Disrupting Sleep: The Effects of Sleep Loss on Psychotic Experiences Tested in an Experimental Study With Mediation Analysis

Role of Inflammation in Short Sleep Duration Across Childhood and Psychosis in Young Adulthood

Importance

Short sleep duration over a prolonged period in childhood could have a detrimental impact on long-term mental health, including the development of psychosis. Further, potential underlying mechanisms of these associations remain unknown.

Objective

To examine the association between persistent shorter nighttime sleep duration throughout childhood with psychotic experiences (PEs) and/or psychotic disorder (PD) at age 24 years and whether inflammatory markers (C-reactive protein [CRP] and interleukin 6 [IL-6]) potentially mediate any association.

Design, Setting, and Participants

This cohort study used data from the Avon Longitudinal Study of Parents and Children. Data analysis was conducted from January 30 to August 1, 2023.

Exposures

Nighttime sleep duration was collected at 6, 18, and 30 months and at 3.5, 4 to 5, 5 to 6, and 6 to 7 years.

Main Outcomes and Measures

PEs and PD were assessed at age 24 years from the Psychosislike Symptoms Interview. CRP level at ages 9 and 15 years and IL-6 level at 9 years were used as mediators. Latent class growth analyses (LCGAs) were applied to detect trajectories of nighttime sleep duration, and logistic regressions were applied for the longitudinal associations between trajectories of nighttime sleep duration and psychotic outcomes at 24 years. Path analyses were applied to test CRP and IL-6 as potential mediators.

Results

Data were available on 12 394 children (6254 female [50.5%]) for the LCGA and on 3962 young adults (2429 female [61.3%]) for the logistic regression and path analyses. The LCGA identified a group of individuals with persistent shorter nighttime sleep duration across childhood. These individuals were more likely to develop PD (odds ratio [OR], 2.50; 95% CI, 1.51-4.15; P < .001) and PEs (OR, 3.64; 95% CI, 2.23-5.95; P < .001) at age 24 years. Increased levels of IL-6 at 9 years, but not CRP at 9 or 15 years, partially mediated the associations between persistent shorter sleep duration and PD (bias-corrected estimate = 0.003; 95% CI, 0.002-0.005; P = .007) and PEs (bias-corrected estimate = 0.002; 95% CI, 0-0.003; P = .03) in young adulthood.

Conclusions and Relevance

Findings of this cohort study highlight the necessity of addressing short sleep duration in children, as persistence of this sleep problem was associated with subsequent psychosis. This study also provides preliminary evidence for future targeted interventions in children addressing both sleep and inflammatory responses.

Case report: Diagnosis and intervention of a non-24-h sleep-wake disorder in a sighted child with a psychiatric disorder

Circadian rhythm sleep-wake disorders (CRSWD) are sleep dysfunctions related to circadian functioning. They are characterized by symptoms of insomnia or excessive sleepiness that occur because the intrinsic circadian pacemaker is not entrained to a 24-h light/dark cycle. Affected individuals with a free-running disorder or hypernycthemeral syndrome (N24SWD) have a longer sleep-wake cycle that produces a sleep pattern that typically delays each day. The disorder is seen in 70% of blind people, and among people with healthy vision, it is a rare pathology. Among sighted cases, 80% are young men and 28% have a psychiatric disorder. The patient was a 14-year-old boy with a psychiatric pathology diagnosed with a PANDAS syndrome (pediatric autoimmune neuropsychiatric disorders associated with streptococci), a sudden acute and debilitating onset of intense anxiety and mood lability accompanied by obsessive compulsive-like issues and/or tics, in association with a streptococcal A infection that occurs immediately prior to the symptoms. As a comorbidity, he exhibited severe insomnia due to an irregular sleep pattern that strongly delayed his sleep schedule day to day. It affected his daily routines, as he was not going to school, and aggravated, furthermore, the psychiatric symptoms. He was referred for sleep consultation, where the case was explored by ambulatory circadian monitoring (ACM) using the novel system Kronowise® (Chronolab, University of Murcia) and diagnosed with a non-24-h sleep-wake disorder (N24SWD). The first treatment approach for the patient was focused on improving symptoms during the acute infection and psychiatric symptoms. Additionally, sleep pathology was treated by light therapy and melatonin. After 8 months and different trials, it was possible to establish a treatment to normalize the symptoms and fix his sleep rhythm in a normal schedule as well as to reduce anxious symptoms during the day. The association of PANDAS and N24SWD has not previously been reported in the literature.

How do the sleep features that characterise depression impact memory?

Depression is associated with general sleep disturbance and abnormalities in sleep physiology. For example, compared with control subjects, depressed patients exhibit lower sleep efficiency, longer rapid eye movement (REM) sleep duration, and diminished slow-wave activity during non-REM sleep. A separate literature indicates that depression is also associated with many distinguishing memory characteristics, including emotional memory bias, overgeneral autobiographical memory, and impaired memory suppression. The sleep and memory features that hallmark depression may both contribute to the onset and maintenance of the disorder. Despite our rapidly growing understanding of the intimate relationship between sleep and memory, our comprehension of how sleep and memory interact in the aetiology of depression remains poor. In this narrative review, we consider how the sleep signatures of depression could contribute to the accompanying memory characteristics.

Sleep disorders predict the 1-year onset, persistence, but not remission of psychotic experiences in preadolescence: a longitudinal analysis of the ABCD cohort data

The relationship between sleep disorder and psychotic experiences in preadolescence has not been extensively studied despite the potential for intervention. The current study addressed this relationship using the Adolescent Brain and Cognitive Development (ABCD) cohort, which provided baseline data from 11,830 10- to 11-year-old; for 4910 of these, 1-year follow-up data were also available. A set of pre-registered multi-level regression models were applied to test whether (a) sleep disorder is associated with psychotic experiences at baseline; (b) baseline sleep disorder predicts psychotic experiences at follow-up; (c) the persistence of sleep disorder predicts persistence of psychotic experiences at follow-up; d) the remission of sleep disorder predicts the remission of psychotic experiences at follow-up. After controlling for potential confounders, sleep disorder was associated with psychotic experiences cross-sectionally (OR = 1.40, 95% CI 1.20-1.63), at 1-year follow-up (OR = 1.32, 95% CI 1.11-1.57), and the persistence of sleep disorder predicted the persistence of psychotic experiences (OR = 1.72, 95% CI 1.44-2.04). However, remission of sleep problems did not predict remission of psychotic experiences (OR = 1.041, 95% CI 0.80-1.35). The results indicate that sleep disorders in preadolescence are common and associated with psychotic experiences, although the lack of co-remission raises questions about the mechanism of association. However, given these findings, and existing evidence in later adolescence and adults, further investigation of sleep as a preventative mental health intervention target in this age group is warranted.

Characteristics of sleep structure in Parkinson's disease patients with hallucinations based on polysomnography

Hallucination is a common non-motor symptom in patients with Parkinson's disease (PD). Additionally, sleep disorders are associated with an increased risk of hallucinations in PD patients. This study aimed to examine the association between hallucination and objective sleep parameters in PD patients. We retrospectively recruited 278 PD patients who underwent polysomnography and clinical assessments and classified them into non-hallucination and hallucination groups. Hallucinations were observed in 77 older PD patients who had more severe motor symptoms and higher scores on the Non-Motor Symptoms Questionnaire (NMSQ), Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) but lower scores on the Montreal Cognitive Assessment (MOCA) and PD Sleep Scale (PDSS) than PD patients without hallucinations. Analysis of the polysomnographic variables in patients with hallucinations showed that they exhibited a decrease in total sleep time, sleep efficiency (SE), rapid eye movement (REM) sleep time and slow wave sleep (SWS, N3) time and percentage but a significant increase in wake time after sleep onset (WASO), periodic limb movement index (PLMI) scores, and stage 2 NREM (N2)percentage. Logistic regression analysis revealed that higher NMSQ scores, lower MOCA scores, lower SE, and a lower percentage of N3 sleep were associated with hallucinations in PD patients. Our results suggested that PD patients with hallucinations had worse sleep quality and differences in sleep architecture (measured by polysomnography).

