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Section A presents a systematic review of the literature exploring the psychosocial challenges faced by young people with delayed sleep phase disorder (DSPD). The review found that young people with DSPD experience psychosocial challenges beyond those of their peers, including poorer cognitive performance and mental health and increased difficulties in social and family relationships. Implications for clinical practice were that clinicians should consider the presence and impact of DSPD in formulations to inform best treatment. Further UK-based research would be beneficial, with a particular focus on qualitative research to explore the young person's inner experience. Section B presents a study exploring adolescents experience of sleep during the covid19 pandemic and proposes a theory of how sleep problems may be perpetuated. Grounded theory was used to analyse the interviews of eleven adolescents who had experienced changes in their sleep since the start of the pandemic. A theoretical model suggested that ways of coping with the pandemic had a detrimental impact on participants sleep, with the way in which this was managed in the longer term affecting recovery of their sleep. The model provides a framework for clinicians when working with adolescents with sleep problems in the wake of the pandemic.

Section A: This report aimed to provide an updated review of the literature on parent sleep in the context of having a child with a physical illness. It focused on psychological factors that may explain sleep difficulties and explores potential consequences of sleep disturbance. A systematic search of four databases yielded 36 studies that were eligible for review. Studies showed a high proportion of parents experiencing sleep disruptions and explored the relationship between parent sleep and mental health. Factors associated with sleep disruption included child illness-related factors, environmental and social factors. Section B: Infant Gastroesophageal Reflux Disease (GORD) occurs when symptoms of reflux require medical intervention. Parents whose infants experience some of the symptoms of GORD are at risk of poorer mental health. This study aimed to estimate the prevalence of mental health difficulties in this population, to test predictors of parental mental health, and to explore differences between different types of GORD. Participants reported significantly higher rates of anxiety and depression than those found in perinatal or general population samples. Results provided support for the predictive power of self-compassion, illness perceptions and illness uncertainty, above and beyond parent satisfaction with sleep, social and relationship support and infant feeding.

Psoriasis is an immune-mediated chronic dermatological condition associated with a range of physical and psychological comorbidities, and a significant disease burden. Healthy sleep plays a key role in maintaining health and wellbeing. Conversely, chronic sleep disturbance significantly increases the risk of developing a range of physical and mental health conditions if left untreated. Sleep disturbance is a known feature of other chronic conditions and is associated with disease-specific influences and consequences. Therefore, given the links between sleep, health and functioning, the experience of sleep disturbance in psoriasis was investigated using a multi-method approach. Chapter One provides an overview of psoriasis and sleep and the potential impact psoriasis and sleep disturbance can have on health and wellbeing. Chapter Two identifies what is known from the existing literature and the limitations of the studies reviewed. From here a prospective research agenda was formulated. A cross-sectional survey (Chapter Three) sought to address the gaps in the literature by examining the extent, characteristics and correlates of sleep disturbance using validated measures. Chapter Four then describes the first in-depth qualitative study exploring the experience of sleep disturbance in people with psoriasis. The Common-Sense Model of Self-Regulation was used as a guiding framework and facilitated exploration of beliefs, emotions and behaviours associated with sleep disturbance. This study provided insights into the role of psoriasis specific factors, the impact of sleep disturbance on daily life and the limited coping options available. Using Experience Sampling Methodology, Chapter Five examined the bi-directional and sequential relationships between sleep disturbance and daytime variables in psoriasis. Multiple daily assessments of psoriasis, mood, night-time experiences and functioning were combined with actigraphy and sleep dairies. This study revealed possible treatment targets to improve sleep and daytime functioning. However, findings related to psoriasis were contrary to previous chapters. The findings from the preceding chapters were synthesised in Chapter Six. The methodologies used were also critically appraised. Clinical implications were discussed in addition to a brief overview of potential avenues for future research.

Background: The human ability to adapt to extreme environments is fascinating. Research into this adaptation has been lacking in Arctic isolated teams because it has concentrated on Antarctic teams. The hazards of the poles often confine the researchers indoors with their colleagues, reducing their privacy. This deployment also limits their contact with loved ones at home. Subsequently, over the course of polar night, rates of anxiety, depression, irritability and sleep disturbance increase (Suedfeld & Palinkas, 2008). Often, the teams complain of cognitive impairments. The High Arctic’s distinctive feature is the polar bear. The presence of bears requires Arctic research station teams to handle fire arms for their personal safety. It also means that fire arms – which are highly restricted in the Antarctic – are ever-present and easily accessible at Arctic stations. This poses a unique psychological challenge for these teams which has not been well-researched. Methodology: This thesis is an original contribution to science in that it employs a mixed-methods approach combining phenomenological interviews, cognitive testing and mental health assessment via questionnaires with a team spending a year at the Polish Polar Station, Hornsund, Svalbard. The participants were ten of the eleven winter team members who spent the year between July 2015 and June 2016 at Hornsund (“Explorers”) and an age-/gender-/education-matched control group (“Controls”). They filled in the Symptom Checklist-90-Revised and the Profile of Mood States-Brief Version in July, September, January, April and June of that year. Cognitive testing was completed in September, January and June; it comprised the Figural Learning and Memory Test, the Sustained Attention to Response Task (SART), the elevator tasks of the Test of Everyday Attention (TEA) and the Raven Standard Progressive Matrices. The interviews took place at the same time as the cognitive testing. Results: The results showed that the most stressful time reported in the questionnaires was April 2016, just after the winter isolation had ended and the sun had risen again. The Explorers reported little subjective complaints about their cognition but they performed near-ceiling on the TEA while scoring far below their Controls on the SART. This implies a dichotomy between sustained attention and inhibition in the Explorers. Their lived experiences were shaped by a struggle to adapt to the other team members rather than by struggling to adapt to the hazardous environment. The environment was perceived as awe-inspiring. Over time, the Explorers shifted their view of the team from informal colleagues to a family which they did not choose to be a member of and then, to friends. Unanimously, other people were seen as the most difficult aspect of the mission. Conclusions: This thesis provides unique insight into a non-Anglo-Saxon Arctic wintering team: the conclusions suggest that participants should receive social training to get along better and be emotionally prepared. The findings can be implemented by my research partner, the Institute of Geophysics (Warsaw) to better select and prepare their future expeditions to Hornsund. Some of the insights such as the nature of the interpersonal stressors may be applicable to space missions.

Literature Review: The current review presents a recent review of the effectiveness of psychological therapies to treat sleep difficulties (such as insomnia and nightmares) in sufferers of posttraumatic stress disorder (PTSD). The review also aimed to investigate whether there are differences in the effectiveness of specific psychological therapies to treat sleep disturbances in PTSD, such as between the different types of psychological therapies such as cognitive behavioural therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT). Eleven studies were included in the review that met the inclusion and exclusion criteria. Results are presented in tables and a descriptive account is included. The review demonstrates that psychological therapies are effective for the treatment of insomnia and other sleep difficulties such as nightmares. However, firm conclusions cannot be drawn about the effectiveness of different types of psychological therapies as studies predominantly used CBT and only one non-CBT study was included in the review. Comparisons between the effectiveness of different CBT approaches is also not possible as there was a large range of diversity in the study characteristics and also there were only a small number of studies for each intervention, which therefore limits the generalisability of results in the current review. It may be that different CBT interventions such as CBT-I or EERT and IRT may be better suited to treat insomnia and nightmares respectively, but further research needs to be conducted into which of these approaches are beneficial for different PTSD specific sleep difficulties. Empirical Paper: Initial studies demonstrate that self-compassion reduces symptoms of PTSD in Armed Forces Veterans (AFV), however the use of self-compassion approaches in AFV is under-researched. The current study utilised self-report and psychophysiological measures to investigate whether a single self-compassion experimental induction reduced hyperarousal symptoms (PTSD Cluster E symptoms) and increased feelings of social connectedness in AFV. The study hypothesised that there would be a decrease in hyperarousal symptoms and an increase in social connectedness, which would be associated with PTSD severity. Fifty-three AFV who had been deployed to a combat zone took part in the study, of which n = 15 (28.3%) currently met criteria for PTSD and n = 4 (7.5%) met criteria for Subsyndromal PTSD on the PCL-5. Participants listened to a recording of a Loving Kindness Meditation for self-compassion (LKM-S) and psychophysiological recordings were taken throughout. Participants completed state measures of hyperarousal and social connectedness before and after the LKM-S. Findings partially demonstrated that self-compassion can be elicited in an AFV population. However, changes on the self-report measures were largely not supported by psychophysiological measures, apart from skin conductance levels (SCL). The longevity of the effects observed in the study were not measured and should be investigated in future studies. Although this study has demonstrated that self-compassion can be elicited within the AFV population, further research is needed including to test a longer self-compassion intervention.

