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BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality
Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality Shaunt A. Markarian, Scott M. Pickett n, Danielle F. Deveson, Brenda B. Kanona Oakland University, Rochester, MI, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 29 October 2012 Received in revised form 6 June 2013 Accepted 7 June 2013
Recent research has indicated that interactions between behavioral inhibition system (BIS)/behavioral activation system (BAS) sensitivity and emotion regulation (ER) difficulties increases risk for psychopathology. Considering sleep quality (SQ) has been linked to emotion regulation difficulties (ERD) and psychopathology, further investigation of a possible mechanism is needed. The current study examined associations between BIS/BAS sensitivity, ERD, and SQ to depression, anxiety, and stress symptoms in an undergraduate sample (n ¼ 459). Positive relationships between BIS sensitivity and both ERD and stress symptoms, and negative relationships between BAS-reward sensitivity and both ERD and depression symptoms were observed. Furthermore, ERD were positively related to depression, anxiety, and stress symptoms. Succeeding analyses revealed differential relationships between ERD and depression, anxiety, and stress symptoms among good quality and poor quality sleepers. The findings are discussed within the context of personality dimensions and self-regulatory mechanisms, along with implications for the treatment of depression, anxiety and sleep difficulties. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Reinforcement sensitivity theory Emotion regulation Sleep quality Depression Anxiety
1. Introduction Recently, emotion regulation difficulties (ERD) have been suggested as a possible explanatory mechanism in the relationship between behavioral inhibition system (BIS) and behavioral activation system (BAS) sensitivity and psychopathology (Bijttebier et al., 2009). There is evidence linking sleep and ERD (Baglioni et al., 2010) and sleep difficulties to psychopathology (Morin and Ware, 1996), but no evidence linking sleep difficulties to BIS/BAS sensitivity. The extant literature on personality dimensions and SQ suggests that personality dimensions associated with negative outcomes are also linked to poor SQ (Gray and Watson, 2002). Given there is limited research examining the association between BIS and BAS sensitivity and sleep difficulties, especially in relation to ERD and psychopathology, the current study aimed to understand the relationships among these variables. Specifically, the links between BIS/BAS sensitivity, ERD, and depression, anxiety, and stress symptomology were examined across SQ groups.
1.1. Revised reinforcement sensitivity theory The revised reinforcement sensitivity theory (rRST; Corr and McNaughton, 2008) postulates three subsystems: BIS, BAS, and the n Correspondence to: Department of Psychology, Oakland University, 209 Pryale Hall, 2200 N. Squirrel Road, Rochester, MI 48309, USA. Tel.: +1 248 370 2307. E-mail address: [email protected] (S.M. Pickett).
fight-flight-freeze system (FFFS). The BIS resolves goal conflict between the BAS and FFFS, and is experienced as negative affect (i.e., anxiety). Alternatively, the BAS responds to rewarding or appetitive stimuli with approach behaviors, and is experienced as positive affect. The FFFS responds to aversive stimuli or threats of non-reward, and relies on the BIS in order to function in accordance with its goals. If BIS successfully inhibits behavior when confronted with aversive stimuli, the FFFS is activated and escape behaviors are engaged; if BIS fails to inhibit behavior, BAS is activated and approach behaviors are engaged. Further, the BAS has been conceptualized as three inter-related dimensions: BASfun-seeking (BAS-fun), BAS-drive, and BAS-reward responsiveness (BAS-reward; Carver and White, 1994). The drive and reward subscales are proposed to play a larger role in responding to cues of impending reward in the midst of behavioral efforts, while BASfun is believed to have a greater impact in determining the extent to which potentially rewarding situations entice engagement (Carver and White, 1994). All of the BAS dimensions have been associated with positive affectivity (Jorm et al., 1999) and some form of impulsivity (Leone and Russo, 2009). Recent research has suggested that BAS-fun may be associated with dysfunctional impulsivity, while BAS-drive and BAS-reward are associated with functional impulsivity (Leone and Russo, 2009). Research has been relatively consistent linking high BIS sensitivity to anxiety-related symptomology, and low BAS sensitivity to depression-related symptomology (Bijttebier et al., 2009). Further, complex interactive patterns of BIS and BAS sensitivity have been associated with poorer mental health outcomes (Hundt et al., 2007).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.06.004
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
S.A. Markarian et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Although there are established relationships between BIS/BAS sensitivity and psychopathology, evidence suggests that direct associations only partially explain the relationship (Bijttebier et al., 2009). Intervening mechanisms, such as ERD, have been proposed to further understand this relationship (Aldao et al., 2010). 1.2. Emotion regulation and rRST ER refers to the modulation of emotional experiences, the understanding and acceptance of emotions, and the ability to behave in accordance with desired goals regardless of emotional state (Gratz and Roemer, 2004). While adaptive ER strategies can have beneficial outcomes, their dysfunctional use may worsen mental health and well-being (Aldao and Nolen-Hoeksema, 2010). Conceptualizations have emphasized that individual differences in BIS/BAS sensitivity may impact ER, affecting emotional responding (Bijttebier et al., 2009). For example, heightened BIS sensitivity may increase emotional responding (e.g., anxiety), creating an emotional context in which maladaptive ER is employed. Research linking personality dimensions to ERD suggests BIS sensitivity is positively related to ERD (Pickett et al., 2012), while the link between BAS sensitivity and ERD is less clear (Tull et al., 2010). Specifically, BAS-reward has been negatively associated and BASfun positively associated with ERD, while there was no association between BAS-drive and ERD (Tull et al., 2010). It is suggested that BAS dimensions may predispose engagement of different reward behaviors, such as various forms of impulsivity (Leone and Russo, 2009). For example, BAS-reward has been negatively associated and BAS-fun has been positively associated with risky health behaviors, such as sexual behaviors, alcohol and drug use, and safety behaviors (Voigt et al., 2009). Further evidence suggests that heightened BIS sensitivity along with ERD may have negative outcomes, such as increased Posttraumatic Stress symptom severity (PTSS) among a female sample of trauma survivors (Pickett et al., 2011). Therefore, the maladaptive attempts to regulate heightened emotional responding, rather than the experience of heightened emotion, increases risk for psychopathology. Alternatively, there has been no research conducted to examine the interaction of BAS dimensions and ERD on problematic outcomes. Nonetheless, emotional reactivity can be affected by a number of factors and investigating these factors could impact the relationship between BIS and BAS sensitivity, ERD, and psychopathology should be examined. Given previous research suggests that SQ plays an important role in emotional health (Baglioni et al., 2010), perhaps understanding the role of SQ in this model would be a worthwhile direction. 1.3. Sleep quality, emotion regulation, and rRST Historically, poor SQ and sleep disruption have been viewed as secondary symptoms of psychopathology; however, the links between SQ/disruption and psychopathology may be more complex. Some evidence suggests that sleep difficulties (i.e., insomnia) may precipitate psychopathology (Baglioni et al., 2010) and that the bidirectional relationship between sleep difficulties and psychopathology may partially be a function of ERD (Baglioni et al., 2010). Although it is difficult to determine causality from the extant research examining ER and sleep difficulties, SQ is clearly an important factor underlying adaptive ER, given evidence indicating that poor SQ negatively impacts ER (Baglioni et al., 2010). Research has demonstrated that poor SQ has negative emotional consequences, such as greater negative emotional reactivity and modulation (Baglioni et al., 2010). Therefore, the reciprocal impact between SQ and ERD may influence the development of psychopathology; however, personality dimensions associated with high emotional