A novel smartphone-based intervention targeting sleep difficulties in individuals experiencing psychosis: A feasibility and acceptability evaluation

OBJECTIVES

Cognitive Behavioural Therapy (CBT) is an effective psychological intervention for sleep difficulties and has been used successfully in individuals with psychosis. However, access is restricted due to lack of resources and staff training. Delivering CBT for sleep problems using smartphone technology may facilitate wider access. This study aimed to evaluate the feasibility, acceptability and potential usefulness of a guided, smartphone-based CBT intervention targeting sleep disturbance for individuals with psychosis.

DESIGN

Participants with psychosis spectrum diagnoses were recruited to a single-arm, uncontrolled study and engaged with the seven-module programme via smartphone app for six weeks with therapist support.

METHOD

Feasibility was assessed by rates of referral, recruitment and completion. Acceptability was assessed by app usage, a satisfaction questionnaire and qualitative analysis of participants' semi-structured interview. Pre- and post-intervention assessment of sleep, psychotic experiences, mood, well-being and functioning was conducted. Mean change confidence intervals were calculated and reported as an indication of usefulness.

RESULTS

Fourteen individuals consented to participation, and eleven completed the post-intervention assessment. On average, each participant engaged with 5.6 of 7 available modules. Qualitative feedback indicated the intervention was considered helpful and would be recommended to others. Suggested improvements to app design were provided by participants. Potential treatment benefits were observed for sleep difficulties, and all outcomes considered, except frequency of hallucinatory experiences.

CONCLUSIONS

It is feasible and acceptable to deliver therapist-guided CBT for sleep problems by smartphone app for individuals with psychosis. This method provides a low-intensity, accessible intervention, which could be offered more routinely. Further research to determine treatment efficacy is warranted.

Sleep Deprivation & Amphetamine Induced Psychosis

OBJECTIVES

To explore the relationship between sleep deprivation and amphetamine-induced psychosis.

METHODS

The patient group included 78 patients with a diagnosis of amphetamine (Captagon)-induced psychosis. The control group included 49 patients with no current or past history of amphetamine (Captagon)-induced psychosis. All study subjects underwent the following: a demographic sheet, a structured clinical interview for SM-IV (SCID 1), a drug use questionnaire, a questionnaire to explore any relationship between sleep deprivation and Captagon-induced psychosis, routine medical investigation, and urine screening for detection of drugs.

RESULTS

The patient group showed significantly higher both regular and maximum daily doses of Captagon. Patients showed more periods of sleep deprivation with the use of Captagon in comparison to controls, especially with the increase of the Captagon dose. Patients believed that the occurrence and termination of sleep deprivation were the cause of the start and end of psychotic experiences (more so than the increase and decrease or stoppage of Captagon doses).

CONCLUSION

sleep deprivation plays an essential role in the development of psychotic symptoms in patients who are using Captagon.

The Mind After Midnight: Nocturnal Wakefulness, Behavioral Dysregulation, and Psychopathology

Sufficient sleep with minimal interruption during the circadian/biological night supports daytime cognition and emotional regulation. Conversely, disrupted sleep involving significant nocturnal wakefulness leads to cognitive and behavioral dysregulation. Most studies to-date have examined how fragmented or insufficient sleep affects next-day functioning, but recent work highlights changes in cognition and behavior that occur when someone is awake during the night. This review summarizes the evidence for day-night alterations in maladaptive behaviors, including suicide, violent crime, and substance use, and examines how mood, reward processing, and executive function differ during nocturnal wakefulness. Based on this evidence, we propose the Mind after Midnight hypothesis in which attentional biases, negative affect, altered reward processing, and prefrontal disinhibition interact to promote behavioral dysregulation and psychiatric disorders.

The nature, consequences, mechanisms, and management of sleep disturbances in individuals at-risk for psychosis

There is strong evidence that sleep disturbances are commonly experienced by people with psychosis. Evidence has also shown that sleep disturbances are present since the very early stages of the disease, even during the pre-diagnostic phase. More recently, research involving young individuals at ultra-high risk (UHR) for psychosis documented frequent occurrence of sleep disturbances in this group. The very early onset of sleep disturbances in the course of psychosis has drawn attention to the possible links between sleep parameters and the risk of psychosis. To date, the nature of sleep disturbances characterizing the UHR stage remains unclear, with available studies having yielded mixed findings. In this regard, we performed this review to update the body of literature on the nature of sleep disturbances, their underlying mechanisms, their clinical and functional consequences, the prevention and intervention strategies in the at-risk for psychosis population. Our findings provided further support to the presence of disturbed sleep in UHR individuals as evidenced by subjective and objective sleep measures such as polysomnography, sleep electroencephalograms, and actigraphy. Reviewing the possible mechanisms underlying the relationship between sleep and psychosis emphasized its complex and multifactorial nature which is yet to be determined and understood. Further research is warranted to determine which facets of sleep disturbances are most detrimental to this specific population, and to what extent they can be causal factors or markers of psychosis.

COVID-19 Infection and Psychotic Experiences: Findings From the Healthy Minds Study 2020

Background

Clinical reports from across the world have documented psychosis in the context of COVID-19 infection; however, there has yet to be a large-scale epidemiological study to confirm this association.

Methods

We analyzed data from the Healthy Minds Study (N = 15,935; conducted between September and December 2020), which was administered online to students attending one of 28 colleges in the United States. Using multivariable logistic regression, we examined the associations between COVID-19 infection/severity and psychotic experiences over the past 12 months, adjusting for age, gender, race/ethnicity, and international student status as well as anxiety and depression.

Results

More than one fifth of the analytic sample reported COVID-19 infection, and about one in six students with COVID-19 infection reported psychotic experiences over the past 12 months. In weighted multivariable logistic regression models, COVID-19 infection was associated with significantly greater odds of having psychotic experiences (adjusted odds ratio 1.36, 95% CI 1.19–1.48). Compared with being asymptomatic, having moderate (adjusted odds ratio 1.85, 95% CI 1.03–3.31) or severe (adjusted odds ratio 1.76, 95% CI 1.11–2.77) symptoms was associated with significantly greater odds of having psychotic experiences. These associations became statistically nonsignificant when adjusting for depression and anxiety. Hospitalization was not significantly associated with psychotic experiences among students with COVID-19 infection.

Conclusions

Psychotic experiences are associated with COVID-19 infections, though much of the association is attenuated when accounting for anxiety and depression. Findings based on this sample of college students should be replicated outside of the college context to determine whether psychosis is a neuropsychiatric symptom during and after COVID-19 infection.

Association of accelerometer-derived sleep measures with lifetime psychiatric diagnoses: A cross-sectional study of 89,205 participants from the UK Biobank

BACKGROUND

Sleep problems are both symptoms of and modifiable risk factors for many psychiatric disorders. Wrist-worn accelerometers enable objective measurement of sleep at scale. Here, we aimed to examine the association of accelerometer-derived sleep measures with psychiatric diagnoses and polygenic risk scores in a large community-based cohort.

METHODS AND FINDINGS

In this post hoc cross-sectional analysis of the UK Biobank cohort, 10 interpretable sleep measures-bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration-were derived from 7-day accelerometry recordings across 89,205 participants (aged 43 to 79, 56% female, 97% self-reported white) taken between 2013 and 2015. These measures were examined for association with lifetime inpatient diagnoses of major depressive disorder, anxiety disorders, bipolar disorder/mania, and schizophrenia spectrum disorders from any time before the date of accelerometry, as well as polygenic risk scores for major depression, bipolar disorder, and schizophrenia. Covariates consisted of age and season at the time of the accelerometry recording, sex, Townsend deprivation index (an indicator of socioeconomic status), and the top 10 genotype principal components. We found that sleep pattern differences were ubiquitous across diagnoses: each diagnosis was associated with a median of 8.5 of the 10 accelerometer-derived sleep measures, with measures of sleep quality (for instance, sleep efficiency) generally more affected than mere sleep duration. Effect sizes were generally small: for instance, the largest magnitude effect size across the 4 diagnoses was β = -0.11 (95% confidence interval -0.13 to -0.10, p = 3 × 10-56, FDR = 6 × 10-55) for the association between lifetime inpatient major depressive disorder diagnosis and sleep efficiency. Associations largely replicated across ancestries and sexes, and accelerometry-derived measures were concordant with self-reported sleep properties. Limitations include the use of accelerometer-based sleep measurement and the time lag between psychiatric diagnoses and accelerometry.

