Abstract
Sleep dysfunction is a pervasive issue in schizophrenia and psychosis. Current knowledge is drawn almost exclusively from studies using quantitative research methodologies that include measures and tools developed in healthy population groups. Qualitative studies investigating the first-person perspectives of sleep problems are therefore important for designing better assessment and treatment tools to meet consumer needs. Focus groups were conducted to elicit detailed information regarding the personal experience of sleep problems, their antecedents and impact, in 14 individuals with schizophrenia-spectrum disorder who experienced insomnia during their illness. Thematic analysis was applied to examine the data and draw treatment implications for sleep management. Insomnia was ubiquitous and frequently co-occurred with other sleep difficulties (nightmares, sleep walking, acting out dreams, etc.) in this group. Discussions revealed themes common across insomnia populations (role of negative mood states and cognitive intrusions) and also new themes on factors contributing to sleep problems in schizophrenia: (1) beliefs that sleep problems cannot be changed; (2) trauma and adversity; (3) lifestyle choices and lack of motivation; and (4) medication side effects. Sleep problems also had profound impact on daytime dysfunctions and disability. The findings point to novel issues that may benefit from consideration in the treatment of sleep problems in schizophrenia. Unhelpful cognitions and behaviours about sleep can be addressed with psychological interventions, activity scheduling and motivational interviewing techniques. Seeking a first-person perspective is vital for identifying issues that will impact on treatment success and recovery.
Similar content being viewed by others
References
Palmese LB, DeGeorge PC, Ratliff JC, Srihari VH, Wexler BE, Krystal AD, et al.: Insomnia is frequent in schizophrenia and associated with night eating and obesity. Schizophrenia Research 133(1–3):238–243, 2011. doi:10.1016/j.schres.2011.07.030
Martin J, Jeste DV, Caliguiri MP, Patterson T, Heaton R, Ancoli-Israel S: Actigraphic estimates of circadian rhythms and sleep/wake in older schizophrenia patients. Schizophrenia Research 47(1):77–86, 2001. doi:10.1016/S0920-9964(00)00029-3
Afonso P, Figueira ML, Paiva T: Sleep–wake patterns in schizophrenia patients compared to healthy controls. The World Journal of Biological Psychiatry 15(7):517–524, 2014. doi:10.3109/15622975.2012.756987
Iyer SN, Boekestyn L, Cassidy CM, King S, Joober R, Malla AK: Signs and symptoms in the pre-psychotic phase: Description and implications for diagnostic trajectories. Psychological Medicine 38(08):1147–1156, 2008. doi:10.1017/S0033291708003152
Monti JM, BaHammam AS, Pandi-Perumal SR, Bromundt V, Spence DW, Cardinali DP, et al.: Sleep and circadian rhythm dysregulation in schizophrenia. Progress in Neuro-Psychopharmacology and Biological Psychiatry 43(0):209–216, 2013. doi:10.1016/j.pnpbp.2012.12.021
Bromundt V, Köster M, Georgiev-Kill A, Opwis K, Wirz-Justice A, Stoppe G, et al.: Sleep-wake cycles and cognitive functioning in schizophrenia. British Journal of Psychiatry 198:269–276, 2011. doi:10.1192/bjp.bp.110.078022
Hofstetter JR, Mayeda A: Sleep and Quality of Life in Schizophrenia. In: Verster JC, Pandi-Perumal SR, Streiner DL (Eds): Sleep and Quality of Life in Clinical Medicine. Totowa, NJ, Humana Press, pp. 299–311, 2008