reactivity, negative affect, and poor mental health outcomes may be contributing factors (Williams and Moroz, 2009). There is little research evidence to support the association between BIS/BAS sensitivity and SQ. However, personality dimensions associated with BIS/BAS sensitivity have been examined in relation to SQ. Specifically, Neuroticism/Negative Emotionality and Negative Temperament, personality dimensions related to high BIS sensitivity (Watson et al., 2005), have been associated with poor SQ variables (Gray and Watson, 2002). Alternatively, Extraversion/ Positive Emotionality, personality dimensions related to high BAS sensitivity (Watson et al., 2005), have been associated with good SQ variables (Gray and Watson, 2002). Further, negative and positive affect, which are mood states associated with BIS and BAS sensitivity, respectively, have differential relationships to SQ. Negative affect has positive associations with poor SQ; whereas, positive affect has negative associations with poor SQ (Norlander et al., 2005). From the existing literature, poor SQ has consistent links to personality dimensions associated with problematic outcomes (Baglioni et al., 2010). Therefore, BIS sensitivity may be related to poor SQ and BAS sensitivity may be related to good SQ; however, the exact mechanisms of association may not yet be understood. Presumably, increased BIS and decreased BAS sensitivity foster heightened emotional reactivity and negative affect, decreased positive affect, and ERD (Tull et al., 2010). Due to the paradoxical increase that maladaptive ER strategies may have on emotional reactivity (Wenzlaff and Wegner, 2000), it is possible that attempts to control perceived negative emotions results in sleep incompatible states (i.e., pre-sleep arousal) and may contribute to sleep difficulties (Jansson and Linton, 2007). Given that poor SQ has negative effects on emotional reactivity and responding, poor SQ may increase emotional reactivity and exacerbate ERD, thus further contributing to sleep difficulties and increasing risk for the development of psychopathology (Baglioni et al., 2010). Currently, however, the functional role of BIS/BAS sensitivity, ERD, and SQ in relation to psychopathology is unknown and requires further investigation. 1.4. Overview and hypotheses The current study investigated the relationships among BIS and BAS sensitivity, ERD, global SQ, and symptoms of depression, anxiety, and stress. In line with previous research (Tull et al., 2010), a negative relationship between BAS-reward and ERD, and positive relationships between BAS-fun and ERD and BIS sensitivity and ERD was expected. No relationship between BAS-drive and ERD was expected given previous research (Tull et al., 2010). No specific hypotheses were posed regarding the impact that SQ may have on the relationships between BIS and BAS sensitivity and ERD due to the exploratory nature of the analyses. Further, given the support of previous research (Gratz and Roemer, 2004), positive relationships between ERD and depression, anxiety, and stress symptoms were expected. Hypotheses of the current study also predict an indirect effect of BIS and BAS-reward sensitivity on depression, anxiety, and stress symptoms through ERD. Two models were compared across SQ groups to investigate the moderating effect of SQ on the relationships among the model variables. Given research suggesting poor SQ is associated with ERD and poor mental health, stronger associations between ERD and depression, anxiety, and stress symptoms in poor quality sleepers were hypothesized. 2. Methods 2.1. Participants Using survey methodology, data was collected from a convenience sample comprised of 459 undergraduate students (96 male) at a large Midwestern university who received partial course credit for participation. Inclusion criteria
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
S.A. Markarian et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ required participants to be at least 18 years of age and fluent in English. The majority were freshmen (38.1%), while 25.2% were sophomores, 25.2% were juniors, and 8.5% were seniors; 2.9% indicated “other” or preferred not to respond. Additionally, 79.5% identified as White, 11.0% as Black, 6.4% as Asian, 2.4% as Native American or Pacific Islander, and 0.4% as other, while 0.2% preferred not to respond. Gender and race were dummy coded to be used as possible covariates (i.e., gender: 0¼ Female, 1¼ Male; race: 0¼non-White, 1¼ White).
2.2. Procedure Participants completed a series of online questionnaires following an online informed consent procedure and were provided with debriefing information on the purpose of the study and given a list of community counseling agencies at the end of the survey.
2.3. Measures 2.3.1. The BIS/BAS scale The BIS/BAS scale (Carver and White, 1994) is a 20-item, self-report measure that assesses BIS and BAS sensitivity using a 4-point likert scale (1 ¼ very true for me, 4¼ very false for me). A total BIS score was calculated by summing 7 items that focus on reactions or the anticipation of punishment cues (e.g. “I worry about making mistakes”). A BAS-drive score was calculated by summing 4 items concerned with the persistent pursuit of desired goals (e.g., “When I want something, I usually go all out to get it”). BAS-fun-seeking (BAS-fun) was scored by summing 4 items that reflect a desire for new rewards and a willingness to approach a potentially rewarding event on the spur of the moment (e.g., “I’m always willing to try something new if I think it will be fun”). BAS-reward was scored by summing 5 items that focus on responses to the occurrence or anticipation of reward (e.g. “When good things happen to me, it affects me strongly”). Higher scores on BIS and the BAS subscales indicate greater sensitivity to aversive and appetitive stimuli, respectively. Internal consistencies for BIS and all three BAS subscales were good (Cronbach's α ranged 0.68–0.79). 2.3.2. Difficulties in emotion regulation scale The Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is a 36-item, self-report measure that assesses the dysregulation of emotion (e.g. “When I′m upset, my emotions feel overwhelming”). Participants rate how often an item applies on a 5-point likert scale (1¼ almost never, 5¼ almost always). A score for overall ERD was calculated by summing all 36 items. Higher scores indicate greater ERD. Internal consistency of ERD was good (Cronbach's α ¼0.94). 2.3.3. Pittsburgh sleep quality index The Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989) is a 19-item selfreport measure that assesses global SQ along seven dimensions: sleep duration, sleep disturbance, sleep quality, sleep efficiency, sleep latency, use of sleep medication, and daytime dysfunction. Each dimension was scored according to Buysse et al. and weighed on a scale from 0 to 3. Global SQ was calculated by summing together all 7 dimensions. Scores4 5 are typically used as the cutoff point distinguishing poor SQ from good SQ. A cutoff score of 8 has been used in previous research and was a good indicator of poor SQ in a large college student sample (Lund et al., 2010). Therefore, scores≥8 represented poor quality sleepers (n ¼247, M ¼10.49, S.D.¼ 2.21) and scoreso 8 represented good quality sleepers (n ¼212, M ¼5.08, S.D. ¼1.60). Cronbach's alpha for the PSQI was 0.61.
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2.3.4. Depression anxiety and stress scale The 21-item Depression Anxiety Stress Scale (DASS-21; Lovibond and Lovibond, 1995) is a self-report measure that assesses symptom severity along three dimensions of psychopathology: depression (“I couldn't seem to experience any positive feeling at all”), anxiety (“I felt scared without any good reason”), and stress (“I find it difficult to relax”). Each dimension was calculated using the sum of 7 items on which participants rated how well each item applied to themselves over the past week using a 4-point likert scale (0¼ did not apply to me at all, 4¼ applied to me very much, or most of the time). Higher scores indicate greater symptom severity. Internal consistencies for the depression, anxiety, and stress scales were good (Cronbach's α ranged 0.82–0.91).
