and Chronotype as Markers of Risk for Severe Mental Illness: Results from a Student Population.

STUDY OBJECTIVES To group participants according to markers of risk for severe mental illness based on subsyndromal symptoms reported in early adulthood and evaluate attributes of sleep across these risk categories. METHODS An online survey of sleep and psychiatric symptomatology (The Oxford Sleep Survey) was administered to students at one United Kingdom university. 1403 students (undergraduate and postgraduate) completed the survey. The median age was 21 (interquartile range = 20-23) and 55.60% were female. The cross-sectional data were used to cluster participants based on dimensional measures of psychiatric symptoms (hallucinations, paranoia, depression, anxiety, and (hypo)mania). High, medium, and low symptom groups were compared across sleep parameters: insomnia symptoms, nightmares, chronotype, and social jet lag. RESULTS Insomnia symptoms, nightmares frequency, and nightmare-related distress increased in a dose-response manner with higher reported subsyndromal psychiatric symptoms (low, medium, and high). The high-risk group exhibited a later chronotype (mid sleep point for free days) than the medium- or low-risk group. The majority of participants (71.7%) in the high-risk group screened positive for insomnia and the median nightmare frequency was two per 14 days (moderately severe pathology). CONCLUSIONS Insomnia, nightmares, and circadian phase delay are associated with increased subsyndromal psychiatric symptoms in young people. Each is a treatable sleep disorder and might be a target for early intervention to modify the subsequent progression of psychiatric disorder.

The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis

Summary Background Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. Methods We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. Findings Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohens d=1·11; p<0·0001), paranoia (−2·22, −2·98 to −1·45, Cohens d=0·19; p<0·0001), and hallucinations (−1·58, −1·98 to −1·18, Cohens d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported. Interpretation To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision. Funding Wellcome Trust.

Treating Sleep Problems in Patients with Schizophrenia.

Background: Sleep disturbance is increasingly recognized as a major problem for patients with schizophrenia but it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy, which we have been evaluating for patients with current delusions and hallucinations in the context of non-affective psychosis. Aims: In this article we describe the lessons we have learned about clinical presentations of sleep problems in schizophrenia and the adaptations to intervention that we recommend for patients with current delusions and hallucinations. Method: Twelve factors that may particularly contribute to sleep problems in schizophrenia are identified. These include delusions and hallucinations interfering with sleep, attempts to use sleep as an escape from voices, circadian rhythm disruption, insufficient daytime activity, and fear of the bed, based upon past adverse experiences. Specific adaptations for psychological treatment related to each factor are described. Conclusions: Our experience is that patients want help to improve their sleep; sleep problems in schizophrenia should be treated with evidence-based interventions, and that the interventions may have the added benefit of lessening the psychotic experiences. A treatment technique hierarchy is proposed for ease of translation to clinical practice.

Nightmares in Patients with Psychosis: The Relation with Sleep, Psychotic, Affective, and Cognitive Symptoms

Objective: To examine the prevalence of nightmares in people with psychosis and to describe the link between nightmares and sleep quality, psychotic, affective, and cognitive symptoms. Methods: Forty participants with psychotic symptoms completed an assessment of nightmares, sleep quality, positive symptoms of psychosis, affect, posttraumatic stress, social functioning, and working memory. Results: Among the patients, 55% reported weekly distressing nightmares. Experience of more frequent nightmares was related to poorer sleep quality and sleep efficiency. More distressing nightmares were positively associated with greater delusional severity, depression, anxiety, stress, and difficulties with working memory. Conclusions: Nightmares might be common in those with psychosis and are associated with increased day- and nighttime impairment. Future research should investigate treatments for nightmares, for people presenting with psychotic symptoms.

Insomnia and hallucinations in the general population: Findings from the 2000 and 2007 British Psychiatric Morbidity Surveys.

Insomnia is common in people experiencing psychosis. It has been identified as a contributory cause of paranoia, but any causal relationship with hallucinations has yet to be established. We tested the hypotheses that insomnia i) has a cross-sectional association with hallucinations ii) predicts new inceptions of hallucinations and iii) that these associations remain after controlling for depression, anxiety, and paranoia. Data from the second (2000, N=8580) and third (2007, N=7403) British Psychiatric Morbidity Surveys were used to assess cross-sectional associations between insomnia and hallucinations. The 2000 dataset included an 18 month follow up of a subsample (N=2406) used to test whether insomnia predicted new inceptions of hallucinations. Insomnia was associated with hallucinations in both cross-sectional datasets. Mild sleep problems were associated with 2–3 times greater odds of reporting hallucinations, whilst chronic insomnia was associated with four times greater odds. Insomnia was also associated with increased odds of hallucinations occurring de novo over the next 18 months. These associations remained significant, although with smaller odds ratios, after controlling for depression, anxiety and paranoia. This is the first longitudinal evidence that insomnia is associated with the development of hallucinatory experiences. Effective treatment of insomnia may lessen the occurrence of hallucinations.

Disrupting Sleep: The Effects of Sleep Loss on Psychotic Experiences Tested in an Experimental Study With Mediation Analysis

Abstract Our view is that insomnia may be a causal factor in the occurrence of psychotic experiences such as paranoia and hallucinations. However, the causal relationship is not established. The aim of the study was to investigate the causal role of insomnia in psychotic experiences via a sleep restriction manipulation. The study was a within-subjects crossover design that included a planned mediation analysis. Sixty-eight nonclinical volunteers underwent a sleep loss condition (restricted to 4 h sleep for 3 nights) and a control condition (standard sleep) in randomized order in 2 consecutive weeks, with a weekend washout period. Psychotic experiences (paranoia, hallucinations, grandiosity, and cognitive disorganization) and candidate mediating variables (negative affect and related processes, working memory, decision making, and perceptual processing) were assessed before and after each condition. Actigraphy verified an average sleep duration of 5 h 15 min in the sleep loss condition, vs 6 h 58 min in the control condition. After the sleep loss condition, relative to the control condition, participants reported significant increases in paranoia, hallucinations, and cognitive disorganization, with no significant changes in grandiosity. The sleep loss condition was also associated with significant increases in negative affect, negative self and other cognitions, worry, and working memory impairment. Mediation analyses indicated that changes in psychotic experiences were mediated by changes in negative affect and related processes, but not memory impairment. The overall conclusion is that insomnia has a causal role in the occurrence of certain psychotic experiences, and that a key route is via negative affect.