International humanitarian aid workers (iHAWs) are professionals often exposed to considerable stress and trauma while delivering humanitarian support to populations in distress. Many studies support the deleterious association between sleep disturbances, alcohol use, posttraumatic stress symptoms (PTSS), and emotional exhaustion (EE). Considering the lack of research on this topic among iHAWs, we conducted an exploratory study to examine relationships among the aforementioned variables in iHAWs. One hundred participants reflected on their on-mission experiences retrospectively while completing the Pittsburgh Sleep Quality Index (PSQI), the PSQI addendum for PTSD (PSQI-A), Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), the Maslach Burnout Inventory (MBI), and the quantity-frequency measure for alcohol. Questionnaire completion rates ranged from 33% to 55%. Stepwise regression models were used to analyze the association between two outcome variables, PCL-5 daytime symptoms and EE measured by the MBI, and predictor variables, alcohol use, and PSQI global, and PSQI-A scores. Independent t-tests were conducted to assess difference in on- and off-mission health behaviors, namely sleep disturbance, alcohol, and marijuana use among iHAWs. Spearman regressions were used to examine the association between aid worker career length and PSQI global score as well as relationship between PCL-5 and MBI. False Discovery Rate was adopted to adjust for alpha inflation. Stepwise regression analyses indicated a significant association between PCL-5 daytime symptoms and PSQI global score after accounting for alcohol use (ΔR2 = 0.139, p = 0.039). Furthermore, PCL-5 daytime symptoms were significantly correlated with PSQI-A score after controlling for PSQI global score and alcohol use (ΔR2 = 0.320, p 0.000). Additionally, EE was significantly correlated with PSQI after accounting for alcohol use (ΔR2 = 0.140, p = 0.034). We did not find a significant difference between on- and off-mission sleep quality, alcohol use, or marijuana use among iHAWs. However, based on Spearman regression, the aid-working career length was significantly correlated with the PSQI component five, sleep disturbance (ρ = 0.451, p = 0.003). Our results corroborate previous findings on the association between sleep disturbances, emotional exhaustion, and PTSS among populations such as first responders, medical professionals, and military personnel. Aid workers and their mental health could benefit from further attention among the research community, especially given the recent increase in conflicts worldwide. While the humanitarian community works on shifting mental health stigmas, sleep health optimization could be an interim step in encouraging iHAWs to seek care. Additionally, the current study focuses on international staff, but the experience of national staff cannot be neglected.

ABSTRACT BACKGROUND: The level of anxiety and sleep disturbances among healthcare providers plays an essential role in overcoming epidemics, especially those on the front lines. It is the responsibility of RTs to provide care to patients with respiratory illnesses. Because of their importance in the health care team, respiratory therapists must have good mental health to do their job to the fullest. It is necessary to identify the subpopulations of healthcare workers who are particularly vulnerable to sleep deprivation and anxiety to characterize them to develop targeted interventions and plan for future crises. PURPOSE: The aim of this study was to assess the prevalence of sleep disturbance and anxiety among RTs in Saudi Arabia during the COVID-19 winter of 2022. METHODS: The study employed a cross-sectional survey that was conducted online and consisted of 44 questions administered to a convenience sample of RTs in Saudi Arabia. The survey was divided into three parts, which were Pittsburgh Sleep Quality Index (PSQI), Zung Self-Rating Anxiety Scale (SAS), and demographic questions. The data analysis was conducted using SPSS version 27. RESULTS: The sample of this research involves 34 respiratory therapists. The majority of the respondents were males 67.6% (n=23), while the females comprised 32.4% (n=11). In addition, 32.4% (n=11) of the participants were from the central region, 14.7% (n=5) were from the east region, 5.9% (n=2) were from the north region and 11.8% (n=4) were from the south region, and 35.3% (n=12) were from the west region. The study showed that the majority of respiratory therapists in Saudi Arabia (79.4%) reported that they had sleep disturbances. The study findings of seven components of the Pittsburg sleep quality index (PSQI) among RTs in Saudi Arabia showed that the component “Sleep latency” was the highest mean score (M=1.8 ± 1.0). The finding revealed that twenty-seven participants out of thirty-four (79.4 %) Reported normal anxiety, with only 20.6% having mild-to-moderate anxiety. Moreover, the study findings indicated no significant difference in sleep disturbances and anxiety levels between RTs in the different regions of Saudi Arabia; sleep disturbances H (4) = 5.026, P = .285, anxiety H (4) = 3.299, P=.509. Additionally, the study found no evidence that anxiety statistically correlated with sleep disturbances among RTs in Saudi Arabia. (P = 0.139). Conclusion: This study provides important insights into the prevalence of sleep disturbances and anxiety among respiratory therapists in Saudi Arabia during the COVID-19 winter of 2022. It is found that a significant proportion of respiratory therapists in Saudi Arabia experienced sleep disturbances. Further research is needed to explore effective strategies to support mental health and quality of sleep among respiratory therapists.

Objective/Background: An emerging area of research is the relationship between sleep disturbance and decrements in energy. Given the paucity of research on the co-occurrence of these two symptoms, study purposes were to identify subgroups of oncology patients with distinct joint sleep disturbance AND morning energy profiles and evaluate for differences among the subgroups in demographic, clinical, and sleep disturbance characteristics, as well as the severity of other common symptoms and QOL outcomes.Patients/Methods: Patients (n=1336) completed measures of sleep disturbance and energy 6 times over two cycles of chemotherapy. All of the other measures were completed at enrollment. Latent profile analysis was used to identify the distinct joint sleep disturbance and morning energy profiles.Results: Three distinct profiles were identified (i.e., Low Sleep Disturbance and High Morning Energy (Normal, 20.6%), Moderate Sleep Disturbance and Love Morning Energy (Moderately Severe, 52.1%), Very High Sleep Disturbance and Very Low Morning Energy (Very Severe, 27.3%). Compared to Normal class, other two classes were more likely to be female, less likely to be employed, and had higher comorbidity burden and poorer functional status. Symptom scores and QOL outcomes exhibited a dose response effect (i.e., as the profile worsened, symptom scores increased and QOL scores decreased).Conclusions: Given the associations between sleep disturbance and decrements in energy and a higher symptom burden, poorer QOL outcomes, and increased mortality, assessment of these two symptoms needs to be a high priority for clinicians and appropriate interventions initiated.

Background: Alzheimer’s dementia and related dementias (hereafter dementia) can affect sleep disturbance (e.g., nighttime awakening behaviors and poor sleep quality among persons with dementia (PWD). Estimates suggest sleep problems affect approximately 60-70% of PWD such as the difficulty of falling asleep and multiple wakes at night resulting in advanced cognitive impairment. In addition to the impact of sleep disturbance on PWD, sleep disturbance also is one of the foremost health problems affecting family caregivers of PWD. Family caregivers (e.g., spouses, partners, and adult children) experience the increased awakenings and demands of PWD at night which is associated with increased stress, depressive symptoms, and burden of caregivers. Little research has investigated dyadic interrelationships in sleep quality among PWD and family caregivers. PWD are often excluded from participation in sleep research due to memory deficits and impaired expressive language. Also, immigrant ethnic minorities (e.g., Korean Americans) are also understudied in sleep research. To fully understand sleep quality among PWD-caregiver dyads, we should include both perspectives together. Purpose: The specific aims of the study are (1) to describe dyads’ sleep parameters (i.e., total/deep/REM/light sleep duration, awaken duration, latency duration, sleep efficiency) using wearable technology (i.e., smart ring) and sleep diaries, (2) to identify interrelationships of sleep parameters between PWD and caregivers, and (3) to describe lived experiences of sleep disturbances and sleep interrelationships of PWD and their family caregivers. Methods: An observational descriptive study design was used using mixed methods including quantitative and qualitative approaches using wearable devices’ data (i.e., smart ring), daily sleep diaries, surveys, and individual interviews with cohabitating PWD and caregivers. Dyads were recruited in Southern California. Wearable technology (i.e., smart ring) monitored sleep parameters (i.e., total/deep/REM/light sleep duration, awaken duration, latency duration, sleep efficiency) for 4 weeks. Validated questionnaires assessed sleep disturbances and depressive symptoms for dyads, stress, and caregiving burden for caregivers. Thematic analysis was applied to dyads’ interview data transcribed verbatim in English. Caregivers provided verbal consent, plus surrogate consent for their PWD. PWD provided verbal assent. All PWD were assessed for their decision-making capacity. Results: A total of 11 dyads (N=22) participated in the study: mean age of PWD was 82.7 years (SD=2.3); caregivers were 69.1 years (SD=10.2). Nine PWD (18.2%) were male, all caregivers (100%) were female, and 4 dyads (36.4 %) used the same bed. Sleep parameters of deep/REM/ awaken duration/ Sleep efficiency of PWD were significantly correlated with those of caregivers, respectively (All Ps < 0.05). Major themes included (1) linked sleep disturbances between PWD and caregivers, (2) sleep disturbances beyond control, (3) mixed attitudes about sleep quality in dyads, (4) language challenges within and outside the Korean American dyads, and (5) dyadic activity: strategies that improve sleep quality for dyads. Conclusion: Findings demonstrate PWD’s sleep parameters (i.e., deep /REM sleep duration, awaken duration, sleep efficiency) were significantly correlated with caregivers’ ones. Additionally, findings illustrate sleep disturbances of dyads (PWD - caregivers) connected to each other were beyond their control. The Korean American dyads (i.e., parent PWD and offspring caregivers) expressed communication challenges among them and also, they addressed limited community resources available in their primary language. A dyadic approach and wearable device used in this study show the potential to measure objective sleep quality for both PWD and their caregivers, particularly the immigrant population. Future studies should address special attention on dyadic approaches and cultural competency with large samples and diverse ethnic minorities.