3. Results Pearson correlations and descriptive statistics were examined for all study variables (see Table 1). Gender was the only demographic variable related to any model variables, indicating females were more likely to report higher BIS sensitivity. Considering that previous research has not shown gender to be a significant factor in the relation between BIS sensitivity and ERD (Tull et al., 2010) and the observed correlation is likely skewed due to a predominantly female sample, gender was not included in the model. Therefore, none of the demographic variables were included in the analyses. Further, BAS-fun and BAS-drive did not correlate with any of the study variables and were therefore not included in the main analysis. Also, BAS-reward did not correlate with anxiety or stress. For this reason, the direct effect of BAS-reward on anxiety and stress symptoms were not examined in the hypothesized model. All other correlations were significant and therefore were represented as pathways in the hypothesized model (see Fig. 1). Significant linear relationships between an independent and a dependent variable are presented in Supplemental Figs. 1–14. A multi-group modeling approach was employed to test similarities in factor structure across models. Mplus (Muthen and Muthen, 2004) was used to determine combined model fit and test two sub-models simultaneously: one for good quality sleepers and one for poor quality sleepers. Using the maximum likelihood method, a non-significant chi-square (χ2) is indicative of good fit. However, to better quantify the degree of fit, the following fit indices were used: the comparative fit index (CFI), with values greater than 0.90 indicative of good fit (Browne and Cudeck, 1993); and the root- mean-square error of approximation (RMSEA), with values greater than 0.10 indicative of poor fit (McDonald and Ho, 2002). Although the hypothesized model fit well, χ2(2, 427) ¼2.67, P¼ ns; RMSEA ¼0.028; CFI ¼ 0.999, fit statistics suggested the pathways from BIS to anxiety, and depression be removed. The
Table 1 Bivariate correlations and descriptive statistics for study variables. Study Variables
1
2
3
4
5
6
7
8
9
1. BAS-Fun 2. BAS-Drive 3. BAS-Reward 4. BIS 5. ER Difficulties 6. PSQI-Global 7. DASS-Depression 8. DASS-Anxiety 9. DASS-Stress 10. Gender (0 ¼Female; 1¼ Male) 11. Class standing 12. Race (0 ¼ Non-White; 1¼ White) Mean Standard deviation
— 0.51 0.49 −0.08 0.02 0.02 −0.03 0.07 0.07 −0.01 −0.05 −0.03 7.8 2.4
— 0.70 −0.05 −0.05 −0.03 −0.09 0.03 0.01 0.03 −0.02 −0.03 6.6 2.6
— 0.16 −0.12 −0.10 −0.14 −0.03 0.01 −0.01 0.02 −0.01 11.4 2.3
— 0.40 0.14 0.21 0.23 0.38 −0.28 −0.06 0.07 14.3 3.9
— 0.35 0.63 0.53 0.63 −0.05 −0.06 0.02 80.1 22.3
— 0.39 0.31 0.42 0.01 0.02 −0.03 8.0 3.3
— 0.67 0.75 0.05 0.03 −0.06 11.1 4.7
— 0.76 −0.05 0.05 0.04 10.5 3.8
— −0.08 −0.01 −0.03 12.8 4.5
Note: Significant correlations (P o 0.05) in boldface.
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
S.A. Markarian et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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BAS reward
depression and stress, (χ2 (9, 427)¼16.328, P¼ ns; RMSEA¼0.06; CFI¼0.992; Δ χ2 (1, 427)¼7.94, Po0.05. Likewise, the path between anxiety and stress was significantly non-invariant, χ2 (9, 427)¼ 22.490, Po0.01; RMSEA¼0.084; CFI¼0.986; Δ χ2 (1, 427)¼14.1, Po0.05.
Depression
ER difficulties
Anxiety
4. Discussion
Stress
BIS
Fig. 1. Hypothesized model for good quality sleepers and poor quality sleepers.
Good Quality Sleepers -.09
Depression (26.4%)
BAS reward -.21
.33
.49
ER difficulties (19.8%)
.17
.43
Anxiety (18.5%)
.40
.47 .42
.43 .19
BIS
Stress (32.5%)
Poor Quality Sleepers -.07
Depression (40.1%)
BAS reward -.16 .20
.62 ER difficulties (17.7%)
.54 .57
.34 Anxiety (28.7%)
.42
.35
.44 .13
BIS
Stress (40.4%)
Fig. 2. Final models for good quality sleepers and poor quality sleepers. All pathways are significant. Significant non-invariant pathways across sleep quality groups are in boldface. Variance accounted for is in parentheses.
final model (see Fig. 2) excluding these pathways, fit well, χ2(2, 427) ¼4.94, P ¼ns; RMSEA ¼0.023; CFI ¼0.999. All pathways were significant. For both good and poor sleepers, BAS-reward was negatively related to ERD, whereas for BIS, this relation was positive. Additionally, ERD were positively related to depression, anxiety, and stress. To determine if paths estimated across good and poor sleepers were invariant, each path was successively held invariant and compared to the model fit of the comparison model. The path from ER to anxiety was significantly non-invariant, χ2 (9, 427) ¼15.204, P ¼ns; RMSEA ¼0.057; CFI¼ 0.994; Δ χ2 (1, 427) ¼6.81, P o0.05. Additionally, the path from ER to depression was also significantly non-invariant, χ2 (9, 427) ¼19.754, P ¼ns; RMSEA ¼0.075; CFI¼0.989; Δ χ2 (1, 427) ¼11.36, P o0.05. Based on the larger path loadings from ER to both depression and anxiety the findings suggest that ER plays a larger role in poor quality sleepers than in good quality sleepers. Paths were significantly non-invariant between depression and anxiety, χ2 (9, 427) ¼22.049, P ¼ o0.01; RMSEA ¼0.08; CFI¼0.986; Δ χ2 (1, 427) ¼ 13.65, P o0.05; and
The current study examined the relationships between BIS sensitivity, BAS-reward sensitivity, ERD, global SQ and symptoms of depression, anxiety, and stress in a large convenience sample of college students. The study hypotheses were supported. High BIS and low BAS-reward sensitivity were indirectly related to anxiety symptoms through their effect on ERD; the indirect pathways from BIS and BAS-reward to stress and depression, respectively, are only partially explained through their effects on ERD. The paths from ERD to depression and anxiety, and paths between depression, anxiety, and stress were non-invariant across SQ groups, suggesting a moderating effect of SQ; path loadings indicate stronger pathways among poor quality sleepers compared to good quality sleepers. As expected and consistent with previous research (Tull et al., 2010), individuals higher in BIS sensitivity and lower in BASreward sensitivity were more likely to report ERD across SQ groups. Conceptually, high BIS sensitivity may increase an individual's negative emotional reactivity (Corr, 2004; Corr and McNaughton, 2008), which if viewed as overly negative may result in the use of ER strategies to regulate emotions (Bijttebier et al., 2009). Research has also shown BIS sensitivity to be positively related to other maladaptive ER strategies, specifically experiential avoidance (Pickett et al., 2011). Alternatively, the negative association between BAS-reward sensitivity and ERD suggests that lower responsiveness to the occurrence or anticipation of reward is associated with a greater likelihood of ERD. Diminished responding to positive emotional rewards has been shown to impair an individual's resilience to negative experiences (Tugade and Fredrickson, 2004). Thus, a lower responsiveness to rewards may affect an individual's ability to detect or anticipate the occurrence of rewards (Henriques and Davidson, 2000) and subsequently impair their abilities to modulate their emotional reactivity (Tugade and Fredrickson, 2004). This could prove beneficial when adjusting to negative life experiences and may help buffer against daily stresses. Specifically, negative life events may be evaluated or experienced as more negative because individuals have difficulty anticipating, predicting, or seeking out rewarding experiences. Therefore, the model would suggest that heightened BIS sensitivity and diminished BAS-reward sensitivity are related to ERD. Interestingly, the lack of invariance across SQ groups for the pathways from BIS sensitivity and BAS-reward sensitivity to ERD is contrary to what was expected. Although research has suggested a link between personality dimensions and sleep disruptions (Gray and Watson, 2002), the findings of the current study suggest weak direct relationships between BIS/BAS sensitivity and of sleep disruption. Further, there is recent evidence to suggest that higher BIS sensitivity may be an initiating factor for the onset sleep disturbance, but that BIS sensitivity may not be directly related to sleep disturbance with regard to the maintenance of insomnia (Gosling et al., 2012). Therefore, the current findings may be better explained in terms of the role that BIS/BAS plays in relation to sleep processes and less so in relation to sleep disruption associated with psychopathology as the current sample was not a clinical sample. Recent research suggests that BAS-reward sensitivity may be more dependent on circadian factors of morning– eveningness (i.e., the preference to organize activity around morning), which was interpreted to mean that those with higher
