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.

Background and Objectives: To characterize the impact of pregabalin on sleep in patients with generalized anxiety disorder (GAD) and to determine whether the impact is a direct or an indirect effect, mediated through the reduction of anxiety symptoms. Methods: A post-hoc analysis of data from a randomized, double-blind, placebo- and active-controlled study in patients with GAD was conducted. Patients received pregabalin 300 mg/day, venlafaxine XR 75 mg/day or placebo for a week, followed by pregabalin 300-600 mg/day, venlafaxine XR 75-225 mg/day, or placebo for 7 weeks. Treatment effect on sleep was evaluated using the Medical Outcomes Study Sleep Scale. Anxiety symptoms were assessed with the Hamilton Anxiety Rating Scale. A mediation model was used to estimate separately for both treatment arms the direct and indirect treatment effects on sleep disturbance. Results: Compared with placebo (n = 128), treatment with pregabalin (n = 121) significantly reduced scores on the sleep disturbance subscale and Sleep Problems Index II at both week 4 and week 8, and the sleep adequacy subscale at week 8. Venlafaxine XR (n = 125) had no significant effect on these measures. The mediation model indicated that 53% of the total pregabalin effect on sleep disturbance was direct (p < 0.01) and 47% indirect, mediated through anxiety symptoms (p < 0.05). Conclusions: Pregabalin decreased sleep disturbance in patients with GAD both directly, and indirectly by reducing anxiety symptoms. Given the drug specificity of the results, this study provides evidence of an additional important pathway of action for pregabalin and its efficacy in GAD.

Bakgrund: Sömnen har stor betydelse för återhämtning vid sjukdom och bevarande av god hälsa. Många gånger skiljer sig vårdmiljön från patienternas normala omvärld och möjligheten för inlagda patienter att påverka sin sovsituation är ofta liten. Syfte: Syftet med denna litteraturstudie var att belysa de faktorer som vuxna patienter upplever som störande för sömnen under sjukhusvistelsen. Metod: Litteraturstudien som genomfördes grundades på tolv utvalda vetenskapliga artiklar. Dessa artiklar granskades, analyserades och sammanställdes. Resultat: Studien visade att det fanns flera olika faktorer som patienterna upplevde som störande för sömnen under sjukhusvistelsen. Det visade sig även förekomma delade meningar kring hur mycket sömnen påverkats utav vistelsen på sjukhus. De faktorer som identifierades som störande för sömnen presenteras under följande kategorier: medicinska faktorer, omvårdnad &amp; sjuksköterske faktorer, omgivningsfaktorer och personliga faktorer. Slutsats: Denna studie visar att den verksamhet som bedrivs idag och de bestämmelser som styr vården bidrar till att patienter upplever svårigheter att sova under sjukhusvistelsen. Det hela tyder på att det är mycket som behöver förbättras i vården, men vården är ett komplext område att förändra. / Background: Sleep is very important for recovery during illness and the preservation of good health. The hospital environment is many times different from the patient’s normal world and the patients' ability to influence their sleep situation is often small. Aim: The aim of this study was to illustrate the factors that adult patients experiencing disruptive for their sleep during hospitalization. Methods: This literature study is based on twelve scholarly articles. These articles were reviewed, analyzed and summarized. Results: The study showed that there were several factors that patients experienced as disturbing for their sleep during hospitalization. It was also shown to be disagreement about how much the hospital stay influenced on the sleep. The factors that were identified in this study are presented under the following categories: medical factors, nursing care and nursing factors, environmental factors and personal factors. Conclusion: This study shows that the activity today and the rules governing the health care contribute to patients’ experience of difficulties to sleep during hospitalization. It all indicates that much improvement is needed in the health care, but it is a complex area to change.

The role of emotional regulation as a predictor for forthcoming sleep disturbances was investigated within the Prospective Investigations on Psychological Processes for Insomnia (PIPPI) study. Participants were classified to one of four sleep groups in accordance with a classification algorithm based on self report-data on nighttime symptoms, daytime symptoms, and sleep disorders other than insomnia. Measures of baseline emotional regulation were then examined as a predictor for follow-up sleep group affiliation. The results indicate that emotional regulation is a non-significant predictor of forthcoming sleep disturbances, also when individual sleep group-movements are controlled for. It is suggested that models on how sleep disturbances evolve are revised, that measures of emotional regulation are refined, and that a person oriented approach is adopted. / Betydelsen av emotionell reglering som prediktor för kommande sömnstörningar undersöktes inom projektet "Prospektiva undersökningar på psykologiska processer rörande insomni". Baserat på självrapporteringsdata för nattidssymptom, dagtidssymptom och andra sömnstörningar än insomni, klassificerades deltagarna till en av fyra sömngrupper i enlighet med en klassificeringsalgoritm. Baslinjedata för emotionell reglering undersöktes sedan som prediktor för sömngruppstillhörighet vid uppföljningsmätningen. Resultatet indikerar att emotionell reglering inte är en signifikant prediktor för kommande sömnstörningar, detta även när individuella förflyttningar mellan sömngrupper tas i beaktande. Det föreslås att modeller för hur sömnstörningar utvecklas revideras, att mått för emotionell reglering förfinas samt att en personorienterad ansats antas.

