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Insomnia disorder is a debilitating sleep disorder that impacts nearly 10% of Canadian adults. Cognitive Behavioural Therapy for insomnia (CBT-I) is a psychological treatment that targets cognitions and behaviours to improve sleep outcomes. CBT-I has been shown to be an effective treatment for insomnia symptoms; however, little is known about the cognitive and physiological underpinnings of the treatment response. This thesis examines correlates of cognitive, clinical, and biological markers of change across group CBT-I treatment. Specifically, we evaluated: (1) objective and subjective cognitive and psychosocial functioning, (2) discrepancies between objective and subjective measures of sleep, and (3) the relationship between a biological marker of stress and sleep parameters. The first study in this thesis investigated how objective and self-report measures of cognitive functioning, and psychosocial functioning changed across CBT-I. Findings illustrated that changes in self-report cognitive ability and psychosocial functioning were related to the improvements in insomnia symptom severity across treatment. The second study investigated the discrepancy between objectively measured sleep with actigraphy and self-reported sleep variables. Findings showed that the mismatch between objective and subjective sleep parameters decreased early on during the implementation of CBT-I. Additionally, improvement of clinical symptoms was related to a decrease in sleep discrepancies across treatment. In the third study, we examined if there was a relationship between a biological marker of oxidative stress across CBT-I. Results showed that following CBT-I, the biological marker was related to both objective sleep parameters and self-reported symptom improvement. Overall, this thesis demonstrates that in our well-characterized sample of adults with insomnia disorder, group CBT-I was associated with significant post-group changes in cognitive, clinical, and biological factors. This has important implications for the factors that may influence an individual’s treatment response to CBT-I, and thus lead to improvements in tailoring treatments to optimize outcomes for treatment of insomnia disorder. / Dissertation / Doctor of Philosophy (PhD) / Insomnia disorder is a sleep disorder that negatively affects day-to-day-functioning and is associated with poorer mental and health outcomes. Cognitive Behavioural Therapy for insomnia (CBT-I) is an established psychological treatment that focuses on changing sleep behaviours and thinking patterns for improving sleep. This thesis aimed to examine factors that may be related to how CBT-I works to improve sleep with both self-reported and objective measures. We investigated whether cognition (e.g., memory and attention), different measures of sleep, clinical symptoms, and biological factors associated with sleep changed across treatment with CBT-I. Results indicated that several self-reported measures of cognition and sleep improved across CBT-I. Our findings suggest that these variables were related to improvements in sleep following CBT-I. By understanding what factors may be contributing to sleep difficulties and change across CBT-I, we can improve treatment outcomes and better adapt treatment strategies to those struggling with insomnia disorder.

Psychological distress is common during pregnancy. The objective of this thesis was to evaluate the effectiveness of antenatal cognitive behavioural based treatments in reducing psychological distress in pregnant women. A systematic review was undertaken of randomised controlled studies utilizing antenatal cognitive behavioural based treatment in reducing anxiety and stress compared to treatment as usual. Eleven papers were identified through a systematic search of databases using predefined criteria comparing intervention groups to treatment as usual in pregnant women with anxiety or stress. The systematic review revealed preliminary evidence for the effectiveness of cognitive behavioural based treatment with several studies noting changes over time in anxiety and stress; however, only a few studies reported intervention effects when compared to control. While the systematic review results suggest that a small number of cognitive behavioural based interventions may be effective in reducing anxiety and stress during pregnancy compared to treatment as usual, confidence in these findings is limited due to methodological limitations such as lack of follow-up, high attrition rates and difficulties with generalisability. The evidence base is currently insufficient and further research which utilises a robust methodology is needed before any reliable conclusions can be drawn. An empirical study was conducted to examine the effectiveness of a brief, single-session stress reduction programme introducing cognitive behavioural techniques aimed at reducing general anxiety, other pregnancy related distress and improving general well-being and pregnancy outcomes. Twenty-nine participants with clinically significant levels of anxiety were recruited to the empirical study from the local maternity hospital. Participants completed measures of general anxiety, pregnancy related anxiety, general well-being and childbirth experience. The control was derived from a historical dataset where 37 participants were matched for baseline anxiety levels. The empirical study demonstrated significant reductions in general anxiety; however, similar findings were also observed in the control group. Significant reductions were observed with pregnancy related anxiety and women also reported their childbirth experience similarly regardless of delivery type. Although our findings were not significant when compared to control, our recruitment design resulted in good return rates following birth. Further studies using sophisticated study design with use of robust control group are required.