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
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reward motivation organize activities during morning times in which there is access to rewards (i.e., morningness; Hasler et al., 2010); however, this is not necessarily related to sleep difficulties. Alternately, BIS does not serve the same function because it is a system based on contextual and situational factors (i.e., perception of threat) and would therefore operate independently of this relationship (Hasler et al., 2010). Specifically, there is no adaptive reason that BIS sensitivity would be related to circadian preference, but BIS sensitivity may be related to disruptions in sleep processes under certain circumstances (i.e., anxiety). Given that the groups were based solely on a SQ classification, which could be determined by a myriad of factors, the lack of invariance across groups may be explained by contextual/situational factors that were not captured by the current model. Given the associations of heightened BIS and diminished BASreward sensitivity with ERD, the positive relationships between ERD and depression, anxiety and stress are not surprising. The findings complement previous research suggesting that BIS and BAS-reward sensitivity along with ERD result in poor mental health (i.e., anxiety symptoms; Pickett et al., 2011). However, the findings are the first to suggest ERD as an intermediate variable in the relationship between BIS and BAS-reward sensitivity and depression and stress symptoms. Interestingly, no direct effects of BIS and BAS-reward sensitivity on anxiety were included in the model after making the necessary modifications dictated by fit statistics. From this finding, it would seem that the effects of BIS and BAS-reward sensitivity on anxiety symptoms are fully explained by the indirect pathways; seemingly, the joint effects of BIS and BAS dimensions may lead to particular ERD that worsen anxiety symptoms. Further, invariance testing indicated stronger associations between ERD and depression and anxiety symptoms in poor quality sleepers compared to good quality sleepers. This suggests that poor SQ may exacerbate depression and anxiety symptoms through the effect on ERD. Although results indicate that ERD alone are sufficient to produce depression and anxiety symptoms, poor SQ may strengthen this relationship; the findings cannot be used as evidence to claim that ERD cause poor SQ, or vice versa, but a relationship is nonetheless present. Overall, the final model illustrates an indirect effect of BIS and BAS-reward sensitivity on depression, anxiety, and stress symptoms through ERD, which are moderated by SQ. Thus, the cumulative effects of a heightened negative emotional reactivity and a decreased responsiveness to reward may increase ERD and when coupled with poor SQ, may culminate in more severe depression, anxiety, and stress symptoms.
4.1. Possible treatment implications Considering that cognitive-behavioral therapy (CBT) is an effective treatment for a wide range of clinical problems, including depression and anxiety (see Butler et al., 2006, for a review), and sleep difficulties (Baglioni et al., 2010), the current findings may suggest an integration of additional techniques (i.e., behavioral activation and mindfulness) into CBT practice. Specifically, behavioral activation has been an effective therapy for depression by increasing involvement in positive activities (Lejuez et al., 2001). As more positive experiences begin to occur, an individual may experience a change in their responsiveness to rewarding activities, thus improving ER (Tugade and Fredrickson, 2004). The extent that emotional processing promotes positive outcomes is considered to be a function of ER strategies (Austenfeld and Stanton, 2004). Further, some evidence suggests that higher levels of positive affect facilitate good quality sleep, which may be a function of adaptive ER (Norlander et al., 2005). Therefore,
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behavioral activation may impact both mood and sleep simultaneously through an effect on ER. Mindfulness-based techniques have been suggested to reduce negative emotional reactivity, ERD, and the use of maladaptive ER strategies (Shapiro et al., 2006). Further, the incorporation of mindfulness into CBT for insomnia is effective for reducing sleep-related difficulties (Ong et al., 2008). Thus, the implications of the current findings are potentially two-fold with regard to treatment. First, mindfulness-based techniques may allow for the acceptance of the heightened negative emotional reactivity associated with BIS sensitivity, subsequently reducing emotional reactivity and the use of maladaptive ER strategies. Second, mindfulness-based techniques may promote good quality sleep by reducing stress and pre-sleep arousal. Mindfulness-based therapies have the potential to impact all aspects of the current model, subsequently reducing symptomology. Future directions should investigate the integration of sleep-specific interventions into standard treatment protocols for depression and anxiety, given the complex relationships between depression, anxiety, and sleep.
4.2. Limitations and future directions The current study was not without limitations. Due to an oversight while constructing the computer-based survey, participant age was not collected. Year in school was used as a proxy for age, which was not related to any of the study variables. Further, it is important to note that the online survey was not conducted under controlled laboratory conditions, which may increase experimental error. Considering that the sample was predominately comprised of white, female participants, generalizability of the findings is limited. Reliance on self-report measures and the use of a combined measure of BIS and FFFS sensitivity, which overlooks their individual contribution and role as distinct systems, are inherent measurement constraints. Further, the use of the term ‘personality dimensions’ is used generally and does not apply directly to the findings of the current study. Where appropriate, BIS/BAS sensitivity are specifically referenced and do not represent other personality dimensions, which were not assessed in the current study. It cannot be assumed that the symptoms of depression and anxiety represent diagnosable disorders. The cross-sectional and correlational design limits interpretation regarding causal relationships among the variables. Further, the moderating effect of SQ on ERD should be interpreted with caution, as it is possible that ERD precipitated poor SQ. Future directions should employ a longitudinal investigation of this model in order to examine temporal relations. Examination of the model in community and clinical populations, with objective measures, is also warranted.
5. Conclusion The present findings suggest that a decreased responsiveness to rewards and a heightened sensitivity to aversive stimuli may predispose for difficulties regulating emotions. Accordingly, ERD lead to greater depression, anxiety and stress symptoms, which then worsen in the presence of poor SQ. Future research investigating self-regulatory mechanisms and personality dimensions within the context of poor SQ holds promise for improving treatments and understanding the mechanisms underlying the development and maintenance of psychopathology.
