- Email: [email protected]
Sleep disturbance and obsessive-compulsive symptoms: Results from the national comorbidity survey replication
Accepted Manuscript Sleep disturbance and obsessive-compulsive symptoms: Results from the national comorbidity survey replication Rebecca C. Cox, Bunmi O. Olatunji PII:
S0022-3956(16)30006-1
DOI:
10.1016/j.jpsychires.2016.01.007
Reference:
PIAT 2799
To appear in:
Journal of Psychiatric Research
Received Date: 23 August 2015 Revised Date:
25 October 2015
Accepted Date: 7 January 2016
Please cite this article as: Cox RC, Olatunji BO, Sleep disturbance and obsessive-compulsive symptoms: Results from the national comorbidity survey replication, Journal of Psychiatric Research (2016), doi: 10.1016/j.jpsychires.2016.01.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Running Head: SLEEP AND OBSESSIVE-COMPULSIVE SYMPTOMS
Sleep Disturbance and Obsessive-Compulsive Symptoms: Results from the National
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Comorbidity Survey Replication
Rebecca C. Cox1*
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Bunmi O. Olatunji1
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Keywords: Sleep; Obsessions; Compulsions; Depression; OCD; Anxiety
* Correspondence concerning this article should be addressed to Rebecca Cox, Department of
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Psychology, Vanderbilt University, 301 Wilson Hall, 111 21st Avenue South, Nashville, TN 37240, email: [email protected]
1
Department of Psychology, Vanderbilt University, Nashville, TN, USA
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Abstract A small body of developing research has found evidence for sleep disturbance in obsessive-
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compulsive disorder (OCD) and links between sleep disturbance and obsessive-compulsive symptoms (OCS) in unselected samples. However, the link between sleep disturbance and OCS is yet to be examined in a nationally representative sample. Furthermore, the extent to which the
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link between sleep disturbance and OCS is accounted for by symptoms of depression remains unclear. To address this gap in the literature, the present study examined the relationship between
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sleep disturbance and OCS in a nationally representative sample. Participants were assessed in the National Comorbidity Survey Replication (NCS-R; n = 2073). Consistent with predictions, results revealed that individuals with sleep disturbance reported increased OCS severity compared to individuals without sleep disturbance. Further, sleep disturbance severity was associated with OCS severity, even when controlling for depression (and other anxiety-related
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disorders). This study is the first to link sleep disturbance and OCS in a nationally representative sample, and these findings highlight the unique role of sleep disturbance in the experience of
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relationship.
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OCS. Future research is necessary to delineate specific mechanisms that may account for this
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1. Introduction Obsessive-compulsive disorder (OCD) is a debilitating disorder characterized by
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obsessions, or repetitive intrusive, distressing thoughts, and compulsions, or repetitive behaviors performed in order to reduce the distress caused by the obsession (American Psychiatric
Association, 2013). While lifetime prevalence estimates indicate that OCD is relatively rare
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(2.3%), results from a nationally representative sample indicate that approximately 28.2% of the population report experiencing obsessive-compulsive symptoms (OCS) in their lifetime (Ruscio
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et al., 2010). Due to the debilitating nature of the disorder, research efforts have increasingly focused on delineating processes that may maintain OCD. Although the majority of extant research examining sleep disturbance in anxiety disorders has focused on posttraumatic stress disorder (see Babson & Feldner, 2011 for a review), a small body of research suggests that sleep
Paterson et al., 2013).
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disturbance may also contribute to obsessive-compulsive disorder (OCD) (Nota et al., 2015;
Sleep is a critical psychobiological process that is involved in the maintenance of
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physical and mental health (Diekelmann & Born, 2010; Goldstein & Walker, 2014; Xie et al., 2013). Similarly, impaired sleep is linked to diverse downstream consequences, including altered
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neural function (Ma et al., 2015; Yoo et al., 2007), impaired cognitive processes (Drummond et al., 2006; Harrison & Horne, 2000), and dysregulated emotional function (Mauss et al., 2013; Minkel et al., 2012). Similarly, sleep disturbance is comorbid with the majority of psychiatric disorders (Benca et al., 1992), including anxiety disorders (Roth et al., 2006). Indeed, subjective sleep complaints are commonly observed among individuals with an anxiety disorder (Marcks et al., 2009; Ramsawh et al., 2009), and recent research suggests that sleep disturbance predicts the development of an anxiety disorder (Batterham et al., 2012; Neckelman et al., 2007).