CONCLUSIONS

In this study, we observed that sleep pattern differences are a transdiagnostic feature of individuals with lifetime mental illness, suggesting that they should be considered regardless of diagnosis. Accelerometry provides a scalable way to objectively measure sleep properties in psychiatric clinical research and practice, even across tens of thousands of individuals.

Sleep Abnormalities in Schizophrenia: State of the Art and Next Steps

Sleep disturbances are commonly observed in schizophrenia, including in chronic, early-course, and first-episode patients. This has generated considerable interest, both in clinical and research endeavors, in characterizing the relationship between disturbed sleep and schizophrenia. Sleep features can be objectively assessed with EEG recordings. Traditionally, EEG studies have focused on sleep architecture, which includes non-REM and REM sleep stages. More recently, numerous studies have investigated alterations in sleep-specific rhythms, including EEG oscillations, such as sleep spindles and slow waves, in individuals with schizophrenia compared with control subjects. In this article, the author reviews state-of-the-art evidence of disturbed sleep in schizophrenia, starting from the relationship between sleep disturbances and clinical symptoms. First, the author presents studies demonstrating abnormalities in sleep architecture and sleep-oscillatory rhythms in schizophrenia and related psychotic disorders, with an emphasis on recent work demonstrating sleep spindles and slow-wave deficits in early-course and first-episode schizophrenia. Next, the author shows how these sleep abnormalities relate to the cognitive impairments in patients diagnosed with schizophrenia and point to dysfunctions in underlying thalamocortical circuits, Ca+ channel activity, and GABA-glutamate neurotransmission. Finally, the author discusses some of the next steps needed to further establish the role of altered sleep in schizophrenia, including the need to investigate sleep abnormalities across the psychotic spectrum and to establish their relationship with circadian disturbances, which in turn will contribute to the development of novel sleep-informed treatment interventions.

Sleep disturbance mediates the link between childhood trauma and clinical outcome in severe mental disorders

BACKGROUND

The experience of childhood trauma is linked to more severe symptoms and poorer functioning in severe mental disorders; however, the mechanisms behind this are poorly understood. We investigate the relationship between childhood trauma and sleep disturbances in severe mental disorders including the role of sleep disturbances in mediating the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.

METHODS

In total, 766 participants with schizophrenia-spectrum (n = 418) or bipolar disorders (n = 348) were assessed with the Childhood Trauma Questionnaire. Sleep disturbances were assessed through the sleep items in the self-reported Inventory of Depressive Symptoms. Clinical symptoms and functioning were assessed with The Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale. Mediation analyses using ordinary least squares regression were conducted to test if sleep disturbances mediated the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.

RESULTS

Symptoms of insomnia, but not hypersomnia or delayed sleep phase, were significantly more frequent in participants with childhood trauma experiences compared to those without. Physical abuse, emotional abuse, and emotional neglect were significantly associated with insomnia symptoms. Insomnia symptoms partly mediate the relationship between childhood trauma and the severity of positive and depressive/anxiety symptoms, in addition to poorer functioning.

CONCLUSION

We found frequent co-occurrence of childhood trauma history and current insomnia in severe mental disorders. Insomnia partly mediated the relationship between childhood trauma and the severity of clinical symptoms and functional impairment.

Dissociation in relation to other mental health conditions: An exploration using network analysis

Dissociative experiences, traditionally studied in relation to trauma and PTSD, may be important phenomena across many different psychological conditions, including as a contributory causal factor for psychotic experiences. In this study, the aim was to explore, using network approaches, how dissociative experiences taking the form of a Felt Sense of Anomaly (FSA) relate to both common mental health conditions and psychotic experiences. 6941 individuals from the general population completed online assessments of FSA-dissociation, post-traumatic stress symptoms (PTSS), anxiety, depression, insomnia, worry, distress tolerance, hallucinations, grandiosity, paranoia, and cognitive disorganization. An undirected partial correlation network analysis was used to explore the network structure, then Bayesian inference with Directed Acyclic Graphs (DAGs) was used to identify potential directions of relationships between dissociation and mental health symptoms. Dissociation was found to be highly connected in both network models. Both networks found direct relationships between dissociation and hallucinations, grandiosity, paranoia, cognitive disorganization, anxiety, depression, and PTSS. In the DAGs analysis, the direction of influence between dissociation and hallucinations, PTSS, anxiety and depression was unclear, however it was found to be probable that dissociation influences paranoia (97.66% of sampled DAGs found the direction dissociation to paranoia, versus 2.34% finding the reverse direction), cognitive disorganization (99.74% vs. 0.26%), and grandiosity (93.49% vs. 6.51%). Further, dissociation was found to be a probable influence of insomnia and distress tolerance via indirect pathways. In summary, dissociation is connected to many mental health disorders, and may influence a number of presentations, particularly psychotic experiences. The importance of dissociation in mental health may therefore currently be under-recognised.

Head-to-Head Comparison of Sedation and Somnolence Among 37 Antipsychotics in Schizophrenia, Bipolar Disorder, Major Depression, Autism Spectrum Disorders, Delirium, and Repurposed in COVID-19, Infectious Diseases, and Oncology From the FAERS, 2004-2020

Objective: Antipsychotic compounds are known to induce sedation somnolence and have expanded clinical indications beyond schizophrenia to regulatory approval in bipolar disorder, treatment-resistant depression, and is being repurposed in infectious diseases and oncology. However, the medical sciences literature lacks a comprehensive association between sedation and somnolence among a wide-range of antipsychotic compounds. The objective of this study is to assess the disproportionality of sedation and somnolence among thirty-seven typical and atypical antipsychotics.

Materials and Methods: Patient adverse drug reactions (ADR) cases were obtained from the United States Food and Drug Administration Adverse Events Reporting System (FAERS) between January 01, 2004 and September 30, 2020 for a wide-array of clinical indications and off-label use of antipsychotics. An assessment of disproportionality were based on cases of sedation and somnolence and calculated using the case/non-case methodology. Statistical analysis resulting in the reporting odds-ratio (ROR) with corresponding 95% confidence intervals (95% CI) were conducted using the R statistical programming language.

Results: Throughout the reporting period, there were a total of 9,373,236 cases with 99,251 specific ADRs reporting sedation and somnolence. Zuclopenthixol (n = 224) ROR = 13.3 (95% CI, 11.6–15.3) was most strongly associated of sedation and somnolence and haloperidol decanoate long-acting injection (LAI) was not statistically associated sedation and somnolence. Further, among atypical antipsychotic compounds, tiapride and asenapine were the top two compounds most strongly associated with sedation and somnolence. Comprehensively, the typical antipsychotics ROR = 5.05 (95%CI, 4.97–5.12) had a stronger association with sedation and somnolence when compared to atypical antipsychotics ROR = 4.65 (95%CI, 4.47–4.84).

Conclusion: We conducted a head-to-head comparison of thirty-seven antipsychotics and ranked the compounds based on the association of sedation and somnolence from ADR data collected throughout 16 years from the FAERS. The results are informative and with recent interests in repurposing phenothiazine antipsychotics in infectious disease and oncology provides an informative assessment of the compounds during repurposing and in psychopharmacology.

Understanding the Relationship Between Sleep Problems in Early Childhood and Borderline Personality Disorder: A Narrative Review

OBJECTIVE

Recent research indicates that sleep problems in childhood precede the development of borderline personality disorder (BPD) symptoms, but the mechanisms by which sleep problems associate with BPD are still unknown. This narrative review aims to provide some potential explanations for how early sleep problems might associate with BPD.

METHODS

We used the biosocial developmental model of BPD as a framework to discuss how sleep problems may associate with BPD. Articles were identified via PubMed and Embase, and papers published between January 1991 and April 2021 were extracted. Authors made a series of literature searches using the following keywords: Sleep problems, Insomnia, Nightmares, Hypothalamic-Pituitary-Adrenal Axis (HPA), Prefrontal Cortex, Family Psychopathology, Disrupted Attachment, Child Maltreatment, Impulsivity, Emotion Regulation, Internalizing, Externalizing, Rumination, Childhood, Adolescence, Young people. The inclusion criteria were published in peer-reviewed journals; human studies or reviews; published in English. The exclusion criteria were commentaries; abstracts from conferences; studies with animal samples. A total of 96 articles were included for the purpose of this review.