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
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Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.psychres.2013.06. 004.
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Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
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A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality Shaunt A. Markarian, Scott M. Pickett n, Danielle F. Deveson, Brenda B. Kanona Oakland University, Rochester, MI, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 29 October 2012 Received in revised form 6 June 2013 Accepted 7 June 2013
Recent research has indicated that interactions between behavioral inhibition system (BIS)/behavioral activation system (BAS) sensitivity and emotion regulation (ER) difficulties increases risk for psychopathology. Considering sleep quality (SQ) has been linked to emotion regulation difficulties (ERD) and psychopathology, further investigation of a possible mechanism is needed. The current study examined associations between BIS/BAS sensitivity, ERD, and SQ to depression, anxiety, and stress symptoms in an undergraduate sample (n ¼ 459). Positive relationships between BIS sensitivity and both ERD and stress symptoms, and negative relationships between BAS-reward sensitivity and both ERD and depression symptoms were observed. Furthermore, ERD were positively related to depression, anxiety, and stress symptoms. Succeeding analyses revealed differential relationships between ERD and depression, anxiety, and stress symptoms among good quality and poor quality sleepers. The findings are discussed within the context of personality dimensions and self-regulatory mechanisms, along with implications for the treatment of depression, anxiety and sleep difficulties. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Reinforcement sensitivity theory Emotion regulation Sleep quality Depression Anxiety
1. Introduction Recently, emotion regulation difficulties (ERD) have been suggested as a possible explanatory mechanism in the relationship between behavioral inhibition system (BIS) and behavioral activation system (BAS) sensitivity and psychopathology (Bijttebier et al., 2009). There is evidence linking sleep and ERD (Baglioni et al., 2010) and sleep difficulties to psychopathology (Morin and Ware, 1996), but no evidence linking sleep difficulties to BIS/BAS sensitivity. The extant literature on personality dimensions and SQ suggests that personality dimensions associated with negative outcomes are also linked to poor SQ (Gray and Watson, 2002). Given there is limited research examining the association between BIS and BAS sensitivity and sleep difficulties, especially in relation to ERD and psychopathology, the current study aimed to understand the relationships among these variables. Specifically, the links between BIS/BAS sensitivity, ERD, and depression, anxiety, and stress symptomology were examined across SQ groups.
1.1. Revised reinforcement sensitivity theory The revised reinforcement sensitivity theory (rRST; Corr and McNaughton, 2008) postulates three subsystems: BIS, BAS, and the n Correspondence to: Department of Psychology, Oakland University, 209 Pryale Hall, 2200 N. Squirrel Road, Rochester, MI 48309, USA. Tel.: +1 248 370 2307. E-mail address: [email protected] (S.M. Pickett).
fight-flight-freeze system (FFFS). The BIS resolves goal conflict between the BAS and FFFS, and is experienced as negative affect (i.e., anxiety). Alternatively, the BAS responds to rewarding or appetitive stimuli with approach behaviors, and is experienced as positive affect. The FFFS responds to aversive stimuli or threats of non-reward, and relies on the BIS in order to function in accordance with its goals. If BIS successfully inhibits behavior when confronted with aversive stimuli, the FFFS is activated and escape behaviors are engaged; if BIS fails to inhibit behavior, BAS is activated and approach behaviors are engaged. Further, the BAS has been conceptualized as three inter-related dimensions: BASfun-seeking (BAS-fun), BAS-drive, and BAS-reward responsiveness (BAS-reward; Carver and White, 1994). The drive and reward subscales are proposed to play a larger role in responding to cues of impending reward in the midst of behavioral efforts, while BASfun is believed to have a greater impact in determining the extent to which potentially rewarding situations entice engagement (Carver and White, 1994). All of the BAS dimensions have been associated with positive affectivity (Jorm et al., 1999) and some form of impulsivity (Leone and Russo, 2009). Recent research has suggested that BAS-fun may be associated with dysfunctional impulsivity, while BAS-drive and BAS-reward are associated with functional impulsivity (Leone and Russo, 2009). Research has been relatively consistent linking high BIS sensitivity to anxiety-related symptomology, and low BAS sensitivity to depression-related symptomology (Bijttebier et al., 2009). Further, complex interactive patterns of BIS and BAS sensitivity have been associated with poorer mental health outcomes (Hundt et al., 2007).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.06.004
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
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Although there are established relationships between BIS/BAS sensitivity and psychopathology, evidence suggests that direct associations only partially explain the relationship (Bijttebier et al., 2009). Intervening mechanisms, such as ERD, have been proposed to further understand this relationship (Aldao et al., 2010). 1.2. Emotion regulation and rRST ER refers to the modulation of emotional experiences, the understanding and acceptance of emotions, and the ability to behave in accordance with desired goals regardless of emotional state (Gratz and Roemer, 2004). While adaptive ER strategies can have beneficial outcomes, their dysfunctional use may worsen mental health and well-being (Aldao and Nolen-Hoeksema, 2010). Conceptualizations have emphasized that individual differences in BIS/BAS sensitivity may impact ER, affecting emotional responding (Bijttebier et al., 2009). For example, heightened BIS sensitivity may increase emotional responding (e.g., anxiety), creating an emotional context in which maladaptive ER is employed. Research linking personality dimensions to ERD suggests BIS sensitivity is positively related to ERD (Pickett et al., 2012), while the link between BAS sensitivity and ERD is less clear (Tull et al., 2010). Specifically, BAS-reward has been negatively associated and BASfun positively associated with ERD, while there was no association between BAS-drive and ERD (Tull et al., 2010). It is suggested that BAS dimensions may predispose engagement of different reward behaviors, such as various forms of impulsivity (Leone and Russo, 2009). For example, BAS-reward has been negatively associated and BAS-fun has been positively associated with risky health behaviors, such as sexual behaviors, alcohol and drug use, and safety behaviors (Voigt et al., 2009). Further evidence suggests that heightened BIS sensitivity along with ERD may have negative outcomes, such as increased Posttraumatic Stress symptom severity (PTSS) among a female sample of trauma survivors (Pickett et al., 2011). Therefore, the maladaptive attempts to regulate heightened emotional responding, rather than the experience of heightened emotion, increases risk for psychopathology. Alternatively, there has been no research conducted to examine the interaction of BAS dimensions and ERD on problematic outcomes. Nonetheless, emotional reactivity can be affected by a number of factors and investigating these factors could impact the relationship between BIS and BAS sensitivity, ERD, and psychopathology should be examined. Given previous research suggests that SQ plays an important role in emotional health (Baglioni et al., 2010), perhaps understanding the role of SQ in this model would be a worthwhile direction. 1.3. Sleep quality, emotion regulation, and rRST Historically, poor SQ and sleep disruption have been viewed as secondary symptoms of psychopathology; however, the links between SQ/disruption and psychopathology may be more complex. Some evidence suggests that sleep difficulties (i.e., insomnia) may precipitate psychopathology (Baglioni et al., 2010) and that the bidirectional relationship between sleep difficulties and psychopathology may partially be a function of ERD (Baglioni et al., 2010). Although it is difficult to determine causality from the extant research examining ER and sleep difficulties, SQ is clearly an important factor underlying adaptive ER, given evidence indicating that poor SQ negatively impacts ER (Baglioni et al., 2010). Research has demonstrated that poor SQ has negative emotional consequences, such as greater negative emotional reactivity and modulation (Baglioni et al., 2010). Therefore, the reciprocal impact between SQ and ERD may influence the development of psychopathology; however, personality dimensions associated with high emotional