Thirty percent of adults experience insomnia, causing distress, impaired functioning, and adverse health outcomes. However, little is known about biomarkers that may inform the understanding of insomnia, including its salience within different racial and ethnic groups. Additionally, knowledge is limited to one important group of individuals who experience insomnia (short sleepers) and factors that may influence effectiveness of their treatment. The aims of this dissertation were to: 1) identify evidence-based biomarkers that have been associated with insomnia in adults through a scoping review, 2) determine if insomnia and discrimination are associated with telomere length (TL) among adults from different racial/ethnic groups, and 3) identify the relationship of psychological distress and sleep-related factors to non-response to CBT-I among short sleepers with insomnia. Twenty-five studies were included in the scoping review. The importance of electroencephalography emerged as a potentially useful biomarker in identifying arousal and inhibition of brain activity associated with insomnia. Conflicting findings regarding relationships of some biomarkers emerged. This review allows researchers to build on what is known and replicate studies to assess reliability. Results from a secondary analysis of the National Institute on Aging’s Health and Retirement Study linked insomnia with shorter telomeres in White individuals. Respondents’ perceived discrimination in everyday life initially strengthened the association between insomnia symptoms and telomere shortening in Black individuals, but the effect was not significant after adjusting for covariates. Further research is needed on insomnia's biological mechanisms and its impact on biomarkers in diverse racial/ethnic groups. Results of a secondary analysis from a Treatment of Insomnia and Depression (TRIAD) study provide evidence that general severity of depression, perceived stress, sleep latency, and sleep reactivity were not associated with treatment response to CBT-I. However, an individual symptom of stress prior to treatment (trouble controlling irritability) was associated with less improvement in response to CBT-I among individuals who slept less than 6 hours per night. Difficulty controlling irritability may reflect a state of heightened stress that precludes effective engagement in CBT-I. Results of this dissertation provide an enhanced understanding of biopsychosocial factors associated with insomnia and its treatment. This new knowledge can inform future research.

Although the importance of sleep difficulties to symptoms of emotional disorders has long been acknowledged, the nature of the potential reciprocal relationship between sleep and emotional disorder symptoms is not yet well understood. The COVID-19 pandemic provided a unique opportunity to study the natural progression of these symptoms over a period marked by increases in stress, sleep problems, and psychological symptoms in the population. Using online data collection, this study followed 1,200 participants (59% male) through one year of the pandemic. Sleep, anxiety, and depressive symptoms were assessed at eight timepoints with assessments occurring more frequently at the beginning of the study. In within-participant analyses, two significant relationships were revealed. Symptoms of anxiety and depression each predicted subsequent change in insomnia symptoms. Interestingly, insomnia did not predict changes in either depressive or anxiety symptoms. These findings document only one direction of effect in the relationships between psychological symptoms and symptoms of insomnia: symptoms predicted insomnia. Implications for understanding the role of insomnia in emotional disorders are discussed.

Background: Evaluating associations between fatigue, sleep disturbance, and depressionand hypothalamic subregional volumes (HSVs) in multiple sclerosis (MS) may further theunderstanding of the pathophysiological substrates of these disabling symptoms.Methods: MS patients from two centers seen between September 10, 2015 and June30, 2020 who completed an MRI of the brain within seven days of a visit were included.Automated segmentation of T1-weighted MRIs was performed to obtain 10 HSVs.Relationships between fatigue, sleep disturbance, and depression and HSVs wereevaluated by linear models.Results: 1962 patients were included. Among the HSVs, the right anterior inferiorsubregion had the largest standardized correlation coefficient (Beta) for fatigue (Beta= -0.049,95% CI [-0.090, -0.009]) and sleep disturbance (Beta= 0.047, 95% CI [0.008, 0.085]). Therewas no statistically detectable relationship between depression and any HSV.Conclusion: These findings support a role of the anterior inferior subregion, includingthe suprachiasmatic nucleus, fatigue and sleep disturbance in MS.

Context – Unrelieved pain and sleep disturbance are common symptoms in patients receiving chemotherapy. Increased stress may be an underlying cause for both symptoms.Objectives – Purposes were to identify subgroups of outpatients with distinct co-occurring pain AND sleep disturbance profiles and to evaluate for differences among these subgroups in demographic and clinical characteristics. In addition, differences in global stress, disease-specific stress, and cumulative life stress, as well as resilience and coping were evaluated. Methods – Patients (n=1343) completed measures of pain, sleep disturbance, stress, resilience and coping. Latent profile analysis was used to identify subgroups of patients with distinct pain AND sleep disturbance profiles. Differences among the subgroups were evaluated using parametric and non-parametric tests. Results – Three distinct profiles were identified (i.e., No Pain + Moderate Sleep Disturbance (SD) (27.6%), Moderate Pain + Moderate SD (38.6%), Severe Pain + High SD (33.8%)). Compared to the other two classes, Severe Pain + High SD class was younger, had fewer years of education, was more likely to be female, more likely to live alone, less likely to be employed, and had a higher level of comorbidity. This class had the highest stress scores and were more likely to report higher rates of adverse childhood experiences (ACEs; e..g, physical and sexual abuse). Conclusions – Given that over 70% of our sample reported clinically meaningful levels of both symptoms and 33.8% reported relatively high rates of ACEs, clinicians need to perform routine assessments; initiate appropriate referrals, and provide effective symptom management interventions including cognitive behavioral therapy.

Background – Sleep disturbance and cancer-related cognitive impairment (CRCI) are two of the most common symptoms reported by patients undergoing chemotherapy. Less is known about how these symptoms co-occur and their associated risk factors.Objective – Study purposes were to identify subgroups of patients with distinct sleep disturbance and CRCI profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, symptom severity scores, and QOL outcomes. Methods – A total of 1330 oncology outpatients receiving chemotherapy completed self-report questionnaires on sleep disturbance and cognitive dysfunction six times over two cycles of chemotherapy. Latent profile analysis was used to identify distinct sleep disturbance AND cognitive dysfunction profiles. Parametric and non-parametric tests were used to evaluate for differences among the classes. Results – Two distinct profiles were identified (i.e., Low = low levels of both sleep disturbance and cognitive dysfunction (53.5%); High = high levels of both sleep disturbance and cognitive dysfunction (45.5%)). Patients in the High class were younger, more likely to be female, had a lower functional status and a higher level of comorbidity. In addition, these patients had a higher symptom burden and a lower quality of life. Conclusion – Almost half of the patients undergoing chemotherapy experienced clinically meaningful levels of both symptoms. Implications for Practice – Of note, sleep disturbance is frequently overlooked by both clinicians and patients. Clinicians need to recommend cognitive rehabilitation and physical activity programs to decrease patients’ symptom burden.

Background – Pain and fatigue are common symptoms in oncology patients.Objective – Study purposes, in a sample of oncology outpatients receiving chemotherapy (n=1342), were to: identify subgroups of patients with distinct worst pain AND morning fatigue profiles and evaluate for differences among the subgroups in demographic and clinical characteristics; as well as the severity of common symptoms and quality of life (QOL) outcomes. Methods – Oncology outpatients receiving chemotherapy (n=1342) completed self-report questionnaires to assess pain and morning fatigue, a total of six times over two cycles of chemotherapy. Joint latent profile analysis was used to identify subgroups of patients with distinct pain and morning fatigue profiles. Differences among the classes were evaluated using parametric and non-parametric tests. Results – Five distinct profiles were identified (no pain and no morning fatigue (27.6%), moderate pain and no morning fatigue (28.2%), moderate pain and morning fatigue (28%), moderate pain and increasing and decreasing morning fatigue (6.9%), severe pain and very high morning fatigue (9.3%). Patients in the three highest profiles had clinically meaningful levels of depression and sleep disturbance and decrements in QOL. Conclusions – Over 44% of the sample had moderate to high levels of both pain and morning fatigue. Unrelieved pain may contribute to disturbed sleep which results in higher levels of morning fatigue. Implications for practice – Clinicians need to assess for pain and fatigue, as well as sleep disturbance during chemotherapy.

