Niall M. Broomfield

Who is pre-occupied with sleep? A comparison of attention bias in people with psychophysiological insomnia, delayed sleep phase syndrome and good sleepers using the induced change blindness paradigm

Cognitive models of insomnia suggest that selective attention may be involved in maintaining the disorder. However, direct assessment of selective attention is limited. Using the inducing change blindness (ICB) paradigm we aimed to determine whether there is attentional preference for sleep‐related stimuli in psychophysiological insomnia (PI) relative to delayed sleep phase syndrome (DSPS) and good sleepers (GS). In the ICB task, a visual scene, comprising both sleep‐related and neutral stimuli, ‘flickers’ back and forth with one element (sleep or neutral) of the scene changing between presentations. Therefore, a 2 × 3 totally between‐participants design was employed. The dependent variable was the number of flickers it took for the participant to identify the change. Ninety individuals (30 per group) were classified using ICSD‐R criteria, self‐report diaries and wrist actigraphy. As predicted, PI detected a sleep‐related change significantly quicker than DSPS and GS, and significantly quicker than a sleep‐neutral change. Unexpectedly, DSPS detected a sleep‐related change significantly quicker than GS. No other differences were observed between the two controls. These results support the notion that there is an attention bias to sleep stimuli in PI, suggesting that selective attention tasks such as the ICB may be a useful objective index of cognitive arousal in insomnia. The results also suggest that there may be an element of sleep preoccupation associated with DSPS. Results are discussed with reference to other experiments on attentional processing in insomnia.

Sleep-related attentional bias in good, moderate, and poor (primary insomnia) sleepers.

Evidence was sought of an attentional bias toward a highly representative object of the bedroom environment in good, moderate, and poor (primary insomnia) sleepers. Using a flicker paradigm for inducing change blindness, the authors briefly presented a single scene comprising a group of bedroom environment and neutral objects to participants and then briefly replaced this scene with an identical scene containing a change made to either a bedroom environment or a neutral object. In a 3 x 2 entirely between-participants design, change-detection latencies revealed a sleep-related attentional bias in poor sleepers but not in good sleepers. A possible bias in moderate sleepers was also revealed. It is suggested that attentional bias has a role in the perpetuation and possibly precipitation of primary insomnia.

Towards a valid, reliable measure of sleep effort

A frequent clinical observation is that patients with insomnia strive to control their sleep. However, sleep is an involuntary physiological process, which cannot be placed under full voluntary control. Therefore, direct, voluntary attempts to control sleep may actually exacerbate and perpetuate insomnia. To date, no reliable scale has been available to test this hypothesis directly. Moreover, while sleep effort is a core International Classification of Sleep Disorders – Revised criterion for psychophysiological insomnia, clinicians lack a reliable measure with which to assess the construct. In this initial scale validation study, we present psychometric data for the Glasgow Sleep Effort Scale based on a relatively small but representative sample of patients with insomnia and good sleepers. The clinical and research value of the new scale is discussed and future research directions are described.

Cognitive and Mood Assessment in Stroke Research Focused Review of Contemporary Studies

Background and Purpose— International guidelines recommend cognitive and mood assessments for stroke survivors; these assessments also have use in clinical trials. However, there is no consensus on the optimal assessment tool(s). We aimed to describe use of cognitive and mood measures in contemporary published stroke trials. Methods— Two independent, blinded assessors reviewed high-impact journals representing: general medicine (n=4), gerontology/rehabilitation (n=3), neurology (n=4), psychiatry (n=4), psychology (n=4), and stroke (n=3) January 2000 to October 2011 inclusive. Journals were hand-searched for relevant, original research articles that described cognitive/mood assessments in human stroke survivors. Data were checked for relevance by an independent clinician and clinical psychologist. Results— Across 8826 stroke studies, 488 (6%) included a cognitive or mood measure. Of these 488 articles, total number with cognitive assessment was 408 (83%) and mood assessment tools 247 (51%). Total number of different assessments used was 367 (cognitive, 300; mood, 67). The most commonly used cognitive measure was Folsteins Mini-Mental State Examination (n=180 articles, 37% of all articles with cognitive/mood outcomes); the most commonly used mood assessment was the Hamilton Rating Scale of Depression(n=43 [9%]). Conclusions— Cognitive and mood assessments are infrequently used in stroke research. When used, there is substantial heterogeneity and certain prevalent assessment tools may not be suited to stroke cohorts. Research and guidance on the optimal cognitive/mood assessment strategies for clinical practice and trials is required.