reactivity, negative affect, and poor mental health outcomes may be contributing factors (Williams and Moroz, 2009). There is little research evidence to support the association between BIS/BAS sensitivity and SQ. However, personality dimensions associated with BIS/BAS sensitivity have been examined in relation to SQ. Specifically, Neuroticism/Negative Emotionality and Negative Temperament, personality dimensions related to high BIS sensitivity (Watson et al., 2005), have been associated with poor SQ variables (Gray and Watson, 2002). Alternatively, Extraversion/ Positive Emotionality, personality dimensions related to high BAS sensitivity (Watson et al., 2005), have been associated with good SQ variables (Gray and Watson, 2002). Further, negative and positive affect, which are mood states associated with BIS and BAS sensitivity, respectively, have differential relationships to SQ. Negative affect has positive associations with poor SQ; whereas, positive affect has negative associations with poor SQ (Norlander et al., 2005). From the existing literature, poor SQ has consistent links to personality dimensions associated with problematic outcomes (Baglioni et al., 2010). Therefore, BIS sensitivity may be related to poor SQ and BAS sensitivity may be related to good SQ; however, the exact mechanisms of association may not yet be understood. Presumably, increased BIS and decreased BAS sensitivity foster heightened emotional reactivity and negative affect, decreased positive affect, and ERD (Tull et al., 2010). Due to the paradoxical increase that maladaptive ER strategies may have on emotional reactivity (Wenzlaff and Wegner, 2000), it is possible that attempts to control perceived negative emotions results in sleep incompatible states (i.e., pre-sleep arousal) and may contribute to sleep difficulties (Jansson and Linton, 2007). Given that poor SQ has negative effects on emotional reactivity and responding, poor SQ may increase emotional reactivity and exacerbate ERD, thus further contributing to sleep difficulties and increasing risk for the development of psychopathology (Baglioni et al., 2010). Currently, however, the functional role of BIS/BAS sensitivity, ERD, and SQ in relation to psychopathology is unknown and requires further investigation. 1.4. Overview and hypotheses The current study investigated the relationships among BIS and BAS sensitivity, ERD, global SQ, and symptoms of depression, anxiety, and stress. In line with previous research (Tull et al., 2010), a negative relationship between BAS-reward and ERD, and positive relationships between BAS-fun and ERD and BIS sensitivity and ERD was expected. No relationship between BAS-drive and ERD was expected given previous research (Tull et al., 2010). No specific hypotheses were posed regarding the impact that SQ may have on the relationships between BIS and BAS sensitivity and ERD due to the exploratory nature of the analyses. Further, given the support of previous research (Gratz and Roemer, 2004), positive relationships between ERD and depression, anxiety, and stress symptoms were expected. Hypotheses of the current study also predict an indirect effect of BIS and BAS-reward sensitivity on depression, anxiety, and stress symptoms through ERD. Two models were compared across SQ groups to investigate the moderating effect of SQ on the relationships among the model variables. Given research suggesting poor SQ is associated with ERD and poor mental health, stronger associations between ERD and depression, anxiety, and stress symptoms in poor quality sleepers were hypothesized. 2. Methods 2.1. Participants Using survey methodology, data was collected from a convenience sample comprised of 459 undergraduate students (96 male) at a large Midwestern university who received partial course credit for participation. Inclusion criteria
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
S.A. Markarian et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ required participants to be at least 18 years of age and fluent in English. The majority were freshmen (38.1%), while 25.2% were sophomores, 25.2% were juniors, and 8.5% were seniors; 2.9% indicated “other” or preferred not to respond. Additionally, 79.5% identified as White, 11.0% as Black, 6.4% as Asian, 2.4% as Native American or Pacific Islander, and 0.4% as other, while 0.2% preferred not to respond. Gender and race were dummy coded to be used as possible covariates (i.e., gender: 0¼ Female, 1¼ Male; race: 0¼non-White, 1¼ White).
2.2. Procedure Participants completed a series of online questionnaires following an online informed consent procedure and were provided with debriefing information on the purpose of the study and given a list of community counseling agencies at the end of the survey.
2.3. Measures 2.3.1. The BIS/BAS scale The BIS/BAS scale (Carver and White, 1994) is a 20-item, self-report measure that assesses BIS and BAS sensitivity using a 4-point likert scale (1 ¼ very true for me, 4¼ very false for me). A total BIS score was calculated by summing 7 items that focus on reactions or the anticipation of punishment cues (e.g. “I worry about making mistakes”). A BAS-drive score was calculated by summing 4 items concerned with the persistent pursuit of desired goals (e.g., “When I want something, I usually go all out to get it”). BAS-fun-seeking (BAS-fun) was scored by summing 4 items that reflect a desire for new rewards and a willingness to approach a potentially rewarding event on the spur of the moment (e.g., “I’m always willing to try something new if I think it will be fun”). BAS-reward was scored by summing 5 items that focus on responses to the occurrence or anticipation of reward (e.g. “When good things happen to me, it affects me strongly”). Higher scores on BIS and the BAS subscales indicate greater sensitivity to aversive and appetitive stimuli, respectively. Internal consistencies for BIS and all three BAS subscales were good (Cronbach's α ranged 0.68–0.79). 2.3.2. Difficulties in emotion regulation scale The Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is a 36-item, self-report measure that assesses the dysregulation of emotion (e.g. “When I′m upset, my emotions feel overwhelming”). Participants rate how often an item applies on a 5-point likert scale (1¼ almost never, 5¼ almost always). A score for overall ERD was calculated by summing all 36 items. Higher scores indicate greater ERD. Internal consistency of ERD was good (Cronbach's α ¼0.94). 2.3.3. Pittsburgh sleep quality index The Pittsburgh Sleep Quality Index (PSQI; Buysse et al., 1989) is a 19-item selfreport measure that assesses global SQ along seven dimensions: sleep duration, sleep disturbance, sleep quality, sleep efficiency, sleep latency, use of sleep medication, and daytime dysfunction. Each dimension was scored according to Buysse et al. and weighed on a scale from 0 to 3. Global SQ was calculated by summing together all 7 dimensions. Scores4 5 are typically used as the cutoff point distinguishing poor SQ from good SQ. A cutoff score of 8 has been used in previous research and was a good indicator of poor SQ in a large college student sample (Lund et al., 2010). Therefore, scores≥8 represented poor quality sleepers (n ¼247, M ¼10.49, S.D.¼ 2.21) and scoreso 8 represented good quality sleepers (n ¼212, M ¼5.08, S.D. ¼1.60). Cronbach's alpha for the PSQI was 0.61.