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Although relatively few studies have objectively measured sleep in those with OCD, extant research indicates that individuals with OCD exhibit multiple disturbances in sleep compared to healthy controls, including decreased total sleep time (Alfano & Kim, 2011; Insel et
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al., 1982; Rapoport et al., 1981; Voderholzer et al., 2007), increased wake after sleep onset (Alfano & Kim, 2011; Insel et al., 1982; Volderholzer et al., 2007), and decreased sleep
efficiency (Hohagen et al., 1994; Rapoport et al., 1981; Voderholzer et al., 2007). Similarly, self-
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reported sleep disturbance has been linked to OCS in clinical and unselected samples. Among children with OCD, subjective sleep problems are associated with OCS severity (Storch et al.,
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2008), and sleep disturbance is linked to poor OCD treatment outcome (Ivarsson & Skarphedinsson, 2015). Likewise, among unselected samples, increased OCS are linked to delayed sleep timing (Nota & Coles, 2015) and subjective insomnia severity (Raines et al., 2015). Further, one recent study found that subjective insomnia severity is uniquely linked to
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obsessions, and this relationship is not accounted for by depression (Timpano et al., 2014). The available evidence suggests that the presence of sleep disturbance may compound the severity and impairment of OCD (Ivarsson & Skarphedinsson, 2015; Robinson et al., 1998).
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However, no study to date has assessed this relationship in a nationally representative sample. Such a study is critical in order to assess whether the link between sleep disturbance and OCS is
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limited to specific subgroups (i.e., undergraduate students; individuals with OCD) or whether this relationship is present in the general population. Evidence for links between sleep disturbance and OCS in the general population may point to a unique role of sleep disturbance in the development of OCS in clinical and subclinical individuals. Such a role may provide evidence for the utility of incorporating sleep-related interventions into a more comprehensive approach to the treatment of OCD. The current study addresses this limitation in the extant
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research by assessing the link between subjective sleep disturbance and OCS in the National Comorbidity Survey Replication (NCS-R). It was hypothesized that individuals with sleep disturbance would report increased OCS compared to individuals without sleep disturbance. A
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careful review of the literature suggests that many of the sleep disturbances associated with OCS are also characteristic of depression. Although some research suggests that the link between subjective sleep disturbance and symptoms of OCD is not accounted for by depression (Timpano
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et al., 2014), others have found that depression may explain this relationship (Diaz-Roman et al., 2015). Given the inconsistent findings in the literature, the present study also examined the
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extent to which sleep disturbance severity is associated with OCS severity when controlling for depression. 2. Materials and Methods 2.1 Sample
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The NCS-R is a nationally representative survey of English-speaking adults (18 or older) residing in the United States who participated in in-person interviews in their homes between February 2001 and April 2003 (see Kessler et al., 2004 for a detailed description of survey
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procedure). All survey participants completed Part I of the survey, which assessed for core psychological disorders (n = 9282), and a subset of participants completed Part II, which
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assessed for additional disorders and clinical correlates, including insomnia (n = 5692). Of the Part II participants, a random subsample (n = 2073) were administered the module assessing OCD. Of the participants who were administered the OCD module, 2 refused to respond, which yielded a final sample of n = 2071 participants included in analysis. Informed consent was obtained from all participants.
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The sample was 50.2% female with a mean age of 45.22 years (SE = .57) ranging from 18 to 94 years. The racial composition of the sample was as follows: Black (12.5%), Hispanic (11.4%), White (72.1%), Other (4.0%). The majority of the participants were married (56.2%),
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while 19.9% were separated, widowed, or divorced, and 23.8% were never married. The years of education obtained by the sample were as follows: 0-11 years (17.1%), 12 years (32.3%), 13-15 years (26.2%), more than 16 years (24.4%).
