Umair Akram

Misperception of tiredness in young adults with insomnia

People with insomnia often exhibit interpretive biases to cues associated with their condition. This study examined whether individuals with insomnia display an interpretive bias, such that they misperceive facial attributes of tiredness in a disorder‐consistent manner. The efficacy of providing feedback related to the accuracy of participants’ perception on later judgements of tiredness was further examined. Forty participants, 20 with DSM‐5‐defined insomnia disorder and 20 normal‐sleepers, participated. The perception of ones own facial appearance of tiredness was assessed twice over two consecutive days using a visual task whereby participants indicated when a morphing image of their face represented their current level of tiredness. Visual and verbal feedback, related to participants’ degree of misperception, was provided on completion of Day 1 testing. Overall, individuals with insomnia perceived their own face as significantly more tired than a baseline neutral photograph was, whereas normal‐sleepers perceived themselves as appearing more alert. This pattern of results was only apparent on Day 1. Although no group × day interaction was established, mean scores suggest an improvement in perception on Day 2 amongst individuals with insomnia only. These findings suggest that individuals with insomnia exhibit a misperception of their facial attributes of tiredness, interpreting them in a disorder‐consistent manner. This finding adds to the body of literature on cognitive models of insomnia, demonstrating more general cognitive biases in the disorder. Further, the results provide suggestive evidence that this misperception may be reformed.

Anxiety Mediates the Relationship between Perfectionism and Insomnia Symptoms: A Longitudinal Study

Objectives Individuals with insomnia often report aspects of perfectionism and symptoms of anxiety and depression. Investigation of these factors together has been limited. As such, the aim of the present study was to examine the extent to which the association between perfectionism and insomnia symptoms was mediated by anxiety and depression, concurrently and longitudinally. Methods Seventy-six members from the general-population participated at baseline. Data from 57 participants were subsequently analysed at twelve-month follow-up. Insomnia symptoms were assessed using The Insomnia Severity Index (ISI). Perfectionism was assessed using two Multidimensional Perfectionism Scales (F-MPS; HF-MPS). Symptoms of anxiety and depression were assessed using The Hospital Anxiety and Depression Scale (HADS). Correlational analysis examined longitudinal associations between perfectionism and insomnia symptoms. Hierarchical regression analysis examined whether significant associations remained after controlling for anxiety and depression. Results Baseline insomnia symptoms were associated with future doubts about action. Further, this relationship was mediated by preceding symptoms of anxiety and concurrent symptoms of insomnia. Similarly, baseline insomnia symptoms were also associated with future parental criticism. However this relationship was partially mediated by preceding symptoms of anxiety, and was not mediated by concurrent insomnia symptoms. Conclusions Symptoms of insomnia appear to be related to an increase in negative perfectionistic thinking in the form of doubts about action and parental criticism, however these relationships appear to be mediated by symptoms of anxiety. Therefore, treatments for insomnia should address anxiety symptoms with the prospect of preventing the accentuation of aspects of perfectionism due to poor sleep.

Preferential attention towards the eye-region amongst individuals with insomnia.

People with insomnia often perceive their own facial appearance as more tired compared with the appearance of others. Evidence also highlights the eye‐region in projecting tiredness cues to perceivers, and tiredness judgements often rely on preferential attention towards this region. Using a novel eye‐tracking paradigm, this study examined: (i) whether individuals with insomnia display preferential attention towards the eye‐region, relative to nose and mouth regions, whilst observing faces compared with normal‐sleepers; and (ii) whether an attentional bias towards the eye‐region amongst individuals with insomnia is self‐specific or general in nature. Twenty individuals with DSM‐5 Insomnia Disorder and 20 normal‐sleepers viewed 48 neutral facial photographs (24 of themselves, 24 of other people) for periods of 4000 ms. Eye movements were recorded using eye‐tracking, and first fixation onset, first fixation duration and total gaze duration were examined for three interest‐regions (eyes, nose, mouth). Significant group × interest‐region interactions indicated that, regardless of the face presented, participants with insomnia were quicker to attend to, and spent more time observing, the eye‐region relative to the nose and mouth regions compared with normal‐sleepers. However, no group × face × interest‐region interactions were established. Thus, whilst individuals with insomnia displayed preferential attention towards the eye‐region in general, this effect was not accentuated during self‐perception. Insomnia appears to be characterized by a general, rather than self‐specific, attentional bias towards the eye‐region. These findings contribute to our understanding of face perception in insomnia, and provide tentative support for cognitive models of insomnia demonstrating that individuals with insomnia monitor faces in general, with a specific focus around the eye‐region, for cues associated with tiredness.