Introduction: Mucosal human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) and is associated with genitals warts, anogenital cancers, and oropharyngeal cancers. Most sexually active persons will become infected with HPV at some point in their lives, however few will develop HPV-related diseases such as warts, lesions, or cancer as a result of the infection. It is unclear why a minority of individuals fail to clear HPV infection and develop clinical disease. Due to initial associations with cervical lesions, much research has focused on women. Th1 type immune responses have been associated with successful response to HPV infection. Factors such as psychological stress and sleep have been associated with immune function. Stress has been associated with cervical lesions, however no study has evaluated effects of stress or sleep on HPV infection. This research sought to examine the associations between perceived stress and sleep problems with HPV prevalence, incidence, and clearance among men. Methods: Men were tested for 37 individual HPV genotypes every 6 months as part of a large natural history study. A total of 426 men were followed over 1 to 4 visits. Perceived stress was measured with a modified 4-item Perceived Stress Scale (PSS-4) assessing stress in the past six months and was dichotomized into high (scores in the 4th quartile) and low perceived stress. Self-reported sleep problems were measured by seven likert-scale items and categorized as high (4th quartile of sleep problems scores), moderate (second and third quartiles; reference group), and low (first quartile). Three HPV classifications were examined; men were categorized as positive for 'Any HPV' if they tested positive for any of the 37 HPV genotypes in the study protocol, men were categorized as positive for 'Oncogenic HPV' if they tested positive for any oncogenic HPV type, and men were categorized as positive for 'Non-oncogenic HPV' if they tested positive for any non-oncogenic HPV genotype. In the prevalence analysis, men who had no detectable HPV infection with any of the 37 types were the reference group in all analyses. Prevalence ratios and 95% confidence intervals (95% CI) were calculated using Poisson regression with robust variance. For HPV clearance and incidence, Cox regression with the robust sandwich estimator was used to calculated hazard ratios and 95% confidence intervals. Results: A total of 424 men had genotyping results available for the prevalence analysis. High perceived stress was significantly associated with higher prevalence of any HPV infection [PR =1.33 (95% CI: 1.06-1.68)] and oncogenic HPV infection [PR=1.53 (95% CI: 1.06-2.20)], adjusting for demographics, sexual behavior, and sleep problems. High self-reported sleep problems was significantly associated with higher prevalence of oncogenic HPV infection [PR=1.50 (95% CI:1.01-2.13)], adjusting for demographics, sexual behavior, and perceived stress. Perceived stress and self-reported sleep problems were not associated with incidence of HPV infection. Perceived stress was not significantly associated with clearance of HPV infection overall. Among men 50 and older however, men with high stress were significantly less likely to clear any HPV infection than those with low stress adjusting for demographics, HR=0.09 (95% CI: 0.02-0.49). Compared to men with moderate sleep problems, those with high sleep problems were significantly less likely to clear an infection with any HPV type, HR=0.68 (95% CI: 0.49-0.94), or an oncogenic HPV type, HR=0.51 (95% CI: 0.28-0.94), after adjustment for demographics and perceived stress. Discussion: This is the first study to examine associations between HPV infection with perceived stress and self-reported sleep problems. It is also the largest study to examine associations between these exposures and an infection outcome. Results suggest that perceived stress and self-reported sleep problems have independent effects on HPV. Evaluation of perceived stress, biological indicators of stress, objective measures of sleep, and measurement of immune parameters may aid in further elucidating how stress and sleep disturbance are related to HPV infection. Determination of modifiable factors that can influence HPV infection may aid in the prevention of adverse disease outcomes related to infection with this virus. Examining the impact of factors such as perceived stress and sleep problems on HPV infection may aid in risk stratification of patients and allow more targeted interventions among those most at risk for developing disease.