Aim. Sleep disturbance (SD) is a common symptom in cancer patients and their caregivers, contributing to increased morbidity, poor quality of life, and poor prognosis. Yet, understanding SD and options for management have been overlooked in both neuro-oncology care and research. This thesis aimed to build an evidence-base for the prevalence and severity of SD in adults with malignant brain tumours (BT) and their caregivers. Methods. Three research studies are presented in this thesis. The first study used a cross-sectional, mixed-methods approach to explore the prevalence, types and risk factors of SD in ambulant BT patients and caregivers using self-reported outcome assessments (Chapter 4); and semi-structured interviews in a sub-sample (Chapter 5). The second study utilised a longitudinal, national clinical dataset prospectively collected in routine care at palliative care centres (Chapter 6). A multi-level analysis was conducted to identify patterns of change in severity and determine clinical indicators for SD throughout palliative care. The final study was a survey (Chapter 7), complemented by a sub-study of semi-structured interviews (Chapter 8), of healthcare professionals (HCPs) to explore their perception and current management of SD in neuro-oncology care. Results. All three studies indicate a high prevalence of SD in both BT patients and caregivers. SD varies both in the type and severity of SD along the BT trajectory; from insomnia post-diagnosis and during initial treatment to hypersomnolence in advanced BT. SD is linked to several other symptoms, such as fatigue in patients and anxiety in caregivers, indicating distress and functional impairment. HCPs perceive SD as a secondary, complex issue which takes low priority in current neuro-oncology care. HCPs report the lack of knowledge and resources for SD screening and management. Implications. Risks and aetiology of SD in BT patients and their caregivers are multifactorial and not necessarily aligned with the current clinical opinion that views corticosteroids as a major causal factor. Findings indicate inadequate recognition and management of SD. An improved approach to detecting sleep issues in routine practice is warranted, to more effectively involve HCPs in proactive management and deliver improved outcomes for patients and caregivers. This body of research provides important groundwork to inform future studies to design, evaluate, and implement optimal sleep assessments, interventions and to plan care in neuro-oncology clinics.

Insomnia is a sleep-wake disorder characterized by difficulty initiating sleep, maintaining sleep, or falling back asleep. The main psychotherapeutic treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBTI). Although the treatment is highly effective, its main limitations include poor adherence and high dropout rates, suggesting that many suffering from insomnia are unable to reap the benefits of CBTI. The present study proposes the use of psychological flexibility from Acceptance and Commitment Therapy (ACT) as a potential framework to examine insomnia. Psychological flexibility looks to promote healthy, flexible behaviors and thoughts to guide the individual towards their goals or values. There are six domains within psychological flexibility and all of which are interrelated and build upon one another. The present study utilized correlational analyses to examine the potential relationship between psychological flexibility and insomnia. A sleep-related psychological flexibility measure (SRPFM) was developed to examine psychological flexibility within a sleep-related context. The measure was designed to estimate a global sleep related psychological flexibility score as well as scores for each of the six individual domains. It was hypothesized that the global sleep related psychological flexibility score would be positively associated with how efficiently our participants slept and be negatively associated with levels of insomnia and daytime sleepiness. It was also hypothesized that the individual domains of psychological flexibility would be positively associated with how efficiently our participants slept and be negatively associated with levels of insomnia and daytime sleepiness. Sleep diaries were used to calculate sleep efficiency for 19 participants throughout the course of one week. Results found that higher endorsement of global sleep related psychological flexibility yielded less endorsement of insomnia. Furthermore, Endorsement of various domains of psychological flexibility yielded less endorsement of insomnia. Essentially, those who are more psychologically flexible are less likely to endorse clinically significant insomnia. The results of this study suggest a relationship between sleep related psychological flexibility and insomnia. This information can be used to guide further examination of this connection as well as the future development of a new adjunctive or standalone treatment for insomnia.

Background: A cancer diagnosis and associated treatments, as well as the uncertainty of thedisease course, are stressful experiences for most patients. However, little information isavailable on the relationship between stress and symptom burden. The study purpose was toevaluate for differences in the severity of fatigue, lack of energy, sleep disturbance, andcognitive function, among three groups of patients with distinct stress profiles.Methods: Patients receiving chemotherapy (n=957) completed measures of general, cancerspecific, and cumulative life stress and symptom inventories. Latent profile analysis was used toidentify subgroups of patients with distinct stress profiles.Results: Three distinct subgroups of patients were identified (i.e., Stressed (39.3%), Normative(54.3%), Resilient (5.7%)). For cognitive function, significant differences were found among thelatent classes (Stressedevening fatigue, compared to the Normative and Resilient classes, the Stressed class reportedhigher severity scores. Compared to the Normative and Resilient classes, the Stressed classreported low levels of morning energy. Compared to the Normative class, the Stressed classreported lower levels of evening energy.Conclusions: Consistent with our a priori hypothesis, patients in the Stressed class had thehighest symptom severity scores for all four symptoms and all of these scores were above theclinically meaningful cutoffs for the various instruments.

Background – Fatigue and sleep disturbance are common co-occurring symptoms in patients receiving chemotherapy (CTX). While the results from the meta-analyses support the use of exercise to decrease the severity of these symptoms, information is needed on patients’ “real world experiences” with the use of exercise during CTX.Objective – Determine the distribution of patients who did and did not exercise on a regular basis and evaluate for differences in demographic and clinical characteristics, as well as the severity of fatigue, decrements in energy, and sleep disturbance among the exercise groups.Methods – Patients (n=1033) completed self-report questionnaires prior to their second or third cycle of CTX. Patients were categorized into 3 exercise (Ex) groups (i.e., NoEx, 150 minutes/week (RecEx). Differences among the groups were evaluated using parametric and nonparametric tests.Results – Only 19.1% of the patients were in the RecEx group. Patients in the NoEx group (37.2%) were had fewer years of education, were more likely to be non-white and unemployed, had a higher BMI and a worse comorbidity profile. Patients in the NoEx group had higher levels of morning fatigue, lower levels of morning and evening energy, and higher levels of sleep disturbance.Conclusions – Findings from this “real world” study suggest that lack of physical activity is associated with higher levels of fatigue and sleep disturbance.Implications for Practice – Given that the most frequently used intervention in this study was walking, clinicians can recommend this inexpensive intervention to patients to manage fatigue and sleep disturbance.

INTRODUCTION: Several previous studies have documented a relationship between sleep problems and suicide. However, this association has not been explored specifically among opioid users. Given that studies have suggested that opioids can interrupt sleep and that opioid users are more likely to attempt suicide than non-users, it is important to further investigate the association between sleep disturbance and suicidal ideation, planning, and attempts among opioid abusers. METHODS: Data from the National Survey on Drug Use and Health 2010-2014 survey were analyzed to assess whether there was an association between sleep problems and suicidal ideation, planning and attempts among individuals who report abusing opioid medications. Prevalence of opioids abusers by demographic characteristics, odds ratios and 95% confidence intervals unadjusted and adjusted by age, gender & mental health disorders were reported. RESULTS: Results indicated that opioids abuse was higher in ages 18 to 25 years. Results of 2011 unadjusted and adjusted analyses showed significant associations between sleep disturbance and suicidal planning. Results of 2012 adjusted analyses showed significant associations between sleep disturbance and suicidal attempts. Results of 2013 unadjusted and adjusted analyses showed significant association between sleep disturbance and suicidal ideation among opioids abusers. DISCUSSION: This research provided some evidence of an association between sleep disturbances and suicidal ideations, planning and attempts among opioids abusers using NSDUH data. This study’s findings can be beneficial for educational and public health prevention programs to promote a better understanding of sleep disturbance, suicidal ideation, planning, and attempts among opioid abusers. More research can help to find risk factors and achieve overall mission of harm reduction among opioids abusers.

Problem: Sleep disturbance is a prevalent symptom that affects up to 88% of oncology patients. It is significant problem for oncology patients due to its association with increased fatigue, depression and vasomotor/endocrine symptoms; poorer functional status and quality of life; and potentially disease progression.Study Objectives: Study purposes were to identify subgroups of patients with distinct sleep disturbance profiles and to evaluate for differences in demographic, clinical, and various sleep characteristics, as well for differences in the severity of co-occurring symptoms among these subgroups.Methods: Outpatients with breast, gynecological, gastrointestinal, or lung cancer (n=1331) completed questionnaires six times over two chemotherapy (CTX) cycles. Sleep disturbance was evaluated using the General Sleep Disturbance Scale (GSDS). Latent profile analysis was used to identify distinct subgroups.Results: Three latent classes with distinct sleep disturbance profiles were identified (Low (25.5%), High (50.8%), Very High (24.0%)). Approximately 75% of the patients had a mean total GSDS score that was above the clinically meaningful cutoff score of 43 across all six assessments. Compared to patients in the Low class, patients in High and Very High classes were significantly younger; had a lower functional status; had higher levels of comorbidity; and were more likely to be female, more likely to have childcare responsibilities, less likely to be employed, and less likely to have gastrointestinal cancer. For all of the GSDS subscale and total scores, significant differences among the latent classes followed the expected pattern (LowConclusions: Clinicians need to perform in-depth assessments of sleep disturbance and co-occurring symptoms to identify high-risk patients and recommend appropriate interventions.