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2.2 Measures
OCS. OCD was assessed with the World Health Organization Composite International
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Diagnostic Interview 3.0 (CIDI 3.0; Kessler & Ustun, 2004). Due to a skip logic error discovered following survey administration (Ruscio et al., 2010), only the first 9 items of the OCD module were examined in the present study. Participants completed 9 yes/no items regarding 9 subtypes of OCD (contamination, checking, ordering, hoarding, sexual/religious, moral, harming, illness,
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other) in response to the following prompt: “Did you ever have a period in your life lasting two weeks or longer when most days you experienced any of the following unpleasant thoughts, images, or impulses, or repeated behaviors that you felt compelled to do?” An OCS severity
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score was created by summing the responses on these 9 items. Sleep Disturbance. Sleep disturbance was assessed in the Chronic Conditions section of
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the CIDI 3.0 with 4 yes/no items each measuring problems with sleep initiation, sleep maintenance, early morning awakening, and daytime sleepiness in response to the following prompt: “Did you have a period lasting two weeks or longer in the past 12 months when you had any of the following problems with your sleep?” Participants endorsing one or more sleep problem were coded as presenting with sleep disturbance, while participants endorsing no sleep
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problem were coded as having no sleep disturbance. Further, a sleep disturbance severity score (0-4) was created by summing the responses on these 4 items. Depression. Depression was assessed with the CIDI 3.0 (Kessler & Ustun, 2004). In the
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present study, depression was defined as experiencing a major depressive episode in the past 12 months. 2.3 Data Analytic Strategy
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All analyses were conducted in SPSS 20.0 using the Part II sample weighting. First, an independent samples t-test was conducted to assess whether individuals who report sleep
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disturbance report increased OCS severity compared to individuals who do not report sleep disturbance. Cohen’s d was calculated using G*Power 3.1 (Faul et al., 2009). Second, an analysis of covariance (ANCOVA) was conducted to assess whether sleep disturbance severity is associated with OCS severity when controlling for depression. Depression was included in the
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model because depression is often comorbid with OCD (Ruscio et al., 2010) and sleep disturbance (Soehner et al., 2014). Cohen’s f was calculated using G*Power 3.1 (Faul et al., 2009).
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3. Results
3.1 Associations Between Study Variables and Frequency of Relevant Disorders
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As shown in Table 1, sleep disturbance severity and major depressive episode in the past
12 months were significantly associated with presence of any lifetime OCS, while presence of sleep disturbance was not significantly associated with presence of lifetime OCS. Further, 42.5% of participants reported the presence of sleep disturbance in the past 12 months, 28.2% reported having experienced OCS in their lifetime, and 7.7% met criteria for a major depressive episode
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in the past 12 months. Presence of additional anxiety disorders and substance use disorders in the past 12 months are shown in Table 2. 3.2 OCS Severity in Participants With and Without Sleep Disturbance
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Results of a t-test revealed that participants who reported sleep disturbance reported significantly increased OCS severity (M = 0.82, SE = 0.06) compared to participants who reported no sleep disturbance (M = 0.31, SE = 0.03), t(42) = 8.73, d = 10.93 p < 0.001.
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3.3 Association Between Sleep Disturbance and OCS Severity
As shown in Table 3, results of an ANCOVA revealed that sleep disturbance severity was
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significantly associated with OCS severity when controlling for depression, F (1, 42) = 47.80, p < 0.001. The total model was significant, F (2, 41) = 70.71, f = .36, p < 0.001, and depression and sleep disturbance severity were significantly associated with OCS severity (see Table 2). Additional ANCOVA models were analyzed to test the association between sleep
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disturbance severity and OCS severity when controlling for other anxiety-related disorders. In all models, sleep disturbance severity remained significantly associated with OCS severity (see Table 4).
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4. Discussion
The present study examined the relationship between sleep disturbance and OCS in a
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nationally representative sample. The results of this study indicate that individuals with sleep disturbance report increased OCS compared to individuals without sleep disturbance. This finding is consistent with previous research linking sleep disturbance with increased symptoms of psychopathology (Tkachenko et al., 2014), including OCS (Raines et al., 2015). Importantly, these findings suggest that the link between sleep disturbance and OCS is not limited to clinical-
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level insomnia, but rather that even minor sleep disturbance may increase the likelihood of experiencing OCS in a diverse and representative sample. The present study also found that sleep disturbance severity is associated with OCS
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severity, even when controlling for depression. This result is consistent with extant research linking insomnia symptoms to OCS when controlling for depression (Timpano et al., 2014) and extends this research by replicating this result in a nationally representative sample. Symptoms
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of depression and OCD often co-occur. However, the results of the present study indicate that increased sleep disturbance severity is linked to increased levels of OCS, and this relationship is
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not accounted for by co-occurring depression. The present study also extends previous research in showing that the link between increased sleep disturbance and increased levels of OCS is also not accounted for by co-occurring anxiety disorder diagnoses. This finding reinforces the notion that the link between sleep disturbance and OCS is unlikely to be a mere artifact of general
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negative affect.
Although these findings indicate a potentially unique link between sleep disturbance and the severity of OCS, the specific mechanism(s) that may account for this relationship is unclear.