Hofstetter JR, Lysaker PH, Mayeda AR: Quality of sleep in patients with schizophrenia is associated with quality of life and coping. Bio Med Central Psychiatry 5:13–17, 2005. doi:10.1186/1471-244X-5-13
Holmes EP, Corrigan PW, Knight S, Flaxman J: Development of a sleep management program for people with severe mental illness. Psychiatric Rehabilitation Journal 19(2):9–15, 1995. doi:10.1037/h0095445
Lester H, Tait L, England E, Tritter J: Patient involvement in primary care mental health: A focus group study. British Journal of General Practice 56(527):415–422, 2006
Byrne R, Davies L, Morrison AP: Priorities and preferences for the outcomes of treatment of psychosis: A service user perspective. Psychosis 2(3):210–217, 2010. doi:10.1080/17522430903456913
Espie CA: “Stepped care”: A health technology solution for delivering cognitive behavioural therapy as a first line insomnia treatment. Sleep 32(12):1549–1558, 2009
Myers E, Startup H, Freeman D: Cognitive behavioural treatment of insomnia in individuals with persistent persecutory delusions: a pilot trial. Journal of Behavior Therapy and Experimental Psychiatry 42:330–336, 2011. doi:10.1016/j.jbtep.2011.02.004
Wagley JN, Rybarczyk B, Nay WT, Danish S, Lund HG: Effectiveness of Abbreviated CBT for insomnia in psychiatric outpatients: Sleep and depression outcomes. Journal of Clinical Psychology 69(10):1043–1055, 2013. doi:10.1002/jclp.21927
Waters F, Chiu V, Janca S, Atkinson A, Ree M: Preferences for different insomnia treatment options in people with schizophrenia and related psychoses: A qualitative study. Frontiers in Psychology, 2015. doi:10.3389/fpsyg.2015.00990
Chiu VW, Harvey RH, Sloan NB, Ree M, Lin A, Janca A, et al.: Cognitive and behavioral factors associated with insomnia in inpatients with schizophrenia and related psychoses. The Journal of Nervous and Mental Disease 203(10):798–803, 2015. doi:10.1097/nmd.0000000000000370
Lyne J, Quinlivan L, Byrne CA, Malone K, Walsh C: Sleep hygiene use in a psychiatry outpatient setting. Irish Medical Journal 104(2):49–50, 2011
Morgan DL, Krueger RA, King J: The Focus Group Kit, Vol. 1–6 The focus group kit, Thousand Oaks, 1998
Krueger RA, Casey MA: Focus Groups: A Practical Guide for Applied Research. 3rd edn. Thousand Oaks, CA, Sage Publications, Inc, 2000
Wreally Studios: Transcribe. 2014
Braun V, Clarke V: Using thematic analysis in psychology. Qualitative Research in Psychology 3(2):77–101, 2006. doi:10.1191/1478088706qp063oa
Vogt DS, King DW, King LA: Focus groups in psychological assessment: enhancing content validity by consulting members of the target population. Psychological Assessment 16(3):231–243, 2004. doi:10.1037/1040-3590.16.3.231
Mume CO: Nightmare in schizophrenic and depressed patients. The European Journal of Psychiatry 23(3):177–183, 2009
Sjöström N, Waern M, Hetta J: Nightmares and sleep disturbances in relation to suicidality in suicide attempters. Sleep 30(1):91–95, 2007
Jansson M, Linton SJ: Psychological mechanisms in the maintenance of insomnia: Arousal, distress, and sleep-related beliefs. Behaviour Research and Therapy 45(3):511–521, 2007. doi:10.1016/j.brat.2006.04.003
Schmidt RE, Harvey AG, Van der Linden M: Cognitive and affective control in insomnia. Frontiers in Psychology 2(349):1–12, 2011. doi:10.3389/fpsyg.2011.00349
Takano K, Sakamoto S, Tanno Y: Repetitive thought impairs sleep quality: An experience sampling study. Behavior Therapy 45(1):67–82, 2014. doi:10.1016/j.beth.2013.09.004