Establishing healthy sleep-wake patterns early in infancy is vitally important as sleep problems can persist. Behavioural sleep interventions such as the parental presence procedure are well established and have been found to improve infant sleep as determined by parent report. The exact nature of this improvement is, however, unclear. Sleep consolidation, sleep-state organisation, and self-soothing are thought likely to change after intervention; however, no known research has comprehensively determined which of these variables change as infant sleep changes in response to intervention. Three participants aged between 7 to 11 months who met the criteria for Infant Sleep Disturbance (ISD) were referred by a Health Centre and the parental presence behavioural sleep intervention was implemented. Parental report and videosomonography (VSG) data were used to measure sleep before and after intervention. While parental report is limited in that parents can only report what they can hear and/or see, VSG offers a tool that can be used to measure sleep-state organisation, state changes, and periods when the infant is awake and quiet. The present research found that infants’ sleep became more consolidated resulting in fewer sleep-wake transitions and night wakings. Infants who had difficulties initiating sleep on their own also demonstrated decrease in Sleep Onset Delay (SOD). Furthermore, infants were found to sleep through a greater number of sleep-state transitions and sleep for a greater duration of time before waking. Collectively this research provides some evidence that changing parental behaviours to those that promote self-initiation through self-soothing and consistency, can change sleep-state organisation and improve self-soothing.

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.

xiv, 111 p. A print copy of this title is available through the UO Libraries. Search the library catalog for the location and call number. / Sleep studies have rarely explored individual differences in sleep disruption and associated outcomes at early ages. In two studies, this dissertation addresses both of these limitations using actigraphy, an activity-derived assessment of sleep, to increase understanding of negative impacts of sleep on early development. Study 1 investigated sleep disruption in foster children and sleep-related treatment outcomes of the Multidimensional Treatment Foster Care for Preschoolers (MTFC-P) intervention program. Study 2 explored individual differences in the associations among sleep, children's behavior, and neurohormonal activity. Four groups of participants ages 3- to 7-years-old were included in both studies: (1) Regular foster care (RFC; n=15); (2) MTFC-P intervention (TFC; n= 17); (3) Low-income community (LIC; n= 18); and 4. Middle-income community (MIC; n=29). Results of Study 1 indicated greater sleep disruption in foster groups, as evidenced by longer sleep latencies and increased variability of sleep duration, in the TFC group than in community groups. There was also indication of a treatment effect as the TFC group slept longer than RFC and LIC groups and had earlier bedtimes, fell asleep earlier, and spent more time in bed than either community group. LIC children had marginally more active sleep than MIC children, indicating a possible role for socioeconomic status in sleep quality. In Study 2, correlational and causal modeling approaches were used to investigate associations among sleep disruption, problem behaviors, and diurnal cortisol. Influences of foster care placement, gender, and age were also examined as potential individual difference factors. Results of mixed linear autoregressive models indicated that children were more likely to display inattentive/hyperactive behaviors after shortened sleep durations. Furthermore, at lower sleep durations, differences among care groups and genders emerged as children in foster care and males were at heightened risk for inattentive/hyperactive behavior problems. No associations between sleep and disruptive problem behaviors were found and there were few associations with morning and evening cortisol values. Results of these studies are discussed in terms of the effectiveness of the MTFC-P program for addressing sleep problems in foster children. Additionally, clinical implications of the heightened likelihood of inattentive/hyperactive behavior problems after disrupted sleep in some children are discussed. / Adviser: Phil Fisher

abstract: Those who have borderline personality disorder (BPD), and those who have subclinical levels of BPD features, experience distress and impairment in important life domains, especially in their interpersonal interactions. It is critical to understand the factors that alleviate BPD symptoms in order to help affected individuals lead healthier lives. Rejection sensitivity and sleep disturbance are two factors that may maintain or exacerbate BPD symptoms, yet new research indicates socially supportive relationships are related to symptom remission. While extensive research exists on the interpersonal impairments associated with borderline personality pathology, little research exists on how individuals with BPD or BPD features perceive and experience their social support. The present study examined the relationships between BPD features, perceived social support, sleep quality, and rejection sensitivity in a racially diverse, large sample of primarily college-aged individuals (N = 396). Results indicated that BPD features had a significant positive relationship with self-reported rejection sensitivity and a significant negative relationship with self-reported perceived social support. Additionally, BPD features had a significant positive relationship with sleep disturbance. Sleep disturbance did not moderate the relationship between BPD features and rejection sensitivity as expected; however, the regression of rejection sensitivity on BPD features and sleep disturbance was significant. Finally, sleep disturbance moderated the relationship between BPD features and rejection sensitivity. Results extend and replicate recent research findings on the possible mechanisms that may maintain and alleviate BPD symptoms. Furthermore, the moderating effect of sleep disturbance on perceived social support for those with higher levels of BPD features is unique to this study. / Dissertation/Thesis / Masters Thesis Counseling Psychology 2016