Objectives: To assess prevalence and correlates of cancer-related sleep disturbance (SD) and hypnotic use, and evaluate changes in cancer symptom burden and health-related quality of life (HRQoL) associated with sleep disturbance change and hypnotic use. Methods: Secondary analysis of the Symptom Outcomes and Practice Patterns (SOAPP) survey of 3,106 adult (aged ≥ 18 years) outpatients receiving treatment for breast, lung, prostate, or colorectal cancer between March 3, 2006 and May 19, 2008. At baseline and approximately four weeks later, patients scored severity of nineteen cancer symptoms from 0='Not present' to 10='As bad as you can imagine'. Both patients and clinicians scored symptom-burden interference for six HRQoL items (from 0='Did not interfere' to 10='interfered completely'). Correlates of SD and hypnotic use were identified using linear and logistic regression, respectively. Multivariate analyses tested whether hypnotic use (Hotelling's T²) or change in SD severity (multivariate linear regression) were associated with changes in symptom burden and HRQoL. Cancer-specific subgroups were evaluated when sample size permitted. Results: SD scores were available for 2,748 participants: 71% female, 86% white, mean age 61 years (range, 23-93 years). Primary cancer sites: breast (51%), colorectal (24%), lung (15%), and prostate (10%). The majority (62.8%) reported SD and 23.5% used hypnotics. The most important SD correlates were other cancer symptoms, regardless of their severity. Distress was the strongest and only universal correlate; cognitive difficulty, drowsiness, and fatigue were also common across cancer-specific subgroups. Hypnotic use was two to three times higher among whites, versus blacks. Several sedating medications correlated positively with hypnotic use, including opioid analgesics and promethazine. Hypnotic use correlated positively with clinician-identified distress, but not with clinician-identified sleep disturbance. Reduced sleep disturbance severity (SDS) correlated with improvement in nearly all symptoms (most notably: distress, dry mouth, and fatigue), and with improved HRQoL (possibly mediated by other symptoms). Hypnotic use correlated modestly with lower overall symptom burden, but not HRQoL change. Conclusions: Relationships observed between SD and many other cancer symptoms argue in favor of therapies that target multiple symptoms. Patterns of hypnotic use raise questions about whether cancer-related SD is being treated adequately, equitably, and effectively.

Studies suggest that sleep disturbance may be an important etiological factor in the development of comorbid anxiety and depressive disorders, whereby anxiety leads to sleep difficulties, which in turn increase the vulnerability for depression. The primary aim of this study was to determine whether the sequential comorbidity patterns observed at the disorder level (i.e., where anxiety disorders most often precede insomnia, and insomnia most often precedes depression) were also present in daily fluctuations of symptoms. The secondary aim was to explore possible moderators of any observed temporal associations. Participants were 15 patients with generalized anxiety disorder (GAD; mean age = 28.9 years, SD = 9.8) and 15 good sleeper controls (mean age = 27.1 years, SD = 8.3) who were comparable in female:male ratio (73% female vs. 67% female). For 14 days, participants wore an actigraph to objectively assess sleep quality (sleep onset latency, total sleep time, wake after sleep onset, sleep efficiency) and completed daily symptom ratings multiple times each day using their smartphones to assess symptoms of anxiety, depressed mood, and subjective sleep quality. Study aims were assessed using multilevel modeling, with daily symptoms nested within individuals. Many of the analyses were lagged such that the time-varying predictor variable preceded the time-varying outcome variable temporally. Consistent with hypotheses, results demonstrated that anxious mood was predictive of later subjective and objective sleep disturbance in individuals with GAD, and this effect was strongest among individuals with higher levels of neuroticism, negative affect, and dysfunctional beliefs about sleep. Anxious mood was not associated with later subsequent sleep disturbance in healthy controls. In the GAD group, subjective and objective sleep disturbance predicted later depressed mood; this effect was moderated by temperament and dysfunctional beliefs about sleep. For the control group, the effect of subjective sleep disturbance on later depressed mood was moderated by neuroticism and the effect of objective sleep disturbance was moderated by dysfunctional beliefs about sleep, suggesting that sleep disturbance may increase vulnerability for depressed mood even in healthy individuals. These results suggest that explicitly targeting sleep disturbance during the treatment of GAD may attenuate the experience of depressive symptoms.

The objective of this study was to determine the effects race, sex and sleep disturbance have on the severity of Parkinson’s disease as assessed by the Hoehn Yahr (HY) score in both the medicated (ON) and non-medicated (OFF) states. The potentially confounding variables of age, time in years from the onset of symptoms to database entry, and education were taken into account. Secondary analysis was also conducted to determine how the non-motor symptoms of dementia, hallucinations and autonomic dysfunction impacted Hoehn Yahr ON and OFF scores. This study used the statistical techniques of the Student’s t-test, ANOVA, Tukey-Kramer test, univariate linear regression, and multivariate regression. The t-tests and ANOVA test revealed that there was no significant differences in mean HY ON and OFF scores between the sexes, patients with and without sleep disturbance, and between the different races analyzed in this study. Patients with and without sleep disturbance did show significantly higher HY ON scores as compared to HY OFF scores, which is peculiar as this finding suggests that these patients are not responding to their medication. The univariate linear regression models did show, however, that time in years from the onset of symptoms to database entry did significantly impact both HY ON and OFF scores, whereas age is only shown to have a significant impact on HY OFF scores. Additionally, the univariate linear regression model analyzing the association between education and HY OFF scores showed that having some high school education, but not receiving a degree, was associated with an increase in HY OFF scores. Several multivariate linear regression models where built to assess the impact different predictor variables had on HY ON and HY OFF scores. The first two multivariate models used the predictor variables of age, race, and time in years from the onset of symptoms until database entry. These models showed that only time in years from the onset of symptoms until database entry impacted HY ON scores, whereas all three of these predictor variables impacted HY OFF scores. Two additional multivariate linear regression models were built to assess how age, race, time in years from the onset of symptoms until database entry, dementia, autonomic dysfunction and hallucinations all impacted HY ON and OFF scores. These models revealed that all of these predictors, when taken together, significantly impacted HY OFF scores, but not HY ON scores. Finally a scatter plot was made comparing HY ON and HY OFF scores. A LOWESS scatter plot smooth line was also superimposed on top of this plot to show the overall trend these scores had on one another. This scatter plot was interesting because it suggested that there were two spate groups of patients contained in this database, those that responded well to medication and those that did not. Overall, this study showed that age, time in years from the onset of symptoms until database entry, education and race impacted HY OFF scores. Furthermore, the analysis indicated that patients who were asked about sleep disturbance did not appear to be responding to medication. There are several limitations to this study, however, with the most important being missing data and the cross-sectional design. Missing data prevented sleep disturbance from being thoroughly analyzed and the cross-sectional design does not allow for any causal relationships to be determined.

Study Objectives: In a sample of outpatients with breast, gastrointestinal (GI), gynecological (GYN), and lung cancer who received two cycles of chemotherapy (CTX) the purposes were to: evaluate for inter-individual differences in the severity of sleep disturbance and to determine which demographic, clinical, and symptom characteristics were associated with initial levels as well as the trajectories of sleep disturbance.Methods: This study is part of a larger, longitudinal study of the symptom experience of oncology outpatients receiving CTX. A total of 1,331 patients completed study questionnaires in their homes, at six time points over two cycles of CTX (prior to CTX administration, approximately 1 week after CTX administration, and approximately 2 weeks after CTX administration). Questionnaires included demographic, clinical, and symptom assessments (i.e., General Sleep Disturbance Scale, Lee Fatigue Scale, Center for Epidemiological Studies-Depression Scale, Spielberger State-Trait Anxiety Inventories, Attentional Function Index).Results: Hierarchical linear modeling based on full maximum likelihood estimation was performed. Characteristics associated with higher initial levels of sleep disturbance included: higher body mass index, poorer functional status, higher trait anxiety, higher depressive symptoms, and higher evening fatigue. Characteristics associated with the worse trajectories of sleep disturbance were higher levels of education and higher sleep disturbance. Characteristics associated with both higher initial levels and worse trajectories of sleep disturbance were higher morning fatigue and worse attentional function.Conclusions: A great deal of inter-individual variability exists in sleep disturbance during CTX. The modifiable and non-modifiable characteristics found in this study can be used to identify higher risk patients and provide earlier interventions to reduce sleep disturbance.