Altered perception of facially expressed tiredness in insomnia

The present study compared normal sleepers and individuals displaying insomnia symptoms in their ratings for the expression intensity of tiredness and alertness whilst observing tired and neutral faces. Fifty-six normal sleepers and 58 individuals with insomnia symptoms observed 98 facial photographs (49 neutral, 49 tired). Using a visual analogue scale, participants were required to rate the extent to which each face appeared as tired and alert. Tired faces were created by manipulating neutral photographs to include previously identified facial tiredness cues. All participants rated sleep-related faces as more tired and less alert relative to neutral photographs. A significant Group × Face × Rating interaction demonstrated that, compared with normal sleepers, the insomnia symptoms group showed lower ratings for the expression of tiredness, but not alertness, whilst observing the tired faces. The findings suggest that the presence of insomnia symptoms is associated with reduced ratings of expression intensity for sleep-related facial photographs displaying tiredness. These outcomes add to the body of literature on how facial cues of tiredness are perceived by those with insomnia symptoms. Further work is required to elucidate the mechanisms underlying the relationship between insomnia symptoms and reduced perceptions of facially expressed tiredness.

Sleep-related attentional bias for tired faces in insomnia: evidence from a dot-probe paradigm

People with insomnia often display an attentional bias for sleep-specific stimuli. However, prior studies have mostly utilized sleep-related words and images, and research is yet to examine whether people with insomnia display an attentional bias for sleep-specific (i.e. tired appearing) facial stimuli. This study aimed to examine whether individuals with insomnia present an attentional bias for sleep-specific faces depicting tiredness compared to normal-sleepers. Additionally, we aimed to determine whether the presence of an attentional bias was characterized by vigilance or disengagement. Forty-one individuals who meet the DSM-5 criteria for Insomnia Disorder and 41 normal-sleepers completed a dot-probe task comprising of neutral and sleep-specific tired faces. The results demonstrated that vigilance and disengagement scores differed significantly between the insomnia and normal-sleeper groups. Specifically, individuals with insomnia displayed difficulty in both orienting to and disengaging attention from tired faces compared to normal-sleepers. Using tired facial stimuli, the current study provides novel evidence that insomnia is characterized by a sleep-related attentional bias. These outcomes support cognitive models of insomnia by suggesting that individuals with insomnia monitor tiredness in their social environment.

Sleep associated monitoring on awakening mediates the relationship between cutaneous body image dissatisfaction and insomnia symptoms

INTRODUCTION This study examined the relationship between dissatisfaction with cutaneous body image and insomnia symptoms, incorporating the mediating role of monitoring for signs of poor-sleep on awakening and throughout the day. METHODS Two hundred twenty-one participants completed The Insomnia Severity Index, Cutaneous Body Image Scale, and subscales of the Sleep Associated Monitoring Index. RESULTS The results demonstrated that insomnia symptoms were significantly associated with a greater dissatisfaction with cutaneous body image. Moreover, this relationship was partially mediated by sleep associated monitoring on awakening, but not throughout the day. CONCLUSIONS These findings provide further understanding of the potential mechanisms underlying negative self-perceptions of physical appearance in insomnia.

The face of tiredness in insomnia from the self‐perspective: A focus on attentional and interpretative biases