Post‐stroke depression: the case for augmented, individually tailored cognitive behavioural therapy

In this review, we begin by considering why post-stroke depression (PSD) is so prevalent. We then examine the current evidence base to support cognitive behavioural therapy (CBT) as a treatment approach for the condition. While there is limited evidence currently, we demonstrate that much remains to be established with regard to PSD and the efficacy of CBT. We argue there is every reason to believe CBT should be an effective treatment, but that clinicians must augment and individually tailor this approach to ensure effectiveness. We set out our rationale for a novel augmented, individually tailored CBT protocol, and describe five key components that we believe once incorporated, and tested using randomized controlled methods, should enhance treatment outcome of PSD.

Covert and overt attention in trait anxiety: a cognitive psychophysiological analysis.

The effect of threatening cues and anxiety upon attention within a Posner paradigm was investigated in two experiments. It was predicted anxious individuals would show a bias to threat-related material. Heart rate and eye movements were obtained to assess the attentional processes associated with this cognitive bias. Sixty and 40 participants were allocated respectively to groups based on self-reported scores of anxiety and repressive coping style. All participants were exposed to threat and non-threat cue words within a word based Posner cueing task. In the second study, spatial position of the target was manipulated, together with instructional set. Differential patterns of attentional disengagement to threat were found that were modulated by trait anxiety in study 2. A bias towards threat involving uninstructed eye movements was observed amongst anxious participants. Repressors made few such eye movements. Findings are discussed in relation to models of attentional deployment to threat.

Depression and anxiety symptoms post-stroke/TIA: prevalence and associations in cross-sectional data from a regional stroke registry

BackgroundMood disorders are commonly seen in those with cerebrovascular disease. Literature to-date has tended to focus on depression and on patients with stroke, with relatively little known about post-stroke anxiety or mood disorder in those with transient ischaemic attack (TIA). We aimed to describe prevalence of depression and anxiety symptoms in stroke and TIA cohorts and to explore association with clinical and socio-demographic factors.MethodsWe used a city wide primary care stroke registry (Glasgow Local Enhanced Service for Stroke - LES). All community dwelling stroke-survivors were included. We described cross-sectional prevalence of depression and anxiety symptoms using the Hospital Anxiety and Depression Scale (HADS). Data on clinical and demographic details was collected and univariable and multivariable analyses performed to describe associations with HADS scores. We examined those with a diagnosis of `stroke’ and `TIA’ as separate cohorts.ResultsFrom 13,283 potentially eligible stroke patients in the registry, we had full HADS data on 4,079. Of the 3,584 potentially eligible TIA patients, we had full HADS data on 1,247 patients. Across the stroke cohort, 1181 (29%) had HADS anxiety scores suggestive of probable or possible anxiety; 993 (24%) for depression. For TIA patients, 361 (29%) had anxiety and 254 (21%) had depression. Independent predictors of both depression and anxiety symptoms were female sex, younger age and higher socioeconomic deprivation score (all p < 0.001).ConclusionUsing HADS, we found a high prevalence of anxiety and depression symptoms in a community-based cohort of patients with cerebrovascular disease.

An Experimental Assessment of a Pennebaker Writing Intervention in Primary Insomnia

This study considers the role of pre-sleep cognitive arousal, worry, and inhibition in sleep onset difficulties. The Pennebaker writing task, which promotes emotional processing by asking people to write about their thoughts, worries, and emotions, has proven effective in several areas of health. Here, the paradigms ability to reduce pre-sleep cognitive arousal (PSCA) and sleep onset latency (SOL) in people with insomnia was tested. Twenty-eight people with insomnia were randomized to three nights of Pennebaker writing or a control condition, following a one-night baseline. The outcomes of change over baseline at Day 4 in pre-sleep cognitive arousal and SOL were compared. Writing significantly reduced pre-sleep cognitive arousal on one out of two measures, but did not significantly reduce SOL.

Cognitive assessment in stroke: feasibility and test properties using differing approaches to scoring of incomplete items

Cognitive screening is recommended in stroke, but test completion may be complicated by stroke related impairments. We described feasibility of completion of three commonly used cognitive screening tools and the effect on scoring properties when cognitive testing was entirely/partially incomplete.

Metacognitive beliefs in primary insomnia: developing and validating the Metacognitions Questionnaire--Insomnia (MCQ-I).

Patients with Primary insomnia often experience intrusive, worrisome cognitive activity in the pre-sleep period. Metacognitive beliefs may explain this yet no valid reliable scale exists. The present study, therefore, developed the Metacognitions Questionnaire--Insomnia (MCQ-I). Following initial metacognitive insomnia profiling interviews, item refinement produced a preliminary 60-item MCQ-I. This was administered to 34 primary insomniacs and 37 normal sleepers. Psychometric data indicate primary insomniac patients score significantly higher than normal sleepers on MCQ-I. Test-retest reliability is good. Face, concurrent, construct and discriminant validity, scale sensitivity and specificity are all acceptable. Further research with larger primary insomnia and normal sleeper samples is now required.