Posttraumatic Stress Disorder (PTSD) is a prevalent anxiety disorder that is debilitating to both veterans and civilians following one or more traumatic events. Sleep disturbances are hallmark features of PTSD. Sleep disturbances and PTSD remain two significant PTSD-related issues that continue to plague veterans returning from active duty, thereby preventing full reintegration into society. The same problem exists for civilians. This research was conducted as a previously collected pilot study data and a secondary data analysis. The purpose of the study consisted of: 1) examining the impact of treatment with Accelerated Resolution Therapy (ART) on symptoms of PTSD and sleep disturbances; 2) examining the relationships and treatment response among both subjective and objective measures of sleep function; and 3) comparing the relationship between PTSD and sleep disturbances among military versus civilians, including the effects of treatment with ART. The study represents one of only a few studies consisting of subjective measures of PTSD (PCL checklist) and sleep quality (Pittsburgh Quality Sleep Index (PSQI)), and objective measurement of sleep function by use of electroencephalography (EEG) testing and based on a 30-minute nap protocol. The aims of this study were to: 1) investigate the effects of ART on comorbid PTSD and sleep disturbances in U.S. veterans measured both subjectively (self-report) and objectively (sleep EEG data) from previously collected pilot study data; 2) assess the relationships between objective and subjective measures of sleep disturbances before and after treatment with ART for symptoms of PTSD in U.S. veterans from previously collected pilot study data; and 3) compare self-report PTSD and sleep disturbances symptoms between civilians and veterans before and after treatment with ART using a secondary analysis from two previously conducted studies. For Specific Aims 1 and 2, the methods consisted of previously collected pilot study data of 8 veterans who were treated with ART at the University of South Florida, College of Nursing. For Specific Aim 3, data were pooled from two completed studies of ART directed by Dr. Kevin Kip that included civilians (n=75) and veterans (n=50) who were treated for PTSD. Data analysis for Aim 1 included the use of paired t tests to compare PSQI score and each stage of sleep measured from qEEG (Delta, Theta, Alpha, Beta, Gamma) before and after treatment with ART. For Aim 2, Pearson correlation was used to assess the relationship between objective measurement of sleep disturbances and subjective sleep quality before and after ART. For Aim 3, multiple linear regression models were fit with PSQI (sleep) score as the dependent variable, PCL (PTSD) score as the primary independent variable, along with a main effect term for military status (civilian versus military) and an interaction term (military status * PCL score). Results for aims 1 and 2 showed the mean age of the sample to be 37.6 years, 87.5% male, 87.5% White (non-Hispanic), 87.5% had experienced prior combat, 50% had experienced 5 or more traumatic memories that impacted their lives, and 87.5% had previous treatment for PTSD. Sample mean scores were above established screening criteria for PTSD (PCL-M = 63.7), sleep disturbance (PSQI = 14.5), and Center for Epidemiologic Studies Depression Scale (CES-D = 28.9). For Aim 1, after treatment with ART, the mean score on the PSQI dropped 4.88 points, mean score on the PCL-M dropped -30.13 points, thereby indicating significant reductions in sleep dysfunction and symptoms of PTSD. Mean Delta 1.5-3.5 Hz waves increased pre/post by 299.89 (p=.032), and Theta 4-6.5 Hz waves increased pre/post mean by 83.07 (p<0.001), both indicative of improved sleep quality. Results for Aim 2 showed statistically significant strong inverse correlations between PSQI and Theta 1.5-3.5 Hz waves (r=-0.79) and PSQI and Alpha 8-11 Hz waves (r=-0.89) at baseline. Post-ART, non-significant trends were observed for higher PSQI scores and higher Beta (conscious, alert) waves. For Aim 3, mean age of military participants (n=50) was 41.9 years versus 40.4 years among civilians (n=75, p=.439). For the military cohort, 18% were female compared to 80% among civilians (p<0.001), with lower Hispanic ethnicity among military compared to civilian participants (12% vs. 27%, p=0.04). In multiple regression analysis, change in PCL score was a strong predictor of change in PSQI score, regardless of military status PCL. In summary, within the setting of PTSD, military participants tend to present with different traumatic exposures and worse sleep quality compared to civilian counterparts. In spite of these differences, the treatment protocol with ART demonstrated similar level of benefit (reduction in symptoms of PTSD and sleep disturbance) for both military and civilian personnel. Thus, nurses caring for individuals with PTSD, whether military or civilian, need to routinely assess sleep disturbances and initiate an open dialogue regarding these conditions. In return, nurses will be able to provide patients with resources to help them better understand and address these concerns, including after experiencing restless nights of sleep. Lastly, nurses should recognize the bi-directional temporal relationship between PTSD and sleep disturbances places. This places a premium on assessing these conditions collectively, rather than as discrete, independent clinical conditions.