Gender differences, also called gender bias, are known to influence research findings in multiple fields. Given that only a limited amount of information is available on gender differences in symptoms in oncology patients, the purposes of this study, in a sample of outpatients receiving chemotherapy (CTX, n = 926), were to evaluate for gender differences in demographic and clinical characteristics, as well as in occurrence rates for and severity ratings of fatigue, energy, and sleep disturbance. Patients completed self-report instruments and medical records were reviewed for disease and treatment information. Across these three common symptoms, female patients had higher occurrence rates for clinically meaningful levels of fatigue and sleep disturbance, as well as decrements in morning energy. In addition, females reported higher severity scores for morning and evening fatigue, sleep disturbance, and decrements in evening energy. Both genders had significant problems with sleep maintenance. All three symptoms were common in both genders. The three symptoms appear to be distinct, yet related and should be assessed on an ongoing basis during CTX.

The number of older adults with cancer is growing at an exponential rate. Given the limited amount of research and the inconsistent findings regarding age differences in common physical symptoms associated with cancer and its treatments, the purposes of this study, in a sample of oncology outpatients receiving chemotherapy (CTX, n = 940), were to evaluate for age differences (i.e., < 65 years old versus > 65 years old) in demographic and clinical characteristics, as well as in occurrence rates for and severity ratings of fatigue, energy, and sleep disturbance. Patients completed self-report questionnaires prior to their next dose of CTX. Overall, our findings suggest that compared to younger patients, older adults experience a lower or similar symptom burden. However, it should be noted that both age groups experienced high occurrence rates and moderate to severe levels of all three symptoms. Therefore, clinicians need to assess all oncology patients receiving CTX for these three symptoms. Future research needs to determine the reasons for these age-related differences as well as for differences among the older age groups.

Sleep disturbance is common in patients with heart failure (HF) and the family caregivers. Sleep disturbance is known as a predictor of poor quality of life (QoL) in individual level. The manner in which patients’ and caregivers’ sleep disturbances influence each other’s QoL has not been determined. The purpose of this dissertation was to investigate the associations of sleep disturbance and outcomes in patients with HF and their primary family caregivers. The specific aims were to: 1) examine whether sleep disturbance of patients and their family caregivers predict their own and their partners’ QoL; 2) examine the mediator effects of depressive symptoms on the association between sleep disturbance and QoL in patients and family caregivers; and 3) provide evidence of the psychometric priorities of the Zarit Burden Interview (ZBI) as a measure of caregiving burden in caregivers of patients with HF. The three specific aims were addressed using secondary analyses of cross-sectional data available from 143 patients with HF and their primary family caregivers. To accomplish Specific Aim One, multilevel dyadic analysis, actor-partner interdependence model was used for 78 patient- caregiver dyads. Individuals’ sleep disturbance predicted their own poor QoL. Caregivers’ sleep disturbance predicted patients’ mental aspect of QoL. For Specific Aim Two, a series of multiple regressions was used to examine the mediation effect in patients and caregivers separately. Depressive symptoms significantly mediated the relationship between sleep disturbance and mental aspect of QoL in patients. The mediation effect was similar in caregivers. For Specific Aim Three, the internal consistency and convergent and construct validity of the ZBI in 124 family caregivers of patients with HF were examined. The results showed that the ZBI is a reliable and valid measure of caregiving burden in this population. This dissertation has fulfilled important gaps in the evidence base for the QoL outcome in patients with HF and caregivers. The findings from this dissertation provided evidence of the importance of monitoring sleep disturbance for better QoL in both patients and caregivers and the importance of assessing caregivers’ sleep disturbance for improving patients’ QoL. It also provided evidence of the importance of managing depressive symptoms when targeting sleep disturbance to improve QoL in both patients and caregivers.

Pain, fatigue, sleep disturbance, and depression are common and frequently occurring symptoms in oncology patients. This symptom cluster is often attributed to the release of pro-inflammatory cytokines. The purposes of this study were to determine whether distinct latent classes of patients with breast cancer (n=398) could be identified based on their experience with this symptom cluster; determine whether patients in these latent classes differed on demographic and clinical characteristics; and to determine whether variations in cytokine genes were associated with latent class membership. Three distinct latent classes were identified: (All Low (61.0%), Low Pain and High Fatigue (31.6%), All High (7.1%)). Compared to patients in the All Low class, patients in the ALL High class were significantly younger, had less education, were more likely to be Non-White, had a lower annual income, were more likely to live alone, had a lower functional status, had a higher comorbidity score, and had more advanced disease. Significant associations were found between interleukin (IL) 6 rs2069845, IL13 rs1295686, and tumor necrosis factor alpha rs18800610 and latent class membership. Findings suggest that variations in pro- and anti-inflammatory cytokine genes are associated with this symptom cluster in breast cancer patients.

Sleep disturbance is a significant problem in the general pediatric population, and it occurs even more frequently in children with Autism Spectrum Disorders (ASDs). Much time and energy has been spent examining the characteristics which predispose children in general to insomnia, and it is likely that similar factors influence sleep in young people with ASDs. Although the dynamics may be similar to those of children in the general population, unique characteristics associated with a diagnosis of ASD may have additive effects and increase the likelihood of developing sleep dysfunction. The purpose of this research was to explore possible cognitive, behavioral, emotional, and physiological risk markers for sleep disturbance in children with ASDs. The investigation involved the analyses of two sets of preexisting data in a cross-sectional design. Study 1 consisted of data from the Autism Treatment Network Registry, and Study 2, involved data collected by the Research Units on Pediatric Psychopharmacology (RUPP) Autism Network. Approximately 40 to 45 variables were analyzed in each study using hierarchical regression modeling to establish the best linear combination of predictors for sleep disturbance and to control for the effects of psychotropic medication use. The results of Study 1 revealed that the combined effects of anxiety, autism symptom severity, sensory sensitivities, communication problems, GI problems, and externalizing behavior were the main associated factors for the development of insomnia. IQ positively predicted sleep disturbance and children with Asperger’s Disorder were especially vulnerable. The amount of variance in sleep outcomes explained by the predictor variables was small to moderate (i.e., R2 ranged from .104 to .201). The results of Study 2 showed that anxiety and compulsive or repetitive behaviors were the main predisposing factors for the development of disturbed sleep, and the amount of the variance in the sleep outcome explained by predictor variables was small-to-moderate (i.e., R2 = .206). Similar to Study 1 findings, level of intelligence positively predicted the sleep dysfunction. Variables that predicted sleep outcomes across both studies were elevated anxiety, medication use and elevated IQ. Elevated anxiety and medication use were consistent with the study hypotheses. IQ was not consistent as it was hypothesized that lower levels of intelligence would be associated with sleep dysfunction. Other variables that contributed to the variance in sleep outcomes in one study, but not the other remain inconclusive (i.e., age, communication deficits, impaired reciprocal social interactions, compulsive and repetitive behaviors, regressed autism, aggressive behavior, GI problems, race, sensory sensitivities, inattentiveness), while yet other variables were found to be inconsistent with the study hypotheses (i.e., parent education level, hyperactivity, oppositional defiance, respiratory problems, epilepsy). Predictor variables were evaluated for the appropriateness of fit in a bidirectional theoretical framework for sleep disturbance in children with ASDs. Secondary analyses revealed relationships between sleep variables, parent stress and quality of life. Associations were also found between visual reception and fine motor skills development.

The majority of pregnancy sleep research has been conducted at sea level and relatively low elevations. Pregnancy at higher altitudes has distinctive physiologic attributes that affect perinatal outcomes and have been correlated with the duration and intensity of altitude. The effect of altitude on adult sleep has been studied at various elevations and has unique characteristics that may impact pregnant women. The effect of altitude on sleep during pregnancy is mostly unknown. This dissertation research explored late pregnancy sleep quantity and quality characteristics at moderate altitude by comparing them to a similar sample at sea level, describing associations between moderate altitude sleep parameters and length of labor by self-report and medical records, and testing associations between sleep and pregnancy outcomes (length of labor and mode of delivery) at moderate altitude. Participants were nulliparous third trimester women (n=50) recruited in Flagstaff, Arizona (elevation 6910 feet [2106 meters]). A 3-day sleep diary and Pittsburgh Sleep Quality Index (PSQI) were completed between 35 gestational weeks and one week prior to delivery. Descriptive statistics, unpaired t-tests, Pearson product-moment correlation coefficients, ANCOVA, multiple regression, and logistic regression were utilized. Results showed that after controlling for education, compared to nulliparous women at sea level, women at moderate altitude reported significantly higher sleep disturbance scores. After controlling for infant birth weight, length of labor was associated with the PSQI self-report measure for sleep onset latency. Together, infant birth weight, maternal weight, age, income, and sleep onset latency, hours of sleep, sleep disturbance, and sleep quality accounted for 51.6% of the variance in length of labor. Mode of delivery was also associated with sleep disturbance.