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It may be the case that the adverse downstream effects of sleep loss, such as impaired executive function (Harrison & Horne, 2000), dysregulated diurnal cortisol (Wright et al., 2015), and
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deficits in systems related to emotional function (Harvey et al., 2011), may increase the likelihood of experiencing symptoms of OCD. Given the cross-sectional nature of the present study, an alternative interpretation may be that repetitive intrusive and distressing thoughts contribute to sleep disturbance by interfering with the initiation and maintenance of sleep. Indeed, extant research indicating high comorbidity between Delayed Phased Sleep Disorder (DPSD) and OCD suggests that sleep disturbance in OCD may be a function of delayed sleep
ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 10 onset (Lange et al., 2012; Turner et al., 2007). Future research is necessary to elucidate mechanisms that may explain why sleep disturbance is linked to OCS. The results of this study indicate that sleep disturbance is related to OCS severity, and
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this finding suggests that addressing sleep disturbance may be useful in the treatment of OCD. Indeed, recent research indicates that persistent sleep problems following OCD treatment are associated with worse treatment outcome (Ivarsson & Skarphedinsson, 2015). However, the
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assessment of OCS in the present study should not be confused with the assessment of OCD per se. Although the representative sample consisted of individuals with a diagnosis of OCD, the
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majority of the participants were in the nonclinical range. Despite this study limitation, it is important to note that taxometric research has shown that OCS are present to a greater or lesser extent in all individuals (Olatunji et al., 2008). Accordingly, the present findings in a nationally representative population are likely to be generalizable to understanding the etiology,
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maintenance, and treatment of OCD.
The results of this study are the first to find that individuals with sleep disturbance report increased OCS and that sleep disturbance severity is linked to OCS severity, even when
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controlling for depression, in a nationally representative population. However, these findings must be considered within the context of additional study limitations. First, sleep disturbance
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was measured subjectively in this study. As the majority of previous research indicating sleep disturbance in OCD utilized objective sleep measurement, future research is necessary to replicate these findings with objective assessments of sleep disturbance. Similarly, the assessment of OCS in the present study was not comprehensive. Additional research utilizing a more thorough assessment of OCS severity is necessary to replicate these findings. Furthermore, the cross-sectional and correlational nature of the present study limits the ability to make
ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 11 inferences about direction or causality. Future research employing longitudinal designs and
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experimental manipulation of sleep is necessary to compliment the present findings.
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ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 17 Table 1 Associations between study measures and presence of lifetime OC symptoms (n = 2071). Measures OR 95% CI 1.40
.91-2.16
2. SDS
.78*
.67-.92
4. DEP
2.52**
1.81-3.50
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1. SDP
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Note. SDP = Sleep disturbance present; SDS = Sleep disturbance severity; DEP = Major depressive episode in the last 12 months. * p < .01; * p < .001
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Percentage of sample meeting criteria for anxiety-related disorders and substance use disorders in the past 12 months. Disorder 12-month frequency 1. Generalized Anxiety Disorder
3.7%
2. Specific Phobia
9%
3. Social Phobia
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7%
4. Panic Disorder
2%
3.3%
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5. Posttraumatic Stress Disorder 6. Alcohol Dependence
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7. Drug Dependence
1.6% 0.6%
ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 19 Table 3
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Summary of the Associations Between Sleep Disturbance Severity (SDS), Depression (DEP), and OCS Severity Variable Coefficient Std. Error t p 95% CI Estimate .88 .13 6.91 .62-1.13 < 0.001 DEP .19 .03 6.91 .13-.24 < 0.001 SDS R2 = .11* * p < .001.
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.08 61.90
<.001
58.67
Panic Disorder
.09 46.94
<.001
69.85
Posttraumatic Stress Disorder
.08 47.0
<.001
62.84
Social Phobia
.09 42.95
<.001
Specific Phobia
.10 50.94
<.001
<.001 <.001
<.001
87.19
<.001
64.65
<.001
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Generalized Anxiety Disorder
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Associations Between Sleep Disturbance Severity (SDS) and and OCS Severity when Controlling for Specific Anxiety-Related Disorders Anxiety Disorder R2 Total Model Total SDS Wald F SDS Wald F Model p controlling for Model p Disorder
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Acknowledgment: We would like to thank the members of the NCS-R research group for making their data available. A list of other NCS-R publications and the measures used in the NCS-R is available at http://www.hcp.med.harvard.edu/ncs.