RESULTS

The evidence from this review suggests that some biological factors and core features of BPD act as potential mechanisms mediating the associations between early sleep and subsequent BPD, while some family-related factors might constitute common risk factors for sleep problems and BPD.

CONCLUSION

The biosocial developmental model of BPD provides a plausible characterization of how sleep disruption might lead to subsequent BPD. Further research on new developmental and early intervention approaches to understand how sleep in early stages associates with BPD could have significant clinical impact on these patients and could inform targeted therapeutic interventions.

The Bidirectional Associations Between Insomnia and Psychotic-Like Experiences Before and During the COVID-19 Pandemic

STUDY OBJECTIVES

Previous literature supports that insomnia is predictive of subsequent psychotic-like experiences (PLEs) in the general population. However, there is a lack of empirical data on the reverse causality between the two variables and on the correlation between the symptom severity of insomnia and PLEs. This study aimed to explore the bidirectional associations between insomnia and PLEs before and during the COVID-19 pandemic.

METHODS

A total of 938 students aged 14-25 years completed both waves of the survey before and during the pandemic (the first wave: October 2019 to November 2019; the second wave: April 2020 to May 2020). PLEs were assessed using the 15-item positive subscale of the community assessment of psychic experiences (CAPE-P15), and insomnia was assessed using three questions on difficulty initiating sleep, difficulty maintaining sleep, and early morning awakening.

RESULTS

Students with baseline insomnia were more likely to exhibit new-onset PLEs during the pandemic (OR: 5.13, 95% CI: 2.54-10.38), while no significant predictive effect of insomnia was found for the persistence and severity of PLEs. Meanwhile, baseline PLEs not only predicted the presence of insomnia during the pandemic (OR: 2.14, 95% CI: 1.25-3.65) but also correlated with its severity (B: 0.89, 95% CI: 0.47-1.31).

CONCLUSION

The study provides the first piece of evidence for the bidirectional association between insomnia and PLEs in the general population. However, although insomnia has an important predictive role in the occurrence of PLEs, it does not predict the persistence and development of PLEs, suggesting that there is a more complex mechanism underlying the process.

Childhood Trauma and Insomnia Increase Suicidal Ideation in Schizophrenia Patients: A Cross-Sectional Study

Objectives: This study aimed to investigate the effect of childhood trauma, especially its specific dimensions, and clinical risk factors for suicidal ideation in patients with schizophrenia. Methods: A total of 83 inpatients with schizophrenia were enrolled and divided into two groups: with suicidal ideation (n = 33) and without suicidal ideation (n = 50). All participants were administered the Childhood Trauma Questionnaire-Short Form, the Insomnia Severity Index, the Beck Scale for Suicide Ideation, the Modified Overt Aggression Scales, the auditory hallucination rating scale, the Hamilton Rating Scale of Depression and the Positive and Negative Syndrome Scale. Results: In our sample, 39.8% of the subjects had suicidal ideation, and 60.6% of them had suffered from childhood trauma. Patients with suicidal ideation had a higher Insomnia Severity Index score, Physical neglect score, the Childhood Trauma Questionnaire-Short Form total score (all P < 0.05) compared to those without. The logistic regression analysis revealed that physical neglect in Childhood Trauma Questionnaire was significantly associated with suicidal ideation (OR = 5.46, P < 0.05, 95% CI = 0.007-0.483). Further stepwise multiple linear regression identified that insomnia (β = 0.272, P = 0.011) and physical neglect (β = 0.257, P = 0.017) were strong risk factors for the severity of suicidal ideation in patients with schizophrenia. Mediation analysis showed that insomnia played a complete mediating role between physical neglect and suicidal ideation. Conclusion: Our results indicate that childhood maltreatment of physical neglect is a strong independent risk factor for suicidal ideation in schizophrenia. The risk is probably aggravated by the poor quality of sleep. Early screening and psychosocial treatment are recommended for psychotic individuals with a trauma history.

Troubles psychotiques et troubles du sommeil : revue de la littérature

Contexte La disparition de la nomenclature des troubles du sommeil dits primaires ou secondaires, rendue obsolète par le Manuel diagnostique et statistique des troubles mentaux (DSM-5), représente bien l’engouement académique actuel pour ce domaine de recherche. Il est de plus en plus reconnu que les troubles du sommeil sont plus que de simples conséquences d’un trouble psychiatrique et qu’ils peuvent persister malgré un traitement adéquat de la condition comorbide et même précéder ou exacerber cette dernière. Les troubles du sommeil dans les troubles psychotiques, très fréquents, sont donc devenus un sujet d’actualité, représentant une cible d’intervention jusqu’ici sous-estimée.

Objectif Cet article vise à présenter l’état des connaissances actuelles sur la relation entre les troubles du sommeil et les troubles psychotiques ainsi que sur l’utilisation de la thérapie cognitivo-comportementale (TCC) pour traiter les troubles du sommeil dans ce contexte.

Méthode L’article fait une recension narrative de la littérature pour décrire la relation bidirectionnelle entre la psychose et les troubles du sommeil, les corrélations cliniques et les traitements ciblant l’insomnie chez les patients psychotiques.

Résultats Malgré la présence d’une relation entre les troubles du sommeil et les troubles psychotiques, les mécanismes neuronaux, hormonaux et socioculturels régissant cette relation demeurent encore incertains. Bien que l’association reliant les troubles du sommeil et les troubles psychotiques demeure à clarifier, les études démontrent qu’elle serait bidirectionnelle et peut engendrer un cercle vicieux où ces deux composantes s’aggravent mutuellement. Dans ce contexte de comorbidités, les modèles unifiés en TCC deviennent un traitement de choix, à condition d’adapter les protocoles de TCC pour insomnie (TCC-i) à une population avec trouble psychotique (TCC-ip).

Conclusion Malgré la complexité de la relation entre les troubles psychotiques et ceux du sommeil, la TCC-i a été démontrée efficace pour traiter les troubles du sommeil dans une population psychotique et pourrait, dans certains cas, permettre d’alléger la symptomatologie psychotique. De futures études sur ce domaine pourraient permettre le développement de protocoles de thérapie cognitivo-comportementale pour les troubles du sommeil mieux adaptés à la population avec troubles psychotiques.

Treating sleep problems in young people at ultra-high-risk of psychosis: study protocol for a single-blind parallel group randomised controlled feasibility trial (SleepWell)

BACKGROUND

Effective interventions, targeting key contributory causal factors, are needed to prevent the emergence of severe mental health problems in young people. Insomnia is a common clinical issue that is problematic in its own right but that also leads to the development and persistence of psychotic experiences. The implication is that treating sleep problems may prevent the onset of psychosis. We collected initial case series data with 12 young people at ultra-high-risk of psychosis. Post-intervention, there were improvements in sleep, depression and psychotic experiences. Now we test the feasibility of a randomised controlled trial, with a clinical aim to treat sleep problems and hence reduce depression, psychotic experiences, and prevent transition to psychosis.

METHODS AND ANALYSIS

A randomised controlled feasibility trial will be conducted. Forty patients aged 14 to 25 years who are at ultra-high-risk of psychosis and have sleep disturbance will be recruited from National Health Service (NHS) mental health services. Participants will be randomised to receive either a novel, targeted, youth-focussed sleep intervention in addition to usual care or usual care alone. Assessor-blinded assessments will be conducted at baseline, 3 months (post-intervention) and 9 months (follow-up). The eight-session psychological intervention will target the key mechanisms which disrupt sleep: circadian rhythm irregularities, low sleep pressure, and hyperarousal. To gain an in-depth understanding of participants' views on the acceptability of the intervention and study procedures, 16 participants (n=10 intervention, n=6 control) will take part in qualitative interviews. Analyses will focus on feasibility outcomes (recruitment, retention, and treatment uptake rates) and provide initial CI estimates of intervention effects. Thematic analysis of the qualitative interviews will assess the acceptability of the intervention and trial procedures.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the NHS Health Research Authority. Findings will be disseminated through peer-reviewed publications, conference presentations, and lay networks.

TRIAL REGISTRATION NUMBER

ISRCTN85601537.

