Sleep in Schizophrenia: Exploring Subjective Experiences of Sleep Problems, and Implications for Treatment

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.

Schizophrenia and sleep disorders: links, risks, and management challenges

“…For example, some patients with sleep disturbances and schizophrenia have negative cognitions associated with sleep, such as nighttime rumination, negative beliefs about the cause of sleep problems, overestimating the health impact of poor sleep, and lack of knowledge of sleep hygiene. 65 , 66 These patients may require targeted psychological interventions to change cognitions surrounding sleep and improve sleep-related habits, rather than implementing a pharmaceutical intervention. Cognitive behavioral therapy has been shown to effectively treat insomnia in patients with schizophrenia, with treatment strategies including stimulus control and increasing daytime activity levels.…”

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

“…Sleep disturbance in general has been increasingly associated with psychotic experiences in both clinical and non-clinical populations ( Chiu et al., 2016 , Davies et al., 2017 , Koyanagi and Stickley, 2015 ) . However, there is a surprising lack of studies investigating the relationship between insomnia (as a specific sleep disorder) and psychosis in individuals with a psychotic disorder ( Reeve et al., 2015 ).…”

Cognitive Behavioral Therapy for Insomnia as Adjunctive Therapy to Antipsychotics in Schizophrenia: A Case Report

“…During the courses of CBT-i treatment, the authors and the patient focused mainly on the four causes cited by Chiu et al ( 30 ), and the 12 problems cited by Waite et al ( 31 ). For instance, as Chiu's fourth cause, the medication side effects were evident as the source of the true problem of sleep disturbance in the sixth session, and the authors and the patient could therefore agree to stop chlorpromazine.…”

“…Six months after his second admission, the authors and the patient started CBT-i according to the CBT-i therapeutic manual ( 29 ). The authors also referred to the four causes cited by Chiu et al ( 30 ): (a) beliefs that sleep problems cannot be changed; (b) trauma and adversity; (c) lifestyle choices and lack of motivation; (d) medication side effects and the 12 problems cited by Waite et al ( 31 ): (a) Poor sleep environment; (b) Lack of daytime activity; (c) Lack of evening activity; (d) Disrupted circadian rhythm; (e) Sleep as an escape from distressing experiences; (f) Fear of bed; (g) Nightmares; (h) Night-time awakenings; (i) Sleep disrupted by voices/paranoia; (j) Worry; (k) Neuroleptic medication side effects; and (l) Reducing hypnotics. Our CBT-i consisted of eight sessions with each session ranging from 30 to 45 min.…”