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Contributors: Ms. Cox designed the study and performed the statistical analyses. Ms. Cox and Dr. Olatunji participated in the preparation of the manuscript and approved the final version.
S0022-3956(16)30006-1
DOI:
10.1016/j.jpsychires.2016.01.007
Reference:
PIAT 2799
To appear in:
Journal of Psychiatric Research
Received Date: 23 August 2015 Revised Date:
25 October 2015
Accepted Date: 7 January 2016
Please cite this article as: Cox RC, Olatunji BO, Sleep disturbance and obsessive-compulsive symptoms: Results from the national comorbidity survey replication, Journal of Psychiatric Research (2016), doi: 10.1016/j.jpsychires.2016.01.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Running Head: SLEEP AND OBSESSIVE-COMPULSIVE SYMPTOMS
Sleep Disturbance and Obsessive-Compulsive Symptoms: Results from the National
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Comorbidity Survey Replication
Rebecca C. Cox1*
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Bunmi O. Olatunji1
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Keywords: Sleep; Obsessions; Compulsions; Depression; OCD; Anxiety
* Correspondence concerning this article should be addressed to Rebecca Cox, Department of
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Psychology, Vanderbilt University, 301 Wilson Hall, 111 21st Avenue South, Nashville, TN 37240, email: [email protected]
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Department of Psychology, Vanderbilt University, Nashville, TN, USA
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Abstract A small body of developing research has found evidence for sleep disturbance in obsessive-
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compulsive disorder (OCD) and links between sleep disturbance and obsessive-compulsive symptoms (OCS) in unselected samples. However, the link between sleep disturbance and OCS is yet to be examined in a nationally representative sample. Furthermore, the extent to which the
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link between sleep disturbance and OCS is accounted for by symptoms of depression remains unclear. To address this gap in the literature, the present study examined the relationship between
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sleep disturbance and OCS in a nationally representative sample. Participants were assessed in the National Comorbidity Survey Replication (NCS-R; n = 2073). Consistent with predictions, results revealed that individuals with sleep disturbance reported increased OCS severity compared to individuals without sleep disturbance. Further, sleep disturbance severity was associated with OCS severity, even when controlling for depression (and other anxiety-related
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disorders). This study is the first to link sleep disturbance and OCS in a nationally representative sample, and these findings highlight the unique role of sleep disturbance in the experience of
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relationship.
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OCS. Future research is necessary to delineate specific mechanisms that may account for this
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1. Introduction Obsessive-compulsive disorder (OCD) is a debilitating disorder characterized by
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obsessions, or repetitive intrusive, distressing thoughts, and compulsions, or repetitive behaviors performed in order to reduce the distress caused by the obsession (American Psychiatric
Association, 2013). While lifetime prevalence estimates indicate that OCD is relatively rare
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(2.3%), results from a nationally representative sample indicate that approximately 28.2% of the population report experiencing obsessive-compulsive symptoms (OCS) in their lifetime (Ruscio
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et al., 2010). Due to the debilitating nature of the disorder, research efforts have increasingly focused on delineating processes that may maintain OCD. Although the majority of extant research examining sleep disturbance in anxiety disorders has focused on posttraumatic stress disorder (see Babson & Feldner, 2011 for a review), a small body of research suggests that sleep
Paterson et al., 2013).
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disturbance may also contribute to obsessive-compulsive disorder (OCD) (Nota et al., 2015;
Sleep is a critical psychobiological process that is involved in the maintenance of
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physical and mental health (Diekelmann & Born, 2010; Goldstein & Walker, 2014; Xie et al., 2013). Similarly, impaired sleep is linked to diverse downstream consequences, including altered
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neural function (Ma et al., 2015; Yoo et al., 2007), impaired cognitive processes (Drummond et al., 2006; Harrison & Horne, 2000), and dysregulated emotional function (Mauss et al., 2013; Minkel et al., 2012). Similarly, sleep disturbance is comorbid with the majority of psychiatric disorders (Benca et al., 1992), including anxiety disorders (Roth et al., 2006). Indeed, subjective sleep complaints are commonly observed among individuals with an anxiety disorder (Marcks et al., 2009; Ramsawh et al., 2009), and recent research suggests that sleep disturbance predicts the development of an anxiety disorder (Batterham et al., 2012; Neckelman et al., 2007).