Harvey AG, Bélanger L, Talbot L, Eidelman P, Beaulieu-Bonneau S, Fortier-Brochu É, et al.: Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal of Consulting and Clinical Psychology 82(4):670–683, 2014. doi:10.1037/a0036606
Morrison AP, Wells A: A comparison of metacognitions in patients with hallucinations, delusions, panic disorder, and non-patient controls. Behaviour Research and Therapy 41(2):251—256, 2003. doi:10.1016/S0005-7967(02)00095-5
Morrison AP, Frame L, Larkin W: Relationships between trauma and psychosis: A review and integration. British Journal of Clinical Psychology 42(4):331–353, 2003. doi:10.1348/014466503322528892
Lunsford-Avery JR, Mittal VA: Sleep dysfunction prior to the onset of schizophrenia: A review and neurodevelopmental diathesis–stress conceptualization. Clinical Psychology: Science and Practice 20(3):291–320, 2013. doi:10.1111/cpsp.12041
Carey K, Purnine D, Maisto S, Carey M, Barnes K: Decisional balance regarding substance use among persons with schizophrenia. Community Mental Health J 35(4):289–299, 1999. doi:10.1023/A:1018705722246
Takaesu Y, Komada Y, Asaoka S, Kagimura T, Inoue Y: Factors associated with long-term use of hypnotics among patients with chronic insomnia. PLoS One. 9(11):e113753, 2014. doi:10.1371/journal.pone.0113753
Holbrook AM, Crowther R, Lotter A, Cheng C, King D: Meta-analysis of benzodiazepine use in the treatment of insomnia. Canadian Medical Association Journal 162(2):225–233, 2000
Barker M, Greenwood K, Jackson M, Crowe S: Cognitive effects of long-term benzodiazepine use. CNS Drugs 18(1):37–48, 2004. doi:10.2165/00023210-200418010-00004
Cates M, Jackson C, Feldman J, Stimmel A, Woolley T: Metabolic consequences of using low-dose quetiapine for insomnia in psychiatric patients. Community Mental Health J 45(4):251–254, 2009. doi:10.1007/s10597-009-9200-0
Evert H, Harvey C, Trauer T, Herrman H: The relationship between social networks and occupational and self-care functioning in people with psychosis. Soc Psychiatry Psychiatr Epidemiol 38(4):180–188, 2003. doi:10.1007/s00127-003-0617-4
Mason M: Sample size and saturation in PhD studies using qualitative interviews. forum qualitative sozialforschung/forum. Qualitative Social Research 11(3):3, 2010
Vincent N, Sande G, Read C, Giannuzzi T: Sleep locus of control: Report on a new scale. Behavioral Sleep Medicine 2(2):79–93, 2004. doi:10.1207/s15402010bsm0202_1
Edinger JD, Wohlgemuth WK: Psychometric comparisons of the standard and abbreviated DBAS-10 versions of the dysfunctional beliefs and attitudes about sleep questionnaire. Sleep Medicine 2(6):493–500, 2001. doi:10.1016/S1389-9457(01)00078-8
Morin CM, Vallières A, Ivers H: Dysfunctional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16). Sleep 30(11):1547, 2007
Espie CA, Inglis SJ, Harvey L, Tessier S: Insomniacs’ attributions: psychometric properties of the dysfunctional beliefs and attitudes about sleep scale and the sleep disturbance questionnaire. Journal of Psychosomatic Research 48(2):141–148, 2000. doi:10.1016/S0022-3999(99)00090-2
Ree MJ, Harvey AG, Blake R, Tang NKY, Shawe-Taylor M: Attempts to control unwanted thoughts in the night: Development of the thought control questionnaire-insomnia revised (TCQI-R). Behaviour Research and Therapy 43:985–998, 2005. doi:10.1016/j.brat.2004.07.003
Ellis J, Mitchell K, Hogh H: Sleep preoccupation in poor sleepers: Psychometric properties of the sleep Preoccupation Scale. Journal of Psychosomatic Research 63(6):579–585, 2007. doi:10.1016/j.jpsychores.2007.07.011