Cognitive models of Social anxiety disorder (SAD) routinely discuss the cognitive biases (e.g., attentional, interpretation, memory) that contribute to thinking about oneself negatively before, during, and after social or performance situations. However, these models do not mention other impacts of negative self-evaluations - including negative evaluations of others - even though cognitive case formulations often include beliefs about oneself, others, the future, and the world. Importantly, CBT for SAD does not always lead to optimal subclinical symptoms at the end of treatment; suggesting that our most evidence-based treatments require modifications. Few studies have experimentally examined the presence of negative evaluations of others within social anxiety, which has led to inconsistent understanding about whether people with social anxiety demonstrate negative evaluations of others. These conflicting findings are even more complicated by no study examining if the negative self-evaluations that are commonly reported by people with SAD cause negative other-evaluations, and vice-versa. I outline two studies in this dissertation where I aimed to understand the relationship (or lack thereof) between negative self-evaluations and negative other-evaluations and its cognitive, behavioural, and emotional consequences. In Study 1, I randomly assigned an unselected sample (N = 152) to provide no-, medium-, or high-evaluations of a videotaped anxious person. Participants also took part in a 10- minute conversation task with a confederate posing as another participant. I measured social anxiety symptoms, state anxiety and electrodermal activity across four-time points, and several measures related to self- and other-evaluations. Overall, my manipulation was effective as participants responded to the subsequent other-evaluations in the way I anticipated. Despite this, I found no differences between conditions on most of my primary self-evaluation outcomes. However, I observed that participants in the high-evaluation condition demonstrated poorer memory recall. In Study 2, I randomly assigned an unselected sample (N = 169) to receive positive, ambiguous, or negative false-feedback following a conversation task with a confederate. My manipulation was effective, and again, I found no differences between conditions on my primary other-evaluation outcomes. Participants in the negative-feedback condition reported greater state anger following the negative evaluation for the remainder of the study, compared to participants in the other conditions. Ultimately, evaluations of others were less problematic than I initially expected. Because I did observe cognitive and emotional consequences of this self-other process, these findings could have important implications for further refinement of SAD models and treatments using Cognitive Behavioural Therapy.

The effectiveness of a Group CBT programme for Social Phobia was assessed using 18 participants recruited from a routine practice setting. Therapy was based on CBT techniques as practiced routinely by the clinical practice, and were not modified for the study by factors such as strict exclusion criteria and adherence to rigid manualised treatments. Pre- to post-treatment effect sizes compared favourably with those reported in a meta-analysis (Taylor, 1996). The findings provide support for the accessibility and effectiveness of group CBT techniques for Social Phobia in field settings. While some individuals within the sample experienced dramatic improvement, some remained severely impaired even at post-treatment. The results of Hierarchical Multiple Regressions indicated that lower levels of pre-treatment depression severity, higher levels of attendance, and greater homework compliance, were predictive of more improvement on some, but not all, measures of outcome. Implications for treatment are discussed.

Background: Psychological research has consistently demonstrated the importance of cognitions in the form of thoughts and images on an individual’s wellbeing. Having pain-related verbal cognitions has been shown to lead to poorer outcomes for patients (McCracken & Turk, 2002). Research in other conditions has shown mental images have a more powerful impact on emotion than verbal cognitions (Holmes & Matthews, 2005). To date however, little work has explored the role of mental imagery in adjustment to chronic pain. Methods Fourteen semi-structured interviews were conducted with individuals with chronic pain. Interview transcripts were analysed according to grounded theory methods to construct a substantive theory of the impact spontaneously-invoked images of pain have on functioning. Results Eight participants reported pain-related imagery and three reported mental images associated with related symptoms. In line with previous findings (Gillanders et al., 2012; Gosden, 2008) the frequency and intensity of pain-related images influenced the degree of distress experienced. There was a distinction made between intrusive mental images and visual descriptions or metaphors of pain. The former being conceptualised as a visual cognition and playing a role in the aetiology and maintenance of distress in chronic pain and therefore an adverse impact on functioning. Conclusion Enhancing our understanding of pain related imagery and its impact on functioning could inform the design of interventions in clinical practice. Working systematically with patients’ idiosyncratic pain related images and the beliefs that are associated with them could be a helpful specific target for therapy.