Sleep Disturbances in Patients with Persistent Delusions: Prevalence, Clinical Associations, and Therapeutic Strategies

Sleep disturbances accompany almost all mental illnesses, either because sound sleep and mental well-being share similar requisites, or because mental problems lead to sleep problems, or vice versa. The aim of this narrative review was to examine sleep in patients with delusions, particularly in those diagnosed with delusional disorder. We did this in sequence, first for psychiatric illness in general, then for psychotic illnesses where delusions are prevalent symptoms, and then for delusional disorder. The review also looked at the effect on sleep parameters of individual symptoms commonly seen in delusional disorder (paranoia, cognitive distortions, suicidal thoughts) and searched the evidence base for indications of antipsychotic drug effects on sleep. It subsequently evaluated the influence of sleep therapies on psychotic symptoms, particularly delusions. The review’s findings are clinically important. Delusional symptoms and sleep quality influence one another reciprocally. Effective treatment of sleep problems is of potential benefit to patients with persistent delusions, but may be difficult to implement in the absence of an established therapeutic relationship and an appropriate pharmacologic regimen. As one symptom can aggravate another, comorbidities in patients with serious mental illness all need to be treated, a task that requires close liaison among medical specialties.

Reduction in social learning and increased policy uncertainty about harmful intent is associated with pre-existing paranoid beliefs: Evidence from modelling a modified serial dictator game

Current computational models suggest that paranoia may be explained by stronger higher-order beliefs about others and increased sensitivity to environments. However, it is unclear whether this applies to social contexts, and whether it is specific to harmful intent attributions, the live expression of paranoia. We sought to fill this gap by fitting a computational model to data (n = 1754) from a modified serial dictator game, to explore whether pre-existing paranoia could be accounted by specific alterations to cognitive parameters characterising harmful intent attributions. We constructed a ‘Bayesian brain’ model of others’ intent, which we fitted to harmful intent and self-interest attributions made over 18 trials, across three different partners. We found that pre-existing paranoia was associated with greater uncertainty about other’s actions. It moderated the relationship between learning rates and harmful intent attributions, making harmful intent attributions less reliant on prior interactions. Overall, the magnitude of harmful intent attributions was directly related to their uncertainty, and importantly, the opposite was true for self-interest attributions. Our results explain how pre-existing paranoia may be the result of an increased need to attend to immediate experiences in determining intentional threat, at the expense of what is already known, and more broadly, they suggest that environments that induce greater probabilities of harmful intent attributions may also induce states of uncertainty, potentially as an adaptive mechanism to better detect threatening others. Importantly, we suggest that if paranoia were able to be explained exclusively by core domain-general alterations we would not observe differential parameter estimates underlying harmful-intent and self-interest attributions.

A great deal of work has tried to explain paranoia through general cognitive principles, although relatively little has tried to understand whether paranoia may be explained by specific changes to social learning processes. This question is crucial, as paranoia is inherently a social phenomenon, and requires mechanistic explanations to match with its dynamic phenomenology. In this paper we wanted to test whether pre-existing and live paranoid beliefs about others specifically altered how an individual attributed harmful intent–the live expression of paranoia–to partners over a series of live interactions. To do this we applied a novel computational model and network analysis to behavioural data from a large sample of participants in the general population that had played a modified Dictator game online, and required them to attribute whether the behaviour of their partner was due to their intent to harm, or their self-interest, on two mutually exclusive scales. Pre-existing paranoid beliefs about others reduced the value of new partner behaviours on evolving attributions of harmful intent. We suggest that both pre-existing paranoid beliefs and momentary paranoia may incur an adaptive cognitive state to better track potentially threatening others, and demonstrate phenomenological specificity associated with mechanisms of live paranoia.

Sleep and Circadian Rhythm Disturbance in Remitted Schizophrenia and Bipolar Disorder: A Systematic Review and Meta-analysis

BACKGROUND

Sleep and circadian rhythm disturbances in schizophrenia are common, but incompletely characterized. We aimed to describe and compare the magnitude and heterogeneity of sleep-circadian alterations in remitted schizophrenia and compare them with those in interepisode bipolar disorder.

METHODS

EMBASE, Medline, and PsycINFO were searched for case-control studies reporting actigraphic parameters in remitted schizophrenia or bipolar disorder. Standardized and absolute mean differences between patients and controls were quantified using Hedges' g, and patient-control differences in variability were quantified using the mean-scaled coefficient of variation ratio (CVR). A wald-type test compared effect sizes between disorders.

RESULTS

Thirty studies reporting on 967 patients and 803 controls were included. Compared with controls, both schizophrenia and bipolar groups had significantly longer total sleep time (mean difference [minutes] [95% confidence interval {CI}] = 99.9 [66.8, 133.1] and 31.1 [19.3, 42.9], respectively), time in bed (mean difference = 77.8 [13.7, 142.0] and 50.3 [20.3, 80.3]), but also greater sleep latency (16.5 [6.1, 27.0] and 2.6 [0.5, 4.6]) and reduced motor activity (standardized mean difference [95% CI] = -0.86 [-1.22, -0.51] and -0.75 [-1.20, -0.29]). Effect sizes were significantly greater in schizophrenia compared with the bipolar disorder group for total sleep time, sleep latency, and wake after sleep onset. CVR was significantly elevated in both diagnoses for total sleep time, time in bed, and relative amplitude.

CONCLUSIONS

In both disorders, longer overall sleep duration, but also disturbed initiation, continuity, and reduced motor activity were found. Common, modifiable factors may be associated with these sleep-circadian phenotypes and advocate for further development of transdiagnostic interventions that target them.

Primary care physician's approach for mental health impact of COVID-19

As the world struggles to control coronavirus infection with the exhausting capacity of health care systems globally, the role of primary care physician and family physician becomes more important as the first point of contact with the community. Limited availability of mental health services in India requires general practitioners to deal with psychological disorders arising due to infection outbreak and its restrictive control strategies. This article discusses what and how primary physicians can manage the psychological burden of a pandemic, and therefore, reducing the reliance on mental health specialist.

Sleep and schizophrenia: From epiphenomenon to treatable causal target

BACKGROUND

Sleep disturbance is a common clinical issue for patients with psychosis. It has been identified as a putative causal factor in the onset and persistence of psychotic experiences (paranoia and hallucinations). Hence sleep disruption may be a potential treatment target to prevent the onset of psychosis and reduce persistent psychotic experiences. The aim of this review is to describe developments in understanding the nature, causal role, and treatment of sleep disruption in psychosis.

METHOD

A systematic literature search was conducted to identify studies, published in the last five years, investigating subjective sleep disruption and psychotic experiences.

RESULTS

Fifty-eight papers were identified: 37 clinical and 21 non-clinical studies. The studies were correlational (n = 38; 20 clinical, 18 non-clinical), treatment (n = 7; 1 non-clinical), qualitative accounts (n = 6 clinical), prevalence estimates (n = 5 clinical), and experimental tests (n = 2 non-clinical). Insomnia (50%) and nightmare disorder (48%) are the most prevalent sleep problems found in patients. Sleep disruption predicts the onset and persistence of psychotic experiences such as paranoia and hallucinations, with negative affect identified as a partial mediator of this relationship. Patients recognise the detrimental effects of disrupted sleep and are keen for treatment. All psychological intervention studies reported large effect size improvements in sleep and there may be modest resultant improvements in psychotic experiences.

CONCLUSIONS

Sleep disruption is a treatable clinical problem in patients with psychosis. It is important to treat in its own right but may also lessen psychotic experiences. Research is required on how this knowledge can be implemented in clinical services.