Agargun M, Kara H, Bilici M, Cilli AS, Telci M, Semiz UB: The Van Dream Anxiety Scale: A subjective measure of dream anxiety in nightmare sufferers. Sleep Hypn 4:204–211, 1999
Pruiksma KE, Taylor DJ, Ruggero C, Boals A, Davis JL, Cranston C, et al.: A psychometric study of the fear of sleep inventory-short form (FoSI-SF). Journal of Clinical Sleep Medicine 10(5):551–558, 2014. doi:10.5664/jcsm.3710
Marshall AJ, Acheson DT, Risbrough VB, Straus LD, Drummond SPA: A psychometric study of the fear of sleep inventory-short form (FoSI-SF). The Journal of Neuroscience 34(35):11754–11760, 2014. doi:10.1523/jneurosci.0478-14.2014
Krakow B, Zadra A: Imagery rehearsal therapy: Principles and practice. Sleep Medicine Clinics 5(2):289–298, . 2010. doi:10.1016/j.jsmc.2010.01.004
Mastin D, Bryson J, Corwyn R: Assessment of sleep hygiene using the sleep hygiene index. J Behav Med 29(3):223–227, 2006. doi:10.1007/s10865-006-9047-6
Adan ANA, Fabbri M, Natale V, Prat G: Sleep beliefs scale (SBS) and circadian typology. Journal of Sleep Research 15(2):125–132, 2006. doi:10.1111/j.1365-2869.2006.00509.x
Fehnel SE, Bann CM, Hogue SL, Kwong WJ, Mahajan SS: The development and psychometric evaluation of the motivation and energy inventory (MEI). Quality of Life Research 13(7):1321–1336, 2004. doi:10.1023/B:QURE.0000037502.64077.4d
Mendoza TR, Wang XS, Cleeland CS, Morrissey M, Johnson BA, Wendt JK, et al.: The rapid assessment of fatigue severity in cancer patients. Cancer 85(5):1186–1196, 1999. doi:10.1002/(SICI)1097-0142(19990301)85
Johns MW: A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep 14(6):540–545, 1991
Maldonado CC, Bentley AJ, Mitchell D: A pictorial sleepiness scale based on cartoon faces. Sleep 27(3):541–550, 2004
Owens JA, Spirito A, McGuinn M, Nobile C:. Sleep Habits and Sleep Disturbance in Elementary School-Aged Children. Journal of Developmental & Behavioral Pediatrics 21(1):27–36, 2000
Dolan DC, Taylor DJ, Okonkwo R, Becker PM, Jamieson AO, Schmidt-Nowara W, et al.: The time of day sleepiness scale to assess differential levels of sleepiness across the day. Journal of Psychosomatic Research 67(2):127–133, 2009. doi:10.1016/j.jpsychores.2009.03.014
Lee KA, Hicks G, Nino-Murcia G: Validity and reliability of a scale to assess fatigue. Psychiatry Research 36(3):291–298, 1991. doi:10.1016/0165-1781(91)90027-M
Shapiro CM, Auch C, Reimer M, Kayumov L, Heslegrave R, Huterer N, et al.: A new approach to the construct of alertness. Journal of Psychosomatic Research 60(6):595–603, 2006. doi:10.1016/j.jpsychores.2006.04.012
Acknowledgments
Sincere thanks to participants and staff at Lorikeets Centre and Graylands Hospital, Perth WA.
Funding
FW is supported financially by the North Metropolitan Area Health Service-Mental Health (NMHS MH). VC is supported by funding from the School of Psychiatry and Clinical Neurosciences at University of Western Australia, a University Postgraduate Award scholarship, top-up scholarship from NMHS MH, and grant from the Schizophrenia Research Institute’s Daniel Beck Memorial Award.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Rights and permissions
About this article
Cite this article
Chiu, V.W., Ree, M., Janca, A. et al. Sleep in Schizophrenia: Exploring Subjective Experiences of Sleep Problems, and Implications for Treatment. Psychiatr Q 87, 633–648 (2016). https://doi.org/10.1007/s11126-015-9415-x
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11126-015-9415-x