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Although relatively few studies have objectively measured sleep in those with OCD, extant research indicates that individuals with OCD exhibit multiple disturbances in sleep compared to healthy controls, including decreased total sleep time (Alfano & Kim, 2011; Insel et
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al., 1982; Rapoport et al., 1981; Voderholzer et al., 2007), increased wake after sleep onset (Alfano & Kim, 2011; Insel et al., 1982; Volderholzer et al., 2007), and decreased sleep
efficiency (Hohagen et al., 1994; Rapoport et al., 1981; Voderholzer et al., 2007). Similarly, self-
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reported sleep disturbance has been linked to OCS in clinical and unselected samples. Among children with OCD, subjective sleep problems are associated with OCS severity (Storch et al.,
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2008), and sleep disturbance is linked to poor OCD treatment outcome (Ivarsson & Skarphedinsson, 2015). Likewise, among unselected samples, increased OCS are linked to delayed sleep timing (Nota & Coles, 2015) and subjective insomnia severity (Raines et al., 2015). Further, one recent study found that subjective insomnia severity is uniquely linked to
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obsessions, and this relationship is not accounted for by depression (Timpano et al., 2014). The available evidence suggests that the presence of sleep disturbance may compound the severity and impairment of OCD (Ivarsson & Skarphedinsson, 2015; Robinson et al., 1998).
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However, no study to date has assessed this relationship in a nationally representative sample. Such a study is critical in order to assess whether the link between sleep disturbance and OCS is
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limited to specific subgroups (i.e., undergraduate students; individuals with OCD) or whether this relationship is present in the general population. Evidence for links between sleep disturbance and OCS in the general population may point to a unique role of sleep disturbance in the development of OCS in clinical and subclinical individuals. Such a role may provide evidence for the utility of incorporating sleep-related interventions into a more comprehensive approach to the treatment of OCD. The current study addresses this limitation in the extant
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research by assessing the link between subjective sleep disturbance and OCS in the National Comorbidity Survey Replication (NCS-R). It was hypothesized that individuals with sleep disturbance would report increased OCS compared to individuals without sleep disturbance. A
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careful review of the literature suggests that many of the sleep disturbances associated with OCS are also characteristic of depression. Although some research suggests that the link between subjective sleep disturbance and symptoms of OCD is not accounted for by depression (Timpano
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et al., 2014), others have found that depression may explain this relationship (Diaz-Roman et al., 2015). Given the inconsistent findings in the literature, the present study also examined the
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extent to which sleep disturbance severity is associated with OCS severity when controlling for depression. 2. Materials and Methods 2.1 Sample
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The NCS-R is a nationally representative survey of English-speaking adults (18 or older) residing in the United States who participated in in-person interviews in their homes between February 2001 and April 2003 (see Kessler et al., 2004 for a detailed description of survey
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procedure). All survey participants completed Part I of the survey, which assessed for core psychological disorders (n = 9282), and a subset of participants completed Part II, which
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assessed for additional disorders and clinical correlates, including insomnia (n = 5692). Of the Part II participants, a random subsample (n = 2073) were administered the module assessing OCD. Of the participants who were administered the OCD module, 2 refused to respond, which yielded a final sample of n = 2071 participants included in analysis. Informed consent was obtained from all participants.
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The sample was 50.2% female with a mean age of 45.22 years (SE = .57) ranging from 18 to 94 years. The racial composition of the sample was as follows: Black (12.5%), Hispanic (11.4%), White (72.1%), Other (4.0%). The majority of the participants were married (56.2%),
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while 19.9% were separated, widowed, or divorced, and 23.8% were never married. The years of education obtained by the sample were as follows: 0-11 years (17.1%), 12 years (32.3%), 13-15 years (26.2%), more than 16 years (24.4%).
