Insomnia is recognized as one of the most common sleep complaints accompanied by daytime consequences in the general population worldwide. In recent years, the use of self-help cognitive behavioral therapy (CBT) has become a popular treatment option for insomnia. Firstly, a systematic review was conducted as an update and extension of a previous review (van Straten & Cuijpers, 2009). Two researchers systematically searched 6 major electronic databases in June 2012. We independently selected relevant publications, extracted data, and evaluated methodological quality according to the Cochrane criteria. Meta-analyses of self-help CBT vs. waiting-list (WL), routine care or no treatment, therapist-administered CBT, and placebo were performed. Twenty randomized controlled trials were included; 10 of which were recent publications. Results showed that self-help CBT improved sleep, sleep-related cognitions, and anxiety and depressive symptoms. Effect sizes for sleep diary-derived sleep efficiency (SE), sleep onset latency (SOL), and wake after sleep onset (WASO) at immediate posttreatment were 0.80, 0.66, and 0.55, respectively. The average attrition rate of self-help CBT at immediate posttreatment was 15.6%. Therapist-administered CBT was significantly more effective than self-help CBT. Subgroup analyses supported the inclusion of telephone consultation, but not “full” multi-component CBT and programs  6 weeks. In conclusion, self-help CBT is efficacious and acceptable as an entry level of a stepped-care model for insomnia. In places where face-to-face treatments are unavailable or too costly, self-help CBT can be considered as an adequate compromise. Secondly, a randomized controlled trial was conducted to evaluate the efficacy of an Internet-based cognitive behavioral therapy for insomnia (CBT-I) in Chinese insomnia population with or without medical and psychiatric comorbidities. Three hundred and twelve eligible participants were randomized to self-help CBT with telephone support (SHS), self-help CBT without telephone support (SH), and WL groups in a ratio of 1:1:1. Participants in the SHS and SH groups received self-help treatment once per week for 6 consecutive weeks, whereas participants in the WL group began treatment after 12 weeks of assessment. In addition to the standard self-help treatment, the participants in the SHS group received weekly brief therapist-administered telephone support. The Internet-based CBT-I showed significant improvements in insomnia symptoms and sleep-related dysfunctional cognitions. Improvement was further enhanced by weekly brief telephone support. The results suggested that Internet-based CBT-I is effective and acceptable to treat insomnia. / published_or_final_version / Psychiatry / Master / Master of Philosophy

published_or_final_version / Psychiatry / Doctoral / Doctor of Philosophy

Comorbid chronic insomnia was found highly prevalent in breast cancer patients. It also persisted through survivorship. Negative emotions upon diagnosis and during the course of cancer treatment might complicate the underlying mediating factors between stress and insomnia found in non-cancer population. Cognitive Behavioural Therapy (CBT) has been evidenced in improving insomnia. With the appreciation of Mindfulness training in improving cognitive flexibility and rumination, a novel treatment approach integrating CBT and mindfulness—Mind-Body Intervention (MBI) was developed. 　　　There were three objectives in the research. Firstly, prevalence data on insomnia and clinical profile of Hong Kong Chinese breast cancer survivors were obtained. Secondly, the mediating roles of negative emotions, hyperarousal, pre-sleep arousals in the relationship between perceived stress and insomnia were examined. Thirdly, the effects of CBT and MBI for breast cancer survivors with insomnia were investigated. 　　　In the first study, 1049 women who survived from non-metastatic breast cancer were invited to complete a survey on stress, mental health, arousals and insomnia. Those who met psychophysiological insomnia were invited to participate in the second study, which was a multisite randomized controlled trial. The 73 participants were allocated to CBT (n=24), MBI (n=27) or waiting list control, WLC (n=22). Both treatments were five weekly-session group therapies. Outcomes on insomnia, mental health, arousals, dysfunctional beliefs, quality of life and mindfulness, were obtained on baseline, post-treatment, 3-month and 6-month follow-ups. 　　　Results of the first study revealed 34.6% of the participants suffered from clinical insomnia, while 15.1%, 27.4% and 12.8% endorsed moderate to extremely severe depression, anxiety and stress respectively. Duration of insomnia was correlated with insomnia severity. Hyperarousal was found moderating cognitive ore-sleep arousal and anxiety, these in turn, together with depression mediated the relationship between perceived stress and insomnia severity. Results of the second study supported the hypothesis both CBT and MBI improved insomnia and other psychological symptoms, while WLC did not. After treatment, significant decreases of 59 and 67 minutes of total wake time per night were found for CBT and MBI respectively. Sleep efficiency values significantly increased in CBT (12.2%) and MBI (12.7%). Moderate to large effect sizes and clinically significant differences were found in most sleep and psychological variables. Generally, CBT produced larger effect sizes than MBI on post-treatment. The therapeutic gains were found sustaining through 3-month to 6-month follow-ups in both treatments. However, the effect sizes of CBT were on the declining trend, while those of MBI were more stable. 　　　The results suggested that insomnia and anxiety were frequently experienced in breast cancer even after completing the medical treatments. The longer the survivors suffered from insomnia, the higher the severity was found. In additional to the cognitive pre-sleep arousal, the important mediating roles of depression and anxiety imply that insomnia treatments should incorporate strategies designed to help in decreasing rumination/worry before bedtime and improving mental health conditions. The findings also provided initial evidence for the efficacy of MBI as a viable treatment for insomnia. More vigorous randomized controlled trial and the long-term efficacy could be further studied. / published_or_final_version / Clinical Psychology / Doctoral / Doctor of Psychology