Past research indicates a causal relationship between emotional writing and health benefits (Smyth, 1998). At present, little is known about the mechanisms underlying change or if the emotional writing paradigm may be applied to a clinical setting. This present study reviewed current models of trauma and hypothesised three mechanisms of change leading to future health benefits: exposure, devaluation, and benefit-finding. Instructions for the standard writing paradigm were manipulated to isolate and increase engagement with each of these processes. It was hypothesised that if any one of these processes were to underlie health benefits, participants assigned to that condition would obtain more benefit than standard writing participants. Individual differences were also hypothesised to interact with each process to amplify or detract from their influence in leading to future benefit. A total of 201 university students were recruited from Griffith University. Participants were assigned to one of five writing conditions: Control, Standard, Exposure, Devaluation, and Benefit-Finding. Sessions were conducted once a week for three weeks. Physiological and self-report measures were taken before, during and after writing sessions. Follow-up assessments of psychological and physical health were taken at 2 and 6-months post-writing. Essay content analysis suggested that participants wrote in the instructed manner. Participants assigned to each of the groups experienced expected amounts of distress and affect changes. Overall, results failed to replicate the beneficial health effects for the standard emotional writing paradigm. There were no significant physical or psychological benefits for the standard trauma-writing participants in comparison to control. However, a trend in the appropriate direction was noted for illness visits at 6-months. Furthermore, in support of Greenberg and Stone's (1992) findings, standard writing participants who disclosed more severe and personal experiences evidenced significant illness visit reductions in comparison to control. Comparisons between standard and experimental trauma writing groups failed to support hypotheses that any one mechanism was responsible for physical health benefits. Examination of psychological self-report measures indicated exposure participants experienced the greatest reduction on the Impact of Events Scale at two months. However, these participants experienced greater reduction of positive affect and growth for the experience. They also became more anxious, depressed, and stressed at six-months follow-up. Process variables were examined within the exposure condition to explain these findings. Habituation was found to be strongly associated with the alternate outcomes. Individual differences. Including alexithymia, absorption, and negative affect, were also related to outcome. Benefit-finding participants experienced the greatest increase on a measure of post-traumatic growth at two-months and positive affect for the experience, but the finding was significant only in comparison to exposure and devaluation groups. The results of this study failed to identify the process of change, but suggest specific areas for future research. The findings demonstrate the importance of comprehensive health research to avoid blanket statements that suggest a paradigm either does or does not lead to health benefits. The results also support the manipulation of the writing paradigm to examine the role of emotion processing in trauma and health research.

The purpose of the current study was to develop a manualized treatment for fibromyalgia syndrome (FM) and to examine the efficacy of the treatment in a randomized controlled clinical trial. FM is a chronic musculoskeletal pain disorder characterized by tender points and generalized pain. Depression, chronic fatigue, and sleep disturbance are common. A biopsychosocial model served as a framework for understanding FM by integrating psychological, social, and physical factors. Cognitive-behavioural therapy (CBT), an empirically validated treatment for arthritis, has also been used with FM patients in an attempt to improve pain control, reduce disability, and increase self-efficacy. Overall, the attention/placebo controlled studies employing CBT as a treatment for FM show that it is not superior to a credible attention placebo. The current study attempted to combine the necessary components of CBT with interpersonal therapy to address relational patterns and personality characteristics that can affect ability to cope with chronic pain. One hundred and five women diagnosed with FM by a rheumatologist were randomly assigned to the CBT-interpersonal treatment condition or an attention-control condition. There were 8 treatment groups with a mean of 6-7 participants in each. The treatment consisted of weekly 2-hour sessions over 8 consecutive weeks. Outcome measures included: FM impact, pain, health care utilization, depression, coping, and self-efficacy. An intention-to-treat analysis was conducted. Results showed that the impact of FM symptoms was reduced following treatment compared to the control group and this was statistically and clinically significant, but was not maintained at 3-month follow-up. Significant improvements were also observed in coping strategies, some of which were maintained at follow-up. Importantly, self-efficacy improved significantly following treatment compared to the control group. Self-efficacy beliefs have been related to pain, coping efforts, disability, and psychological functioning. Directions for future research may include a focus on long-term maintenance of treatment gains that may be mediated by improvements in self-efficacy. There is strong evidence that changes in self-efficacy are enduring and affect changes in health behaviours and health status.

The purpose of the current study was to develop a manualized treatment for fibromyalgia syndrome (FM) and to examine the efficacy of the treatment in a randomized controlled clinical trial. FM is a chronic musculoskeletal pain disorder characterized by tender points and generalized pain. Depression, chronic fatigue, and sleep disturbance are common. A biopsychosocial model served as a framework for understanding FM by integrating psychological, social, and physical factors. Cognitive-behavioural therapy (CBT), an empirically validated treatment for arthritis, has also been used with FM patients in an attempt to improve pain control, reduce disability, and increase self-efficacy. Overall, the attention/placebo controlled studies employing CBT as a treatment for FM show that it is not superior to a credible attention placebo. The current study attempted to combine the necessary components of CBT with interpersonal therapy to address relational patterns and personality characteristics that can affect ability to cope with chronic pain. One hundred and five women diagnosed with FM by a rheumatologist were randomly assigned to the CBT-interpersonal treatment condition or an attention-control condition. There were 8 treatment groups with a mean of 6-7 participants in each. The treatment consisted of weekly 2-hour sessions over 8 consecutive weeks. Outcome measures included: FM impact, pain, health care utilization, depression, coping, and self-efficacy. An intention-to-treat analysis was conducted. Results showed that the impact of FM symptoms was reduced following treatment compared to the control group and this was statistically and clinically significant, but was not maintained at 3-month follow-up. Significant improvements were also observed in coping strategies, some of which were maintained at follow-up. Importantly, self-efficacy improved significantly following treatment compared to the control group. Self-efficacy beliefs have been related to pain, coping efforts, disability, and psychological functioning. Directions for future research may include a focus on long-term maintenance of treatment gains that may be mediated by improvements in self-efficacy. There is strong evidence that changes in self-efficacy are enduring and affect changes in health behaviours and health status.