The extent to which an individual has slept may influence how their physical appearance is perceived by others and oneself. The poor nature of one’s sleep can be observed through a number of dermatological characteristics (e.g., wrinkles/fine lines and bags around the eyes, dropped corners of the mouth and heavy eyes) pertaining to tiredness (Knoll, Attkiss, & Persing, 2008; Sundelin et al., 2013). Further, research concurs that facial photographs of sleep-deprived individuals are rated as less attractive, less healthy, more tired and less sociable when compared to well-rested (Axelsson et al., 2010; Sundelin, Lekander, Sorjonen, & Axelsson, 2017). As such, it appears that limited sleep may lead to dermatological changes in the face which subsequently may influence the perception of others, potentially leading to psychosocial implications relating to partner and workplace interaction(s) and with health care providers (Gupta, Gupta, & Knapp, 2015). There may be a number of mechanisms promoting these physiological changes; for example, tiredness can result in the relaxing of the muscles, which would inherently alter one’s facial expression (Enoka & Stuart, 1992). Moreover, sleep promotes blood flow to the skin and changes in skin blood coloration occur with lack of sleep, leading the face to appear paler (Kr€auchi & Wirz-Justice, 2001), which could act as a contributing factor to an increased perception of tiredness (Sundelin et al., 2013). Insomnia, by definition, encompasses subjective reports of poor sleep (American Psychiatric Association, 2013), and while the experience of tiredness is reported commonly (Balter & Uhlenhuth, 1991), this population often displays objectively better sleep than that reported subjectively (Perlis, Merica, Smith, & Giles, 2001; Tang & Harvey, 2004, 2006; Van Den Berg et al., 2008). Considering the aforementioned research, which focuses largely upon studies of extreme sleep deprivation, it would be reasonable to assume that those with insomnia might not actually appear physically tired to the same extent, perhaps falling somewhere between sleep-sated and sleep-deprived. As such, people with insomnia may not necessarily be judged as negatively by others as may be a person who has experienced a transient bout of severe sleep-deprivation. However, a different picture emerges if we examine how individuals with insomnia perceive themselves. In an article published in the Journal of Sleep Research, data from our group demonstrated that when using a visual task where participants indicated when a continuously morphing image of their face, varying in degrees of tiredness and alertness, represented their current level of tiredness, individuals with insomnia displayed an interpretive bias such that they misperceived their own face as appearing more tired than they physically were (Akram, Ellis, Myachykov, & Barclay, 2016a). Conversely, this bias did not extend to the perception of other people’s faces which were more accurately perceived (Akram, Ellis, Myachykov, & Barclay, 2016b). When asked to explore and examine their own and other people’s faces, a follow-up study in the Journal of Sleep Research (Akram, Ellis, Myachykov, & Barclay, 2017) determined that people with insomnia were quicker to direct initial attention to and maintain overall attention towards areas of the face associated with tiredness (Knoll et al., 2008; Nguyen, Isaacowitz, & Rubin, 2009; Sundelin et al., 2013). Further, it has also been evidenced that the self-reported severity of insomnia symptoms is related to reduced ratings of expression intensity for tired facial photographs of other people (Akram, Sharman, & Newman, 2017). It is relevant to note, however, that these studies used samples of a relatively young age (compared with other research in insomnia). While this was to account for changes to sleep continuity and increased sensitivity to early signs of skin ageing (Akram et al., 2017), these outcomes cannot be extrapolated to older adults experiencing insomnia. Despite this, it seems that while individuals with insomnia display an equivalent level of attention towards both their own and other people’s facial features relating to tiredness (Akram et al., 2017), only their own facial attributes of tiredness are interpreted in a manner consistent with the physical presence of an objective sleep disturbance (Akram et al., 2016a, 2016b). This may be explained from a cognitive perspective, specifically in terms of biases of attention, which may consequently influence interpretation. Individuals with insomnia report selectively attending to, and monitoring, bodily sensations on waking and throughout the day for signs of a poor night’s sleep, fatigue and tiredness (i.e., sore head, heavy eyes, poor facial complexation), which has been evidenced as mediated by the extent of sleep-related monitoring on awakening (Akram, 2017; Semler & Harvey, 2004). As the face is used in social perception to portray one’s internal state to others (Allison, Puce, & McCarthy, 2000), we may theorize that those with insomnia attend to other people’s facial attributes of tiredness, evaluating these features and drawing comparisons to their own. Certainly, if this is the case, comparisons of this nature (e.g., ‘I look exhausted compared with everybody else’) may serve to heighten pre-existing worry, arousal and distress as described in cognitive models of insomnia (Espie, Broomfield, Macmahon, Macphee, & Taylor, 2006; Harvey, 2002). From a clinical perspective, one must ask two questions: first, can we correct these biases of attention and interpretation; and secondly, would this alter reported insomnia symptomology? Tentatively, research suggests that providing feedback regarding the accuracy of how individuals with insomnia perceive their own faces in terms of tiredness served to positively influence subsequent interpretations, Received: 8 November 2017 | Accepted: 12 December 2017 DOI: 10.1111/jsr.12657

Sleep-related attentional bias for faces depicting tiredness in insomnia: evidence from an eye-tracking study