Disrupted Sleep and Circadian Rhythms in Schizophrenia and Their Interaction With Dopamine Signaling

Sleep and circadian rhythm disruption (SCRD) is a common feature of schizophrenia, and is associated with symptom severity and patient quality of life. It is commonly manifested as disturbances to the sleep/wake cycle, with sleep abnormalities occurring in up to 80% of patients, making it one of the most common symptoms of this disorder. Severe circadian misalignment has also been reported, including non-24 h periods and phase advances and delays. In parallel, there are alterations to physiological circadian parameters such as body temperature and rhythmic hormone production. At the molecular level, alterations in the rhythmic expression of core clock genes indicate a dysfunctional circadian clock. Furthermore, genetic association studies have demonstrated that mutations in several clock genes are associated with a higher risk of schizophrenia. Collectively, the evidence strongly suggests that sleep and circadian disruption is not only a symptom of schizophrenia but also plays an important causal role in this disorder. The alterations in dopamine signaling that occur in schizophrenia are likely to be central to this role. Dopamine is well-documented to be involved in the regulation of the sleep/wake cycle, in which it acts to promote wakefulness, such that elevated dopamine levels can disturb sleep. There is also evidence for the influence of dopamine on the circadian clock, such as through entrainment of the master clock in the suprachiasmatic nuclei (SCN), and dopamine signaling itself is under circadian control. Therefore dopamine is closely linked with sleep and the circadian system; it appears that they have a complex, bidirectional relationship in the pathogenesis of schizophrenia, such that disturbances to one exacerbate abnormalities in the other. This review will provide an overview of the evidence for a role of SCRD in schizophrenia, and examine the interplay of this with altered dopamine signaling. We will assess the evidence to suggest common underlying mechanisms in the regulation of sleep/circadian rhythms and the pathophysiology of schizophrenia. Improvements in sleep are associated with improvements in symptoms, along with quality of life measures such as cognitive ability and employability. Therefore the circadian system holds valuable potential as a new therapeutic target for this disorder.

Insomnia and suicidal ideation in nonaffective psychosis

Study Objectives

Insomnia is a common symptom in the clinical course of schizophrenia. There is a robust association between insomnia and suicidality in other psychiatric disorders. Two previous studies found associations between insomnia and suicide attempt or completed suicide in patients with schizophrenia. We hypothesized that greater insomnia would be associated with greater levels of suicidal ideation in patients with schizophrenia and other nonaffective psychoses.

Methods

We recruited 108 inpatients and outpatients age 18-65 between July 2010 and July 2016 with DSM-IV nonaffective psychosis (schizophrenia, schizoaffective disorder, or schizophreniform disorder). We investigated relationships between current insomnia (Insomnia Severity Index [ISI]), suicidal ideation over the past week, and lifetime history of suicide attempt (Beck Scale for Suicide Ideation [BSS]) in regression analyses.

Results

After controlling for potential confounders, insomnia was a significant indicator of suicidal ideation (β = 0.27, p = 0.032). Insomnia was also a significant indicator of a high BSS score (≥16; OR = 1.14, 95% CI: 1.01-1.28, p = 0.029). Furthermore, participants with severe insomnia were almost 15 times more likely to have a lifetime history suicide attempt than participants without current insomnia (OR = 14.8, 95% CI: 1.4-157, p = 0.025). Insomnia was also an indicator of greater PANSS total (β = 0.33, p = 0.001), positive subscale (β = 0.32, p = 0.002), and general subscale (β = 0.40, p < 0.001) scores.

Conclusions

Insomnia is associated with suicidal ideation, lifetime suicide attempt, and greater psychopathology in patients with schizophrenia. Our findings suggest that formal assessment of insomnia may be germane to the clinical care of patients with schizophrenia as a marker of suicide risk and symptom severity.

Paranoia, sensitization and social inference: findings from two large-scale, multi-round behavioural experiments

The sensitization model suggests that paranoia is explained by over-sensitivity to social threat. However, this has been difficult to test experimentally. We report two preregistered social interaction studies that tested (i) whether paranoia predicted overall attribution and peak attribution of harmful intent and (ii) whether anxiety, interpersonal sensitivity and worry predicted the attribution of harmful intent. In Study 1, we recruited a large general population sample (N = 987) who serially interacted with other participants in multi-round dictator games and matched to fair, partially fair or unfair partners. Participants rated attributions of harmful intent and self-interest after each interaction. In Study 2 (N = 1011), a new sample of participants completed the same procedure and additionally completed measures of anxiety, worry and interpersonal sensitivity. As predicted, prior paranoid ideation was associated with higher and faster overall harmful intent attributions, whereas attributions of self-interest were unaffected, supporting the sensitization model. Contrary to predictions, neither worry, interpersonal sensitivity nor anxiety was associated with harmful intent attributions. In a third exploratory internal meta-analysis, we combined datasets to examine the effect of paranoia on trial-by-trial attributional changes when playing fair and unfair dictators. Paranoia was associated with a greater reduction in harmful intent attributions when playing a fair but not unfair dictator, suggesting that paranoia may also exaggerate the volatility of beliefs about the harmful intent of others.

Sleep disturbance and sleep-related impairment in psychotic disorders are related to both positive and negative symptoms

A large literature indicates that sleep disturbances are associated with paranoia and other positive symptoms in psychotic disorders. However, few studies have examined the potential association between sleep disturbances and negative symptoms and the results have been inconsistent. The current study examined the hypothesis that sleep problems would be associated with more severe positive and negative symptoms in a transdiagnostic sample of individuals with psychosis (N = 90). Further, we examined whether sleep would be related to negative symptoms above and beyond the contribution of paranoia, other positive symptoms, and depression-anxiety. Results replicated prior research in finding that both sleep disturbance and sleep-related impairment were related to more severe paranoia, other positive symptoms and depression-anxiety. Consistent with our hypothesis, more severe sleep disturbance and sleep-related impairment were related to greater negative symptoms; this was evident across both motivation-pleasure deficits and diminished expression. Sleep variables remained significantly related to motivation-pleasure deficits even after controlling for other non-negative symptoms. These results indicate the broad symptom impact of sleep disturbances and may suggest a novel treatment target to improve negative symptoms.

Effects of Total and Partial Sleep Deprivation on Reflection Impulsivity and Risk-Taking in Deliberative Decision-Making

STUDY OBJECTIVES

To evaluate the effects of total and partial sleep deprivation on reflection impulsivity and risk-taking in tasks requiring deliberative decision-making processes.

PARTICIPANTS AND METHODS

Seventy-four healthy young adults were selected to participate in two independent experiments, each consisting of a crossover design. In Experiment 1, 32 participants were tested after one night of regular sleep (RS), and after one night of total sleep deprivation (TSD). In Experiment 2, 42 participants were tested following five nights of RS and after five nights of partial sleep deprivation (PSD), implying five hours of sleep per night. In both the experiments, two deliberative decision-making tasks were administered, involving different decision-making constructs. The Mosaic Task (MT) assessed reflection impulsivity, the tendency to gather information before making a decision. The Columbia Card Task cold version (CCTc) evaluated risk-taking propensity in a dynamic environment.

RESULTS

Unlike TSD, PSD led to an increment of reflection impulsivity and risk-taking. Nevertheless, analyses taking into account the individuals' baseline (RS) performance showed consistent results between the two experimental sleep manipulations. Participants who gathered more information to make decisions in the MT when well-rested, then relied on less evidence under sleep loss, and more cautious participants in the CCTc tended to make riskier decisions.

CONCLUSION

Results pointed to differential consequences of sleep deprivation depending on the habitual way to respond during decision-making involving deliberative reasoning processes. Results were interpreted according to a putative interaction between sleep loss effect and individual difference factors.

Sleep problems and attenuated psychotic symptoms in youth at clinical high-risk for psychosis

There has been growing interest on the effect of sleep problems on psychotic and prodromal symptoms. The current study investigated cross-sectional relations between sleep problems and attenuated psychotic symptoms in a large sample of 740 youth at Clinical High Risk (CHR) for psychosis in an attempt to replicate previous findings and assess whether findings from general population samples and psychotic samples extend to this CHR sample. Sleep problems were found to be significantly positively associated with attenuated psychotic symptom severity. Sleep problems were also found to be more closely associated with certain specific prodromal symptoms (e.g., suspiciousness and perceptual abnormalities) than other attenuated psychotic symptoms. Further, we found that depression mediated the cross-sectional association between sleep problems and paranoid symptoms only. This adds to a growing body of evidence suggesting the mediation role of depression is more pronounced for paranoid-type psychotic symptoms as compared to other psychotic symptoms (e.g., hallucinations).

Cognitive Behavioural Therapy for Nightmares for Patients with Persecutory Delusions (Nites): An Assessor-Blind, Pilot Randomized Controlled Trial

OBJECTIVE

Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions.

METHOD

This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs).

RESULTS

All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = -7.0; 95% CI, -12.6 to -1.3; d = -1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (-20.8; 95% CI, -43.2 to 1.7; d = -0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1).

CONCLUSIONS

CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.

Adolescent Paranoia: Prevalence, Structure, and Causal Mechanisms

BACKGROUND

Adolescence can be a challenging time, characterized by self-consciousness, heightened regard for peer acceptance, and fear of rejection. Interpersonal concerns are amplified by unpredictable social interactions, both online and offline. This developmental and social context is potentially conducive to the emergence of paranoia. However, research on paranoia during adolescence is scarce.