ABSTRACTObjectiveThe study purposes were to attempt to replicate the association found in our previous study of patients and family caregivers1 between IL6 and sleep disturbance and to identify additional genetic associations in a larger sample of patients with breast cancer. DesignDescriptive, longitudinal studySettingPatients were recruited from breast care centers located in a Comprehensive Cancer Center, two public hospitals, and four community practices.ParticipantsWomen (n=398) with breast cancer who had surgery on one breast with no distant metastasis.MeasurementsQuestionnaires including the Karnofsky Performance Status (KPS) scale and Self-Administered Comorbidity Questionnaire (SCQ). The 21-item General Sleep Disturbance Scale (GSDS) was used to assess sleep disturbance prior to surgery and monthly for 6 months. ResultsPatients who were younger, had lower KPS scores, and more comorbidities were more likely to be in the high sleep disturbance class. Variations in three cytokine genes (i.e., Interleukin 13, Nuclear Factor Kappa Beta 2, and Interleukin 1 receptor 2) predicted latent class membership.ConclusionsGenetic markers may partially explain inter-individual variability among symptom trajectories. Determination of a high risk phenotype and associated genotypes allows for earlier identification of patients at higher risk for developing sleep disturbance and other behavioral symptoms leading to the development of more targeted clinical interventions.Key words: Sleep disturbance, breast cancer, cytokine genes, growth mixture modeling, latent class, symptom trajectories.

Often sleep is overlooked when school professionals are considering causes of problem behavior during school hours, but research shows sleep has a global effect on functioning. Previous studies have primarily focused on adolescent sleep needs. Therefore more research was needed on how sleep affects elementary aged children. The purpose of this study was to discover whether disturbed sleep, measured by a cutoff score on the Children’s Sleep Habits Questionnaire (CSHQ), had a direct effect on behavior during the school day. Behavior problems were going to be measured by office referrals for infractions defined in the school district’s discipline code. Not enough office referrals occurred for students whose parents participated in the study to complete data analysis as planned; however, results did indicate that the majority of students with disturbed sleep experienced difficulty with Morning Waking.

An Evaluation of Sleep and Pain Prior to and After Surgery for Breast CancerChristina Van Onselen, RN, MS, PhD Sleep disturbance is a common problem in women with breast cancer. However, only a limited amount of information is available on sleep disturbance and its correlates in these women. In this longitudinal study of neuropathic pain, lymphedema, and common symptoms in women who underwent surgery for breast cancer, 398 women with unilateral breast cancer were enrolled prior to surgery. Sleep disturbance and daytime sleepiness (DS) were assessed with the General Sleep Disturbance Scale (GSDS). Patients completed questionnaires prior to and for six months after surgery to assess clinical, demographic, and symptom characteristics. Prior to surgery, 28% of the patients had breast pain. Women with pain were younger, reported lower functional status, were more likely to be non-white, had not gone through menopause, and had a higher number of biopsies. Significantly higher percentage of women with breast pain (66.7%) had a mean total GSDS score above the cutoff for clinically meaningful sleep disturbance. No between group differences were found in any GSDS subscales or total GSDS scores or in fatigue and energy scores. Overall mean GSDS scores remained above the cutoff for clinically meaningful sleep disturbance over six months of the study. Higher severity scores for hot flashes, attentional fatigue, and physical fatigue predicted higher levels of sleep disturbance prior to surgery. Higher levels of depressive symptom scores predicted higher levels of sleep disturbance prior to surgery that declined slowly over six months. Higher levels of depressive symptoms, fatigue, and attentional fatigue predicted increased DS prior to surgery. Growth Mixture Modeling found three distinct subgroups of patients (i.e., High Sustained class (55.0%) had a high GSDS score prior to surgery that remained high for six months; Low class (39.7%) had low GSDS score prior to surgery that persisted; Decreasing class (5.3%) had a high total GSDS score at baseline that decreased and then stabilized). Decreasing and High Sustained classes had higher physical fatigue, attentional fatigue, depressive symptoms, and trait anxiety compared to the Low class. High Sustained class had a higher proportion of women with hot flashes, lower energy scores and higher state anxiety scores than the Low class.

This study investigated the relationship among anxiety, depression, and sleep disturbances and the treatment of these three disorders through neurotherapy. Research suggests that these conditions commonly co-occur in the general population and that central nervous system (CNS) arousal may play a primary role in the development and maintenance of these disorders. Several recent studies suggested that neurotherapy, a biofeedback-based treatment for CNS dysregulation, might be an effective treatment for comorbid conditions, particularly the ones of interest here, depression, anxiety, and sleep disturbances. This investigation used a clinical case-series design to assess pre/post neurotherapy changes on objective measures of anxiety, depression, and sleep and to determine whether changes in anxiety and depression then predict improvements in sleep quality. Data for 23 participants (10 males) were obtained from files of adults (Mage = 40.22 years, SD = 16.20) who received at least 15 neurotherapy sessions (M = 47.83 sessions, SD = 22.23) the University of North Texas Neurotherapy Lab. Matched pair t-tests revealed that symptoms of sleep disturbance, depression, and anxiety showed significant improvements following neurotherapy. Neurotherapy treatment effect sizes generally ranged from moderate to large (d = .414 - .849). Multiple regression analysis found that changes in self-reported anxiety symptoms, but not depressive symptoms, predicted observed improvements in sleep quality (adjusted R2 = .26). Last, the implications and limitations were discussed in relation to neurotherapy practice and the associated research.

Sleep disturbances impact physical and mental health in brain tumor survivors, leading to sub-optimal participation in life activities. Technological advances in cancer treatments have improved five-year survival rates for childhood brain tumors to nearly 75%. With growing numbers of brain tumor survivors, mitigation of serious late sequelae from cancer treatments becomes increasingly important. This study evaluated factors associated with sleep quality in adult survivors of childhood brain tumors and a population-based comparison group. The Cancer-Related Factors Affecting Sleep model developed by Vena et al. (2004) provided a conceptual framework for this study. Participants were recruited from the University of Minnesota and St. Jude Children's Research Hospital clinical treatment databases. The comparison group was recruited from a national mailing database service. The first aim evaluated differences in global and component sleep quality between survivors and the comparison group. Using multiple variable linear regression and logistic regression, no differences in global sleep quality were detected between survivors and the comparison group. However, survivors were two and a half times more likely than the comparison group to have longer sleep latency, taking on average 33 minutes to fall asleep after going to bed. Females in both groups reported worse sleep quality, including more daytime dysfunction, and risk of poor sleep (PSQI global scores > 10). The second aim evaluated cancer treatment effects on sleep quality among brain tumor survivors. Tumor location and surgery were not significant predictors of sleep however, radiation to the hypothalamus approached significance among survivors for longer sleep latency. Exploratory analyses identified radiation to the hypothalamus and age at diagnosis < 5 as predictors of lower vigor subscale scores on the POMS. No treatment variables predicted abnormal BSI scores among the survivors. The third aim evaluated a path model proposing post-treatment variables including obesity, depression, and fatigue as mediators of global sleep quality. In addition, gender, age, radiation to the hypothalamus and age at diagnosis < 5 were included in the model as exogenous variables. Obesity and depression were not strong predictors of global sleep quality however, gender and age at diagnosis < 5 predicted higher fatigue subscale scores. Fatigue itself significantly predicted higher (worse) global sleep quality scores within the model. This study revealed new and surprising information about sleep latency in brain tumor survivors. It also confirmed known associations with sleep and gender and a strong relationship between fatigue and sleep quality. Given these findings, future studies can begin to focus on identifying additional factors impacting sleep in these survivors.

ABSTRACTPURPOSE: This study compared the occurrence rates for and severity of sleep disturbance in cancer patient-family caregiver (FC) dyads.PATIENTS AND METHODS: One hundred and two dyads were recruited from two radiation therapy (RT) departments. Patients and their FCs completed the Pittsburgh Sleep Quality Index (PSQI) and the General Sleep Disturbance Scale (GSDS) and wore wrist actigraphs to obtain subjective and objective measures of the occurrence and severity of sleep disturbance at the initiation of RT.RESULTS: While the occurrence rates of clinically significant levels of sleep disturbance were high for both patients and their FCs, no differences were found between the dyads in these occurrence rates. Very few between group differences were found in the severity of any of the sleep-wake parameters using both the subjective and objective measures of sleep disturbance.CONCLUSIONS: The findings from this study suggest that cancer patients and their FCs experience similar levels of sleep disturbance and that both groups could benefit from interventions that aim to promote restful sleep. In addition to routine and systematic assessment of sleep disturbance by oncology clinicians, interventions are needed that take into account the specific needs of the patient and the FC as well as the potential for partners' sleep patterns to influence one another.