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2.2 Measures
OCS. OCD was assessed with the World Health Organization Composite International
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Diagnostic Interview 3.0 (CIDI 3.0; Kessler & Ustun, 2004). Due to a skip logic error discovered following survey administration (Ruscio et al., 2010), only the first 9 items of the OCD module were examined in the present study. Participants completed 9 yes/no items regarding 9 subtypes of OCD (contamination, checking, ordering, hoarding, sexual/religious, moral, harming, illness,
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other) in response to the following prompt: “Did you ever have a period in your life lasting two weeks or longer when most days you experienced any of the following unpleasant thoughts, images, or impulses, or repeated behaviors that you felt compelled to do?” An OCS severity
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score was created by summing the responses on these 9 items. Sleep Disturbance. Sleep disturbance was assessed in the Chronic Conditions section of
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the CIDI 3.0 with 4 yes/no items each measuring problems with sleep initiation, sleep maintenance, early morning awakening, and daytime sleepiness in response to the following prompt: “Did you have a period lasting two weeks or longer in the past 12 months when you had any of the following problems with your sleep?” Participants endorsing one or more sleep problem were coded as presenting with sleep disturbance, while participants endorsing no sleep
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problem were coded as having no sleep disturbance. Further, a sleep disturbance severity score (0-4) was created by summing the responses on these 4 items. Depression. Depression was assessed with the CIDI 3.0 (Kessler & Ustun, 2004). In the
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present study, depression was defined as experiencing a major depressive episode in the past 12 months. 2.3 Data Analytic Strategy
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All analyses were conducted in SPSS 20.0 using the Part II sample weighting. First, an independent samples t-test was conducted to assess whether individuals who report sleep
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disturbance report increased OCS severity compared to individuals who do not report sleep disturbance. Cohen’s d was calculated using G*Power 3.1 (Faul et al., 2009). Second, an analysis of covariance (ANCOVA) was conducted to assess whether sleep disturbance severity is associated with OCS severity when controlling for depression. Depression was included in the
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model because depression is often comorbid with OCD (Ruscio et al., 2010) and sleep disturbance (Soehner et al., 2014). Cohen’s f was calculated using G*Power 3.1 (Faul et al., 2009).
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3. Results
3.1 Associations Between Study Variables and Frequency of Relevant Disorders
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As shown in Table 1, sleep disturbance severity and major depressive episode in the past
12 months were significantly associated with presence of any lifetime OCS, while presence of sleep disturbance was not significantly associated with presence of lifetime OCS. Further, 42.5% of participants reported the presence of sleep disturbance in the past 12 months, 28.2% reported having experienced OCS in their lifetime, and 7.7% met criteria for a major depressive episode
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in the past 12 months. Presence of additional anxiety disorders and substance use disorders in the past 12 months are shown in Table 2. 3.2 OCS Severity in Participants With and Without Sleep Disturbance
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Results of a t-test revealed that participants who reported sleep disturbance reported significantly increased OCS severity (M = 0.82, SE = 0.06) compared to participants who reported no sleep disturbance (M = 0.31, SE = 0.03), t(42) = 8.73, d = 10.93 p < 0.001.
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3.3 Association Between Sleep Disturbance and OCS Severity
As shown in Table 3, results of an ANCOVA revealed that sleep disturbance severity was
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significantly associated with OCS severity when controlling for depression, F (1, 42) = 47.80, p < 0.001. The total model was significant, F (2, 41) = 70.71, f = .36, p < 0.001, and depression and sleep disturbance severity were significantly associated with OCS severity (see Table 2). Additional ANCOVA models were analyzed to test the association between sleep
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disturbance severity and OCS severity when controlling for other anxiety-related disorders. In all models, sleep disturbance severity remained significantly associated with OCS severity (see Table 4).
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4. Discussion
The present study examined the relationship between sleep disturbance and OCS in a
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nationally representative sample. The results of this study indicate that individuals with sleep disturbance report increased OCS compared to individuals without sleep disturbance. This finding is consistent with previous research linking sleep disturbance with increased symptoms of psychopathology (Tkachenko et al., 2014), including OCS (Raines et al., 2015). Importantly, these findings suggest that the link between sleep disturbance and OCS is not limited to clinical-
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level insomnia, but rather that even minor sleep disturbance may increase the likelihood of experiencing OCS in a diverse and representative sample. The present study also found that sleep disturbance severity is associated with OCS
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severity, even when controlling for depression. This result is consistent with extant research linking insomnia symptoms to OCS when controlling for depression (Timpano et al., 2014) and extends this research by replicating this result in a nationally representative sample. Symptoms
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of depression and OCD often co-occur. However, the results of the present study indicate that increased sleep disturbance severity is linked to increased levels of OCS, and this relationship is
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not accounted for by co-occurring depression. The present study also extends previous research in showing that the link between increased sleep disturbance and increased levels of OCS is also not accounted for by co-occurring anxiety disorder diagnoses. This finding reinforces the notion that the link between sleep disturbance and OCS is unlikely to be a mere artifact of general
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negative affect.
Although these findings indicate a potentially unique link between sleep disturbance and the severity of OCS, the specific mechanism(s) that may account for this relationship is unclear.