STUDY OBJECTIVES To date, evidence of an attentional bias in insomnia has mostly been obtained through reaction time tasks, with a limited number of studies using eye tracking. Here, using an eye-tracking paradigm, this study sought to determine whether individuals with insomnia display an attentional bias for novel faces depicting tiredness. METHODS Individuals with insomnia (n = 20) and normal sleepers (n = 20) viewed a series of face pairs depicting neutral and tired expressions each for periods of 4000 milliseconds. Eye movements were recorded using eye tracking, and first fixation onset, first fixation duration, total fixation duration, and total gaze duration were examined for three interest regions (eyes, nose, mouth). RESULTS Significant group × face interactions for total fixation duration and total gaze duration indicated that, regardless of interest-region, participants with insomnia spent more time fixating on and observing tired faces relative to neutral faces when compared with normal sleepers. Additionally, significant group × face × interest-region interactions for total fixation duration and total gaze duration indicated that participants with insomnia spent more time observing the eye region of the tired faces than the eye region of the neutral faces when compared with normal sleepers. CONCLUSIONS Individuals with insomnia display an attentional bias toward tired faces, more specifically for the eye region compared to normal sleepers. These findings contribute to our understanding of face perception in insomnia and provide more objective support for cognitive models of insomnia, suggesting that individuals with insomnia selectively attend to faces for tiredness cues.

The therapeutic potential of attentional bias modification training for insomnia: study protocol for a randomised controlled trial

BackgroundThe efficacy of attentional bias modification (ABM) as a treatment for anxiety and depression has been extensively studied with promising results. Despite some evidence of sleep-related attentional biases in insomnia, only a small number of studies, yielding mixed results, have examined the application of ABM in insomnia. This study specifically aims to determine whether ABM can reduce (i) the presence of an attentional bias for sleep-related threatening words; (ii) insomnia symptom severity; (iii) sleep onset latency; and (iv) pre-sleep cognitive arousal amongst individuals with insomnia compared to a non-treatment control group of individuals with insomnia.Methods/designWe propose a randomised controlled trial of 90 individuals from the general population who meet the criteria for Insomnia Disorder. Following an initial examination for the presence of a sleep-related attentional bias using the dot-probe paradigm, participants will be randomised to an online attentional bias modification training condition, or to a standard attentional bias task (non-treatment) control condition. Both conditions will be delivered online by a web platform. All participants allocated to the non-treatment control group will be offered ABM training once the study is complete. The primary outcome will be the attentional bias indices of vigilance and disengagement and self-reported insomnia symptoms, sleep onset latency and pre-sleep cognitive arousal. Attentional bias and insomnia symptoms will be assessed at baseline (day 1) and post-treatment (2 days after the final training session: day 9). Insomnia symptoms will be again assessed at follow-up (day 16). Secondary outcomes include examining whether sleep associated monitoring and worry are related to a sleep-related attentional bias in insomnia, and whether such reports reduce following ABM. All main analyses will be carried out on completion of follow-up assessments. The trial is supported by the Department of Psychology, Sociology and Politics at Sheffield Hallam University.DiscussionThis study will extend the research base examining the efficacy of attentional bias modification for insomnia.Trial registrationISRCTN (ISRCTN11643569, registered on 5 June 2018).

The relationship between Type D personality and insomnia.

OBJECTIVES Type D personality is characterized by the combination of social inhibition and negative affectivity. This study examined the relationship between Type D personality and insomnia symptoms amongst a sample of the general-population. METHODS Adults from the general-population (n = 392) completed online measures of Type D personality (DS14) and insomnia severity. RESULTS Individuals with the Type D personality trait reported significantly greater symptoms of insomnia relative to Non-Type Ds. Moreover, insomnia-symptoms were independently related to negative affectivity (NA) and social inhibition (SI) and the Type D interaction (i.e. synergistic product of SI and NA). Linear regression analysis determined that NA but not SI significantly predicted insomnia symptoms after controlling for age and sex. However, after accounting for the Type D interaction, negative affectivity remained the only significant predictor of insomnia-symptoms. CONCLUSIONS The Type D personality type appears to be related to insomnia-symptoms, both as a categorical and dimensional construct. These outcomes support prior research evidencing that whilst Type D personality is related to poor sleep in adolescents, NA appears to be the main contributor.