3
2.3.4. Depression anxiety and stress scale The 21-item Depression Anxiety Stress Scale (DASS-21; Lovibond and Lovibond, 1995) is a self-report measure that assesses symptom severity along three dimensions of psychopathology: depression (“I couldn't seem to experience any positive feeling at all”), anxiety (“I felt scared without any good reason”), and stress (“I find it difficult to relax”). Each dimension was calculated using the sum of 7 items on which participants rated how well each item applied to themselves over the past week using a 4-point likert scale (0¼ did not apply to me at all, 4¼ applied to me very much, or most of the time). Higher scores indicate greater symptom severity. Internal consistencies for the depression, anxiety, and stress scales were good (Cronbach's α ranged 0.82–0.91).
3. Results Pearson correlations and descriptive statistics were examined for all study variables (see Table 1). Gender was the only demographic variable related to any model variables, indicating females were more likely to report higher BIS sensitivity. Considering that previous research has not shown gender to be a significant factor in the relation between BIS sensitivity and ERD (Tull et al., 2010) and the observed correlation is likely skewed due to a predominantly female sample, gender was not included in the model. Therefore, none of the demographic variables were included in the analyses. Further, BAS-fun and BAS-drive did not correlate with any of the study variables and were therefore not included in the main analysis. Also, BAS-reward did not correlate with anxiety or stress. For this reason, the direct effect of BAS-reward on anxiety and stress symptoms were not examined in the hypothesized model. All other correlations were significant and therefore were represented as pathways in the hypothesized model (see Fig. 1). Significant linear relationships between an independent and a dependent variable are presented in Supplemental Figs. 1–14. A multi-group modeling approach was employed to test similarities in factor structure across models. Mplus (Muthen and Muthen, 2004) was used to determine combined model fit and test two sub-models simultaneously: one for good quality sleepers and one for poor quality sleepers. Using the maximum likelihood method, a non-significant chi-square (χ2) is indicative of good fit. However, to better quantify the degree of fit, the following fit indices were used: the comparative fit index (CFI), with values greater than 0.90 indicative of good fit (Browne and Cudeck, 1993); and the root- mean-square error of approximation (RMSEA), with values greater than 0.10 indicative of poor fit (McDonald and Ho, 2002). Although the hypothesized model fit well, χ2(2, 427) ¼2.67, P¼ ns; RMSEA ¼0.028; CFI ¼ 0.999, fit statistics suggested the pathways from BIS to anxiety, and depression be removed. The
Table 1 Bivariate correlations and descriptive statistics for study variables. Study Variables
1
2
3
4
5
6
7
8
9
1. BAS-Fun 2. BAS-Drive 3. BAS-Reward 4. BIS 5. ER Difficulties 6. PSQI-Global 7. DASS-Depression 8. DASS-Anxiety 9. DASS-Stress 10. Gender (0 ¼Female; 1¼ Male) 11. Class standing 12. Race (0 ¼ Non-White; 1¼ White) Mean Standard deviation
— 0.51 0.49 −0.08 0.02 0.02 −0.03 0.07 0.07 −0.01 −0.05 −0.03 7.8 2.4
— 0.70 −0.05 −0.05 −0.03 −0.09 0.03 0.01 0.03 −0.02 −0.03 6.6 2.6
— 0.16 −0.12 −0.10 −0.14 −0.03 0.01 −0.01 0.02 −0.01 11.4 2.3
— 0.40 0.14 0.21 0.23 0.38 −0.28 −0.06 0.07 14.3 3.9
— 0.35 0.63 0.53 0.63 −0.05 −0.06 0.02 80.1 22.3
— 0.39 0.31 0.42 0.01 0.02 −0.03 8.0 3.3
— 0.67 0.75 0.05 0.03 −0.06 11.1 4.7
— 0.76 −0.05 0.05 0.04 10.5 3.8
— −0.08 −0.01 −0.03 12.8 4.5
Note: Significant correlations (P o 0.05) in boldface.
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
S.A. Markarian et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
4
BAS reward
depression and stress, (χ2 (9, 427)¼16.328, P¼ ns; RMSEA¼0.06; CFI¼0.992; Δ χ2 (1, 427)¼7.94, Po0.05. Likewise, the path between anxiety and stress was significantly non-invariant, χ2 (9, 427)¼ 22.490, Po0.01; RMSEA¼0.084; CFI¼0.986; Δ χ2 (1, 427)¼14.1, Po0.05.
Depression
ER difficulties
Anxiety
4. Discussion
Stress
BIS
Fig. 1. Hypothesized model for good quality sleepers and poor quality sleepers.
Good Quality Sleepers -.09
Depression (26.4%)
BAS reward -.21
.33
.49
ER difficulties (19.8%)
.17
.43
Anxiety (18.5%)
.40
.47 .42
.43 .19
BIS
Stress (32.5%)
Poor Quality Sleepers -.07
Depression (40.1%)
BAS reward -.16 .20
.62 ER difficulties (17.7%)
.54 .57
.34 Anxiety (28.7%)
.42
.35
.44 .13
BIS
Stress (40.4%)
Fig. 2. Final models for good quality sleepers and poor quality sleepers. All pathways are significant. Significant non-invariant pathways across sleep quality groups are in boldface. Variance accounted for is in parentheses.
final model (see Fig. 2) excluding these pathways, fit well, χ2(2, 427) ¼4.94, P ¼ns; RMSEA ¼0.023; CFI ¼0.999. All pathways were significant. For both good and poor sleepers, BAS-reward was negatively related to ERD, whereas for BIS, this relation was positive. Additionally, ERD were positively related to depression, anxiety, and stress. To determine if paths estimated across good and poor sleepers were invariant, each path was successively held invariant and compared to the model fit of the comparison model. The path from ER to anxiety was significantly non-invariant, χ2 (9, 427) ¼15.204, P ¼ns; RMSEA ¼0.057; CFI¼ 0.994; Δ χ2 (1, 427) ¼6.81, P o0.05. Additionally, the path from ER to depression was also significantly non-invariant, χ2 (9, 427) ¼19.754, P ¼ns; RMSEA ¼0.075; CFI¼0.989; Δ χ2 (1, 427) ¼11.36, P o0.05. Based on the larger path loadings from ER to both depression and anxiety the findings suggest that ER plays a larger role in poor quality sleepers than in good quality sleepers. Paths were significantly non-invariant between depression and anxiety, χ2 (9, 427) ¼22.049, P ¼ o0.01; RMSEA ¼0.08; CFI¼0.986; Δ χ2 (1, 427) ¼ 13.65, P o0.05; and
The current study examined the relationships between BIS sensitivity, BAS-reward sensitivity, ERD, global SQ and symptoms of depression, anxiety, and stress in a large convenience sample of college students. The study hypotheses were supported. High BIS and low BAS-reward sensitivity were indirectly related to anxiety symptoms through their effect on ERD; the indirect pathways from BIS and BAS-reward to stress and depression, respectively, are only partially explained through their effects on ERD. The paths from ERD to depression and anxiety, and paths between depression, anxiety, and stress were non-invariant across SQ groups, suggesting a moderating effect of SQ; path loadings indicate stronger pathways among poor quality sleepers compared to good quality sleepers. As expected and consistent with previous research (Tull et al., 2010), individuals higher in BIS sensitivity and lower in BASreward sensitivity were more likely to report ERD across SQ groups. Conceptually, high BIS sensitivity may increase an individual's negative emotional reactivity (Corr, 2004; Corr and McNaughton, 2008), which if viewed as overly negative may result in the use of ER strategies to regulate emotions (Bijttebier et al., 2009). Research has also shown BIS sensitivity to be positively related to other maladaptive ER strategies, specifically experiential avoidance (Pickett et al., 2011). Alternatively, the negative association between BAS-reward sensitivity and ERD suggests that lower responsiveness to the occurrence or anticipation of reward is associated with a greater likelihood of ERD. Diminished responding to positive emotional rewards has been shown to impair an individual's resilience to negative experiences (Tugade and Fredrickson, 2004). Thus, a lower responsiveness to rewards may affect an individual's ability to detect or anticipate the occurrence of rewards (Henriques and Davidson, 2000) and subsequently impair their abilities to modulate their emotional reactivity (Tugade and Fredrickson, 2004). This could prove beneficial when adjusting to negative life experiences and may help buffer against daily stresses. Specifically, negative life events may be evaluated or experienced as more negative