To date, no studies have evaluated for differences in subjective and objective measures of sleep disturbance in oncology outpatients with and without pain. This descriptive cross-sectional study, recruited 182 patients with mixed types of cancer from two radiation therapy (RT) departments at the time of the patient's simulation visit. Approximately 38% of the sample reported moderate to severe pain, with a mean worst pain intensity of 6.2 (SD = 2.4) on an 11-point scale. Significant main effects of pain group were found for the PSQI subscales of quality and disturbance, as well as the global PSQI score with patients in pain reporting higher scores than patients without pain. Significant main effects of pain group were found for the GSDS subscales of quality, medications, and daytime sleepiness, as well as the total GSDS score with patients in pain reporting higher scores than patients without pain. In addition, significant differences in objective reports of nocturnal sleep/rest, daytime wake/activity, and circadian activity rhythm parameters between pain groups were found. These data indicate that pain is prevalent among oncology outpatients and substantially impairs sleep. Further research is warranted to describe more completely the effects of age and gender in the context of pain and sleep disturbances in oncology outpatients prior to radiation therapy.

Age-related change in the sleep quality of women in aged-care is a key area in gender and ageing research. Not only does the structure of sleep change with age, but so too do the perceptions and beliefs around sleep, and the sleep management strategies available to women. Surprisingly however, the essence of the sleep beliefs and self-management strategies of women in aged-care remains largely unexplored. What is clear, is that this essence is not sufficiently captured by current clinical measures, reflecting the notion that sleep researchers and elderly women hold discordant beliefs regarding sleep quality. In order to address that disjuncture, this mixed methods study aimed to investigate a) the meanings of good and poor sleep quality for elderly women in aged-care, and b) women's self-management of sleep quality.

It is widely accepted that sleep disturbances occur in patients recovering from coronary artery bypass graft (CABG) surgery. This sleep disturbance, at least in theory, might retard or limit the return of functionality and exacerbate psychological states known to increase use of health care services and adversely affect prognosis. This study explored possible relations between sleep, self-rated aerobic physical capacity and physical activity in a sample of patients who underwent CABG surgery. Secondary analysis investigated the possible concurrent influences of post-CABG health complaints and depression on sleep function. Measures included the Pittsburgh Sleep Quality Questionnaire; the Veterans Specific Activity Questionnaire; the Paffenbarger Physical Activity Questionnaire; the Health Complaint Scale and the Beck Depression Inventory, Version II. The physical measure of body composition was also used. Fifty-five subjects completed baseline questionnaires for all measures just prior to surgery, excluding the Paffenbarger Physical Activity Questionnaire. Follow-up evaluations were repeated at 3 mo post-CABG for the same measures and the patients were also asked to report their patterns of post-surgical physical activity involvement. Correlation coefficients were calculated to determine whether a correlation existed between the measures. Significant correlations were found between pre-surgical and post-surgical sleep score, sleep subscales, functional capacity, depression and health complaints (p < 0.05). Post-CABG sleep and physical activity did not exhibit a significant correlation. A number of secondary analyses were performed in an effort to isolate possible influences of confounding factors, such as depression, body mass index > 27, and a ventricular ejection fraction (EF) < 30. In the low EF subgroup, overall sleep score and self-rated functional capacity were strongly correlated before surgery was performed (r = -0.85; p < 0.01). Stepwise regression equations were constructed to predict sleep outcome before and after surgery. Somatic health complaints, depression, and skinfold measures were found to be predictors for pre-surgical sleep (R2 = 0.52), as well as post-surgical sleep (R2 = 0.78). Fitness measures of functional capacity and physical activity were not a significant predictor of sleep. The findings of this study suggest that a modest correlation exists between functional capacity and sleep in CABG patients; however, predictors including health complaints, depression and skinfold measures serve as better indicators for sleep outcome before and after CABG surgery.

การศึกษานี้เป็นวิจัยเชิงพรรณนามีวัตถุประสงค์เพื่อศึกษาลักษณะการเกิดอาการ อ่อนล้าและอาการนอนหลับแปรปรวนในวัยรุ่น โรคมะเร็งที่ได้รับการรักษาด้วยยาเคมีบำบัดใน โรงพยาบาล กลุ่มตัวอย่าง คือ วัยรุ่น โรคมะเร็งที่ได้รับการรักษาด้วยยาเคมีบำบัดในโรงพยาบาล ตติยภูมิจำนวน 2 แห่ง จำนวน 33 ราย โดยการเลือกแบบเจาะจง เครื่องมือที่ใช้ในการเก็บรวบรวม ข้อมูลคือ แบบประเมินอาการอ่อนล้าสำหรับวัยรุ่น โรคมะเร็งและแบบบันทึกการนอนหลับประจำวัน เพื่อประเมินอาการนอนหลับแปรปรวน วิเคราะห์ข้อมูลโดยใช้สถิติเชิงบรรยาย ผลการศึกษา พบว่า วัยรุ่น โรคมะเร็งที่ได้รับการรักษาด้วยยาเคมีบำบัดในโรงพยาบาลส่วนใหญ่ มีระดับความรุนแรง ของอาการอ่อนล้าอยู่ในระดับเล็กน้อยถึงปานกลาง ไม่พบอาการนอนหลับแปรปรวนที่ได้จากการ บันทึกการนอนหลับประจำวัน มีการใช้เวลาในการนอนหลับเฉลี่ยมากที่สุุด เท่ากับ 9.24 ชั่วโมง ซึ่งอยู่ ในวันที่ 2 ของการได้รับยาเคมีบำบัด มีการงีบหลับในตอนกลางวันอยู่ ระหว่าง 31–60 นาที ต่อวัน ในทั้ง 3 วัน ระยะเวลาตั้งแต่เข้านอนจนกระทั่งหลับส่วนใหญ่ใช้เวลามากกว่า 40 นาทีวัยรุ่น รายงานการรับรู้รู้สึกถึงความเพียงพอในการนอนหลับว่ารู้สึกง่วงเล็กน้อยในวันที่่ 1 และรู้สึก ค่อนข้างง่วงเพิ่มขึ้นในวันที่ 3 ผลการวิจัยนี้เป็นข้อมูลพื้นฐานเพื่อให้พยาบาลและบุคลากรทาง การแพทย์อื่นๆ มีความตระหนักถึงการเกิดอาการอ่อนล้าและอาการนอนหลับแปรปรวนในวัยรุ่น โรคมะเร็งที่ได้รับการรักษาด้วยยาเคมีบำบัดในโรงพยาบาลและควรประเมินอาการเหล่านี้ทุกวัน เพื่อวางแผนการพยาบาลที่เหมาะสมต่อไป

การวิจัยเชิงวิเคราะห์แบบภาคตัดขวางนี้มีวัตถุประสงค์เพื่อศึกษาปัจจัยที่มีความสัมพันธ์กับ การรบกวนการนอนหลับในเด็กวัยก่อนเรียนที่มีปัญหาการหายใจผิดปกติขณะหลับในเขต กรุงเทพมหานคร กลุ่มตัวอย่างเป็นเด็กวัยก่อนเรียนที่มีปัญหาการหายใจผิดปกติขณะ หลับ จำนวน 212 คน โดยสุ่มตัวอย่างแบบหลายขั้นตอน เก็บรวบรวมข้อมูลโดยแบบสอบถาม และแบบตรวจร่างกาย ใช้สถิติการวิเคราะห์การถดถอยพหุโลจิสติกส์ พบว่า กลุ่มตัวอย่าง เป็นเพศหญิงและชายใกล้เคียงกัน อายุเฉลี่ย 5.21 ปี มีการติดเชื้อระบบทางเดินหายใจ ไม่บ่อยและบ่อยครั้ง ร้อยละ 47.2 และ 16.5 ตามลำดับ มีประวัติโรคหวัดจากภูมิแพ้ ร้อยละ 16 มีประวัติโรคหืด ร้อยละ 5.2 มีต่อมทอนซิลโตดังนี้คือ เกรด 4 ร้อยละ 8.5 เกรด 3 ร้อยละ 30.2 และเกรด 2 ร้อยละ 25.9 ภาวะอ้วนพบร้อยละ 10.4 ประวัติสัมผัสควันบุหรี่ ในครอบครัวพบร้อยละ 55.2 ซึ่งร้อยละ 69.2 บิดาสูบบุหรี่และสูบบุหรี่เฉลี่ย 11-20 มวน ต่อวัน กลุ่มตัวอย่างมีการรบกวนการนอนหลับร้อยละ 77.8 หลังจากที่มีการควบคุม ตัวแปร พบว่า การติดเชื้อระบบทางเดินหายใจบ่อยครั้ง (AOR = 4.6; 95%CI = 1.26, 16.27; p = 0.02) และต่อมทอนซิลโตมาก (เกรด 3-4) (AOR = 2.8; 95%CI = 1.07, 7.47; p = 0.03) มีความสัมพันธ์กับการรบกวนการนอนหลับในเด็กวัยก่อนเรียนที่มีปัญหา การหายใจผิดปกติขณะหลับอย่างมีนัยสำคัญทางสถิติ ดังนั้นจึงควรส่งเสริมให้มีการจัด โปรแกรมให้ความรู้ในการดูแลและป้องกันการติดเชื้อระบบทางเดินหายใจและต่อมทอนซิลโต ในเด็กกลุ่มนี้ เพื่อให้มีคุณภาพการนอนหลับที่ดีขึ้น