Accurate assessment of sleep-wake patterns is important for sleep researchers and clinicians. Actigraphs are low-cost, non-intrusive, wrist-worn activity detectors used to estimate sleep-wake patterns in a natural environment for several nights. Although actigraphy shows good sensitivity (sleep detection), it has consistently demonstrated poor specificity (wakefulness detection while lying in bed relatively motionless). Because insomnia is characterized by wakefulness in bed, actigraphy may not be a valid objective measure of wakefulness for this group. It is possible that refinement of actigraphy software settings for sleep/wake algorithms might improve specificity. The current studies investigated this hypothesis by comparing wake parameters from 48 combinations of actigraphy settings to determine which sleep/wake algorithms best inform insomnia diagnosis and treatment. In the first study, none of the 48 actigraphy setting combinations consistently discriminated between adults with insomnia (n = 69) and non-insomnia (n = 80) on all three wake parameters, and no setting clearly discriminated between groups for the composite variable, total wake time. Similarly, in the second study, no setting combinations consistently discriminated between adults treated for insomnia (n = 18) and controls with untreated insomnia (n = 26) on all three wake parameters. Although two setting combinations discriminated between groups for the composite variable, total wake time, the values were extreme which raises validity concerns. Therefore, no actigraphy setting recommendations can be made based on the current findings. This research offers insights about the effects of actigraphy software settings on actigraphy specificity as it pertains to the diagnosis and treatment of insomnia.

Traditional treatment for insomnia has been chemotherapy-- despite short-term value and side effects. Need for an alternative has led to research on behavioral treatment methods for insomnia. Relaxation training has consistently produced effective results, but the limited research on biofeedback and stimulus control suggests that they too may be viable alternate treatment methods. The present research investigated electromyogram (EMG) biofeedback, pseudo-EMG biofeedback, relaxation, training, and stimulus control as methods of treating sleep-onset insomnia. Volunteers consisting of 12 males and 24 females were recruited through newspaper advertisements. Subjects had no known physical cause for insomnia and were either free of sleeping medication or kept their dosage constant during the study. Subjects were matched for age and sex, randomly assigned to one of the four treatment groups, then randomly assigned to one of three therapists. Results indicated that pretreatment EMG scores for the four groups were high but not significantly different-- while post treatment EMG scores were not significantly reduced. Pretreatment sleep-latency measures were high, but not significantly different from each other. Post treatment latency measures were significantly reduced, but not significantly different from each other. Correlation between EMG-change scores and sleep-latency-change measures was non-significant. Pretreatment nightly awakenings for the four groups were not significantly different. Post treatment awakenings for the four groups were significantly reduced, but not significantly different from each other. There were not significant interactions for therapist or treatment with any of the dependent variables.