METHOD

Our aim was to examine the prevalence, structure, and probabilistic causal mechanisms of adolescent paranoia. A representative school cohort of 801 adolescents (11-15 y) completed measures of paranoia and a range of affective, cognitive, and social factors. A Bayesian approach with Directed Acyclic Graphs (DAGs) was used to assess the causal interactions with paranoia.

RESULTS

Paranoid thoughts were very common, followed a continuous distribution, and were hierarchically structured. There was an overall paranoia factor, with sub-factors of social fears, physical threat fears, and conspiracy concerns. With all other variables controlled, DAG analysis identified paranoia had dependent relationships with negative affect, peer difficulties, bullying, and cognitive-affective responses to social media. The causal directions could not be fully determined, but it was more likely that negative affect contributed to paranoia and paranoia impacted peer relationships. Problematic social media use did not causally influence paranoia.

CONCLUSIONS

There is a continuum of paranoia in adolescence and occasional suspicions are common at this age. Anxiety and depression are closely connected with paranoia and may causally contribute to its development. Paranoia may negatively impact adolescent peer relationships. The clinical significance of paranoia in adolescents accessing mental health services must now be established.

Schizophrenia liability shares common molecular genetic risk factors with sleep duration and nightmares in childhood

Background: Sleep abnormalities are common in schizophrenia, often appearing before psychosis onset; however, the mechanisms behind this are uncertain. We investigated whether genetic risk for schizophrenia is associated with sleep phenotypes. Methods: We used data from 6,058 children and 2,302 mothers from the Avon Longitudinal Study of Parents and Children (ALSPAC). We examined associations between a polygenic risk score for schizophrenia and sleep duration in both children and mothers, and nightmares in children, along with genetic covariances between these traits. Results: Polygenic risk for schizophrenia was associated with increased risk of nightmares (OR=1.07, 95% CI: 1.01, 1.14, p=0.02) in children, and also with less sleep (β=-44.52, 95% CI: -88.98, -0.07; p=0.05). We observed a similar relationship with sleep duration in mothers, although evidence was much weaker (p=0.38). Finally, we found evidence of genetic covariance between schizophrenia risk and reduced sleep duration in children and mothers, and between schizophrenia risk and nightmares in children. Conclusions: These molecular genetic results support recent findings from twin analysis that show genetic overlap between sleep disturbances and psychotic-like experiences. They also show, to our knowledge for the first time, a genetic correlation between schizophrenia liability and risk of nightmares in childhood.

Sleep Disorders in Early Psychosis: Incidence, Severity, and Association With Clinical Symptoms

Sleep disturbance is known to be associated with psychosis, but sleep disorders (eg, insomnia, nightmare disorder, sleep apnea) have rarely been investigated. We aimed to provide the first detailed assessment of sleep disorders and their correlates in patients with early psychosis. Sixty outpatients aged between 18 and 30 with nonaffective psychosis were assessed for sleep disorder presence, severity, and treatment using a structured diagnostic interview, sleep diaries, and actigraphy. Psychotic experiences, mood, and psychological wellbeing were also measured. Forty-eight patients (80%) had at least one sleep disorder, with insomnia and nightmare disorder being the most common. Comorbidity of sleep disorders within this group was high, with an average of 3.3 sleep disorders per patient. Over half of the sleep disorders had been discussed with a clinician but almost three-quarters had received no treatment. Treatment according to clinical guidelines was rare, occurring in only 8% of cases (n = 13). Sleep disorders were significantly associated with increased psychotic experiences, depression, anxiety, fatigue, and lower quality of life. Sleep disorders are very common in patients with psychosis, may have wide-ranging negative effects, and merit routine assessment and treatment in psychiatric practice.

Sleep duration and psychotic experiences in patients at risk of psychosis: A secondary analysis of the EDIE-2 trial

Sleep disturbance is common among individuals at risk of psychosis, yet few studies have investigated the relationship between sleep disturbance and clinical trajectory. The Early Detection and Intervention Evaluation (EDIE-2) trial provides longitudinal data on sleep duration and individual psychotic experiences from a cohort of individuals at risk of psychosis, which this study utilises in an opportunistic secondary analysis. Shorter and more variable sleep was hypothesised to be associated with more severe psychotic experiences and lower psychological wellbeing. Mixed effect models were used to test sleep duration and range as predictors of individual psychotic experiences and psychological wellbeing over the 12-24 months (with assessments every 3 months) in 160 participants. Shorter sleep duration was associated with more severe delusional ideas and hallucinations cross-sectionally and longitudinally. The longitudinal relationships did not remain significant after conservative controls were added for the previous severity of psychotic experiences. No significant relationships were found between the sleep variables and other psychotic experiences (e.g. cognitive disorganisation), or psychological wellbeing. The results support a relationship between shorter sleep duration and delusional ideas and hallucinations. Future studies should focus on improving sleep disturbance measurement, and test whether treating sleep improves clinical trajectory in the at-risk group.

A Twin Study on the Association Between Psychotic Experiences and Tobacco Use During Adolescence

OBJECTIVE

Psychotic experiences (PE) are dimensional phenomena in the general population that resemble psychotic symptoms, such as paranoia and hallucinations. This is the first twin study to explore the degree to which tobacco use and PE share genetic or environmental influences. Previous studies on the association between adolescent tobacco use and PE have not considered PE dimensionally, included negative symptoms, or accounted for confounding by sleep disturbance and stressful life events.

METHOD

An unselected adolescent twin sample (N = 3,787 pairs; mean age = 16.16 years) reported on PE (paranoia, hallucinations, cognitive disorganization, grandiosity, and anhedonia) and regularity of tobacco use. Parents rated the twins' negative symptoms. Regression analyses were conducted while adjusted for sociodemographic characteristics, prenatal maternal smoking, cannabis use, sleep disturbance, and stressful life events. Bivariate twin modeling was used to estimate the degree of genetic and common and unique environmental influences shared between tobacco use and PE.

RESULTS

Regular smokers were significantly more likely to experience paranoia, hallucinations, cognitive disorganization, and negative symptoms (β = 0.17-0.34), but not grandiosity or anhedonia, than nonsmokers, after adjustment for confounders. Paranoia, hallucinations, and cognitive disorganization correlated ≥0.15 with tobacco use (r = 0.15-0.21, all p < .001). Significant genetic correlations (r_A=0.37-0.45) were found. Genetic influences accounted for most of the association between tobacco use and paranoia (84%) and cognitive disorganization (81%). Familial influences accounted for 80% of the association between tobacco use and hallucinations.

CONCLUSION

Tobacco use and PE during adolescence were associated after adjustment for confounders. They appear to co-occur largely because of shared genetic influences.

Schizophrenia liability shares common molecular genetic risk factors with sleep duration and nightmares in childhood

Background: Sleep abnormalities are common in schizophrenia, often appearing before psychosis onset; however, the mechanisms behind this are uncertain. We investigated whether genetic risk for schizophrenia is associated with sleep phenotypes. Methods: We used data from 6,058 children and 2,302 mothers from the Avon Longitudinal Study of Parents and Children (ALSPAC). We examined associations between a polygenic risk score for schizophrenia and sleep duration in both children and mothers, and nightmares in children, along with genetic covariances between these traits. Results: Polygenic risk for schizophrenia was associated with increased risk of nightmares (OR=1.07, 95% CI: 1.01, 1.14, p=0.02) in children, and also with less sleep (β=-44.52, 95% CI: -88.98, -0.07; p=0.05). We observed a similar relationship with sleep duration in mothers, although evidence was much weaker (p=0.38). Finally, we found evidence of genetic covariance between schizophrenia risk and reduced sleep duration in children and mothers, and between schizophrenia risk and nightmares in children. Conclusions: These molecular genetic results support recent findings from twin analysis that show genetic overlap between sleep disturbances and psychotic-like experiences. They also show, to our knowledge for the first time, a genetic correlation between schizophrenia liability and risk of nightmares in childhood.