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It may be the case that the adverse downstream effects of sleep loss, such as impaired executive function (Harrison & Horne, 2000), dysregulated diurnal cortisol (Wright et al., 2015), and
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deficits in systems related to emotional function (Harvey et al., 2011), may increase the likelihood of experiencing symptoms of OCD. Given the cross-sectional nature of the present study, an alternative interpretation may be that repetitive intrusive and distressing thoughts contribute to sleep disturbance by interfering with the initiation and maintenance of sleep. Indeed, extant research indicating high comorbidity between Delayed Phased Sleep Disorder (DPSD) and OCD suggests that sleep disturbance in OCD may be a function of delayed sleep
ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 10 onset (Lange et al., 2012; Turner et al., 2007). Future research is necessary to elucidate mechanisms that may explain why sleep disturbance is linked to OCS. The results of this study indicate that sleep disturbance is related to OCS severity, and
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this finding suggests that addressing sleep disturbance may be useful in the treatment of OCD. Indeed, recent research indicates that persistent sleep problems following OCD treatment are associated with worse treatment outcome (Ivarsson & Skarphedinsson, 2015). However, the
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assessment of OCS in the present study should not be confused with the assessment of OCD per se. Although the representative sample consisted of individuals with a diagnosis of OCD, the
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majority of the participants were in the nonclinical range. Despite this study limitation, it is important to note that taxometric research has shown that OCS are present to a greater or lesser extent in all individuals (Olatunji et al., 2008). Accordingly, the present findings in a nationally representative population are likely to be generalizable to understanding the etiology,
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maintenance, and treatment of OCD.
The results of this study are the first to find that individuals with sleep disturbance report increased OCS and that sleep disturbance severity is linked to OCS severity, even when
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controlling for depression, in a nationally representative population. However, these findings must be considered within the context of additional study limitations. First, sleep disturbance
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was measured subjectively in this study. As the majority of previous research indicating sleep disturbance in OCD utilized objective sleep measurement, future research is necessary to replicate these findings with objective assessments of sleep disturbance. Similarly, the assessment of OCS in the present study was not comprehensive. Additional research utilizing a more thorough assessment of OCS severity is necessary to replicate these findings. Furthermore, the cross-sectional and correlational nature of the present study limits the ability to make
ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 11 inferences about direction or causality. Future research employing longitudinal designs and
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experimental manipulation of sleep is necessary to compliment the present findings.
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ACCEPTED MANUSCRIPT Sleep and Obsessive-Compulsive Symptoms 17 Table 1 Associations between study measures and presence of lifetime OC symptoms (n = 2071). Measures OR 95% CI 1.40
.91-2.16
2. SDS
.78*
.67-.92
4. DEP
2.52**
1.81-3.50
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1. SDP
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Note. SDP = Sleep disturbance present; SDS = Sleep disturbance severity; DEP = Major depressive episode in the last 12 months. * p < .01; * p < .001
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Percentage of sample meeting criteria for anxiety-related disorders and substance use disorders in the past 12 months. Disorder 12-month frequency 1. Generalized Anxiety Disorder
3.7%
2. Specific Phobia
9%
3. Social Phobia
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7%
4. Panic Disorder
2%
3.3%
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5. Posttraumatic Stress Disorder 6. Alcohol Dependence
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7. Drug Dependence
1.6% 0.6%
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Summary of the Associations Between Sleep Disturbance Severity (SDS), Depression (DEP), and OCS Severity Variable Coefficient Std. Error t p 95% CI Estimate .88 .13 6.91 .62-1.13 < 0.001 DEP .19 .03 6.91 .13-.24 < 0.001 SDS R2 = .11* * p < .001.
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.08 61.90
<.001
58.67
Panic Disorder
.09 46.94
<.001
69.85
Posttraumatic Stress Disorder
.08 47.0
<.001
62.84
Social Phobia
.09 42.95
<.001
Specific Phobia
.10 50.94
<.001
<.001 <.001
<.001
87.19
<.001
64.65
<.001
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Generalized Anxiety Disorder
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Associations Between Sleep Disturbance Severity (SDS) and and OCS Severity when Controlling for Specific Anxiety-Related Disorders Anxiety Disorder R2 Total Model Total SDS Wald F SDS Wald F Model p controlling for Model p Disorder
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Acknowledgment: We would like to thank the members of the NCS-R research group for making their data available. A list of other NCS-R publications and the measures used in the NCS-R is available at http://www.hcp.med.harvard.edu/ncs.
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Contributors: Ms. Cox designed the study and performed the statistical analyses. Ms. Cox and Dr. Olatunji participated in the preparation of the manuscript and approved the final version.