Insomnia, negative affect, and psychotic experiences: Modelling pathways over time in a clinical observational study

Insomnia has been shown to contribute to the development of psychotic experiences, predominantly via increasing negative affect. However, the role of insomnia in the persistence of psychotic experiences is yet to be investigated in a clinical population. Furthermore, other plausible influences, such as psychotic experiences contributing to insomnia, remain to be evaluated. This study tests the role of insomnia as a predictor of persistence of psychotic experiences versus other potential causal routes. Twenty-nine patients aged 18-30 with non-affective psychosis completed three assessments over three months of their insomnia, negative affect, and psychotic experiences. Mixed effect models allowed comparisons between hypothesis-based models (comprising insomnia as predictor, negative affect as mediator, and psychotic experiences as outcome) and oppositional models, where relationships were reversed. The results supported the hypothesised mediation model above models where negative affect was primary. Insomnia was also found to be a stronger predictor of later hallucinations than vice versa, although a bidirectional relationship was indicated between insomnia and paranoia. In conclusion, insomnia predicts persistence of psychotic experiences over time to the same or greater extent than psychotic experiences contribute to insomnia. This supports insomnia as a potential intervention target in psychosis.

Capturing Rest-Activity Profiles in Schizophrenia Using Wearable and Mobile Technologies: Development, Implementation, Feasibility, and Acceptability of a Remote Monitoring Platform

Background

There is growing interest in the potential for wearable and mobile devices to deliver clinically relevant information in real-world contexts. However, there is limited information on their acceptability and barriers to long-term use in people living with psychosis.

Objective

This study aimed to describe the development, implementation, feasibility, acceptability, and user experiences of the Sleepsight platform, which harnesses consumer wearable devices and smartphones for the passive and unobtrusive capture of sleep and rest-activity profiles in people with schizophrenia living in their homes.

Methods

A total of 15 outpatients with a diagnosis of schizophrenia used a consumer wrist-worn device and smartphone to continuously and remotely gather rest-activity profiles over 2 months. Once-daily sleep and self-rated symptom diaries were also collected via a smartphone app. Adherence with the devices and smartphone app, end-of-study user experiences, and agreement between subjective and objective sleep measures were analyzed. Thresholds for acceptability were set at a wear time or diary response rate of 70% or greater.

Results

Overall, 14 out of 15 participants completed the study. In individuals with a mild to moderate symptom severity at baseline (mean total Positive and Negative Syndrome Scale score 58.4 [SD 14.4]), we demonstrated high rates of engagement with the wearable device (all participants meeting acceptability criteria), sleep diary, and symptom diary (93% and 86% meeting criteria, respectively), with negative symptoms being associated with lower diary completion rate. The end-of-study usability and acceptability questionnaire and qualitative analysis identified facilitators and barriers to long-term use, and paranoia with study devices was not a significant barrier to engagement. Comparison between sleep diary and wearable estimated sleep times showed good correspondence (ρ=0.50, P<.001).

Conclusions

Extended use of wearable and mobile technologies are acceptable to people with schizophrenia living in a community setting. In the future, these technologies may allow predictive, objective markers of clinical status, including early markers of impending relapse.

Is the Ebbinghaus illusion a size contrast illusion?

The Ebbinghaus illusion, in which a central target surrounded by larger context figures looks smaller than when surrounded by smaller context figures, is usually classified as a size contrast illusion. Thus "size contrast" is the dominant account of this effect. However, according to an alternative "contour interaction" account this phenomenon has little to do with size contrast but is rather caused by distance-dependent attractive and repulsive interactions between neural representation of contours. Here evidence is presented against the size contrast account and consistent with the contour interaction account. Experiment 1 was a control study confirming that the illusion can be obtained using displays consisting only of squares, which are more convenient to manipulate than the standardly used circles. In Experiment 2, the standard configuration involving small context figures surrounding the target was compared to a novel configuration, which involved many "spread" small context figures. The illusory effect of the standard context was stronger than the illusory effect of the spread context, in accord with the prediction of the contour interaction account, and contrary to the prediction of the size contrast account. In Experiment 3 two novel configurations were used, based on standard and spread contexts. The results were in accord with the prediction of the contour interaction account, whereas the size contrast account had no prediction because the stimuli did not involve conventional size contrast. Additional aspects of the stimuli and an account of the illusion based on a perspective interpretation are also discussed.

Sleep quality and paranoia: The role of alexithymia, negative emotions and perceptual anomalies

Recent evidence suggests that sleep problems are associated with psychotic like experiences including paranoia. However, the mechanisms underpinning this association are not well understood and thus studies modelling hypothesised mediating factors are required. Alexithymia, the inability to recognise and describe emotions within the self may be an important candidate. In two separate studies we sought to investigate factors mediating the relationship between sleep quality and paranoia using a cross-sectional design. Healthy volunteers without a mental health diagnosis were recruited (study 1, N = 401, study 2, N = 402). Participants completed a series of measures assessing paranoia, negative emotions, alexithymia and perceptual anomalies in an online survey. In study 1, regression and mediation analyses showed that the relationship between sleep quality and paranoia was partially mediated by alexithymia, perceptual anomalies and negative affect. In contrast, study 2 found that the relationship between sleep quality and paranoia was fully mediated by negative affect, alexithymia and perceptual anomalies. The link between sleep quality and paranoia is unclear and reasons for discrepant results are discussed. Novel findings in this study include the link between alexithymia and paranoia.

Treating Sleep Problems in Young People at Ultra-High Risk of Psychosis: A Feasibility Case Series

Background: Our view is that sleep disturbance may be a contributory causal factor in the development and maintenance of psychotic experiences. A recent series of randomized controlled intervention studies has shown that cognitive-behavioural approaches can improve sleep in people with psychotic experiences. However, the effects of psychological intervention for improving sleep have not been evaluated in young people at ultra-high risk of psychosis. Improving sleep might prevent later transition to a mental health disorder. Aims: To assess the feasibility and acceptability of an intervention targeting sleep disturbance in young people at ultra-high risk of psychosis. Method: Patients were sought from NHS mental health services. Twelve young people at ultra-high risk of psychosis with sleep problems were offered an eight-session adapted CBT intervention for sleep problems. The core treatment techniques were stimulus control, circadian realignment, and regulating day-time activity. Participants were assessed before and after treatment and at a one month follow-up. Results: All eligible patients referred to the study agreed to take part. Eleven patients completed the intervention, and one patient withdrew after two sessions. Of those who completed treatment, the attendance rate was 89% and an average of 7.6 sessions (SD = 0.5) were attended. There were large effect size improvements in sleep. Post-treatment, six patients fell below the recommended cut-off for clinical insomnia. There were also improvements in negative affect and psychotic experiences. Conclusion: This uncontrolled feasibility study indicates that treating sleep problems in young people at ultra-high of psychosis is feasible, acceptable, and may be associated with clinical benefits.

A structural equation model of the relationship between insomnia, negative affect, and paranoid thinking

Background

A growing body of evidence points to relationships between insomnia, negative affect, and paranoid thinking. However, studies are needed to examine (i) whether negative affect mediates the relation between insomnia and paranoid thinking, (ii) whether different types of insomnia exert different effects on paranoia, and (iii) to compare the impact of objective and self-reported sleeping difficulties.

Method

Structural equation modelling was therefore used to test competing models of the relationships between self-reported insomnia, negative affect, and paranoia. n = 348 participants completed measures of insomnia, negative affect and paranoia. A subset of these participants (n = 91) went on to monitor their sleep objectively (using a portable sleep monitor made by Zeo) for seven consecutive nights. Associations between objectively recorded sleep, negative affect, and paranoia were explored using linear regression.

Results

The findings supported a fully mediated model where self-reported delayed sleep onset, but not self-reported problems with sleep maintenance or objective measures of sleep, was directly associated with negative affect that, in turn, was associated with paranoia. There was no evidence of a direct association between delayed sleep onset or sleep maintenance problems and paranoia.

Conclusions

Taken together, the findings point to an association between perceived (but not objective) difficulties initially falling asleep (but not maintaining sleep) and paranoid thinking; a relationship that is fully mediated by negative affect. Future research should seek to disentangle the causal relationships between sleep, negative affect, and paranoia (e.g., by examining the effect of an intervention using prospective designs that incorporate experience sampling). Indeed, interventions might profitably target (i) perceived sleep quality, (ii) sleep onset, and / or (iii) emotion regulation as a route to reducing negative affect and, thus, paranoid thinking.