because individuals have difficulty anticipating, predicting, or seeking out rewarding experiences. Therefore, the model would suggest that heightened BIS sensitivity and diminished BAS-reward sensitivity are related to ERD. Interestingly, the lack of invariance across SQ groups for the pathways from BIS sensitivity and BAS-reward sensitivity to ERD is contrary to what was expected. Although research has suggested a link between personality dimensions and sleep disruptions (Gray and Watson, 2002), the findings of the current study suggest weak direct relationships between BIS/BAS sensitivity and of sleep disruption. Further, there is recent evidence to suggest that higher BIS sensitivity may be an initiating factor for the onset sleep disturbance, but that BIS sensitivity may not be directly related to sleep disturbance with regard to the maintenance of insomnia (Gosling et al., 2012). Therefore, the current findings may be better explained in terms of the role that BIS/BAS plays in relation to sleep processes and less so in relation to sleep disruption associated with psychopathology as the current sample was not a clinical sample. Recent research suggests that BAS-reward sensitivity may be more dependent on circadian factors of morning– eveningness (i.e., the preference to organize activity around morning), which was interpreted to mean that those with higher
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
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reward motivation organize activities during morning times in which there is access to rewards (i.e., morningness; Hasler et al., 2010); however, this is not necessarily related to sleep difficulties. Alternately, BIS does not serve the same function because it is a system based on contextual and situational factors (i.e., perception of threat) and would therefore operate independently of this relationship (Hasler et al., 2010). Specifically, there is no adaptive reason that BIS sensitivity would be related to circadian preference, but BIS sensitivity may be related to disruptions in sleep processes under certain circumstances (i.e., anxiety). Given that the groups were based solely on a SQ classification, which could be determined by a myriad of factors, the lack of invariance across groups may be explained by contextual/situational factors that were not captured by the current model. Given the associations of heightened BIS and diminished BASreward sensitivity with ERD, the positive relationships between ERD and depression, anxiety and stress are not surprising. The findings complement previous research suggesting that BIS and BAS-reward sensitivity along with ERD result in poor mental health (i.e., anxiety symptoms; Pickett et al., 2011). However, the findings are the first to suggest ERD as an intermediate variable in the relationship between BIS and BAS-reward sensitivity and depression and stress symptoms. Interestingly, no direct effects of BIS and BAS-reward sensitivity on anxiety were included in the model after making the necessary modifications dictated by fit statistics. From this finding, it would seem that the effects of BIS and BAS-reward sensitivity on anxiety symptoms are fully explained by the indirect pathways; seemingly, the joint effects of BIS and BAS dimensions may lead to particular ERD that worsen anxiety symptoms. Further, invariance testing indicated stronger associations between ERD and depression and anxiety symptoms in poor quality sleepers compared to good quality sleepers. This suggests that poor SQ may exacerbate depression and anxiety symptoms through the effect on ERD. Although results indicate that ERD alone are sufficient to produce depression and anxiety symptoms, poor SQ may strengthen this relationship; the findings cannot be used as evidence to claim that ERD cause poor SQ, or vice versa, but a relationship is nonetheless present. Overall, the final model illustrates an indirect effect of BIS and BAS-reward sensitivity on depression, anxiety, and stress symptoms through ERD, which are moderated by SQ. Thus, the cumulative effects of a heightened negative emotional reactivity and a decreased responsiveness to reward may increase ERD and when coupled with poor SQ, may culminate in more severe depression, anxiety, and stress symptoms.
4.1. Possible treatment implications Considering that cognitive-behavioral therapy (CBT) is an effective treatment for a wide range of clinical problems, including depression and anxiety (see Butler et al., 2006, for a review), and sleep difficulties (Baglioni et al., 2010), the current findings may suggest an integration of additional techniques (i.e., behavioral activation and mindfulness) into CBT practice. Specifically, behavioral activation has been an effective therapy for depression by increasing involvement in positive activities (Lejuez et al., 2001). As more positive experiences begin to occur, an individual may experience a change in their responsiveness to rewarding activities, thus improving ER (Tugade and Fredrickson, 2004). The extent that emotional processing promotes positive outcomes is considered to be a function of ER strategies (Austenfeld and Stanton, 2004). Further, some evidence suggests that higher levels of positive affect facilitate good quality sleep, which may be a function of adaptive ER (Norlander et al., 2005). Therefore,
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behavioral activation may impact both mood and sleep simultaneously through an effect on ER. Mindfulness-based techniques have been suggested to reduce negative emotional reactivity, ERD, and the use of maladaptive ER strategies (Shapiro et al., 2006). Further, the incorporation of mindfulness into CBT for insomnia is effective for reducing sleep-related difficulties (Ong et al., 2008). Thus, the implications of the current findings are potentially two-fold with regard to treatment. First, mindfulness-based techniques may allow for the acceptance of the heightened negative emotional reactivity associated with BIS sensitivity, subsequently reducing emotional reactivity and the use of maladaptive ER strategies. Second, mindfulness-based techniques may promote good quality sleep by reducing stress and pre-sleep arousal. Mindfulness-based therapies have the potential to impact all aspects of the current model, subsequently reducing symptomology. Future directions should investigate the integration of sleep-specific interventions into standard treatment protocols for depression and anxiety, given the complex relationships between depression, anxiety, and sleep.
4.2. Limitations and future directions The current study was not without limitations. Due to an oversight while constructing the computer-based survey, participant age was not collected. Year in school was used as a proxy for age, which was not related to any of the study variables. Further, it is important to note that the online survey was not conducted under controlled laboratory conditions, which may increase experimental error. Considering that the sample was predominately comprised of white, female participants, generalizability of the findings is limited. Reliance on self-report measures and the use of a combined measure of BIS and FFFS sensitivity, which overlooks their individual contribution and role as distinct systems, are inherent measurement constraints. Further, the use of the term ‘personality dimensions’ is used generally and does not apply directly to the findings of the current study. Where appropriate, BIS/BAS sensitivity are specifically referenced and do not represent other personality dimensions, which were not assessed in the current study. It cannot be assumed that the symptoms of depression and anxiety represent diagnosable disorders. The cross-sectional and correlational design limits interpretation regarding causal relationships among the variables. Further, the moderating effect of SQ on ERD should be interpreted with caution, as it is possible that ERD precipitated poor SQ. Future directions should employ a longitudinal investigation of this model in order to examine temporal relations. Examination of the model in community and clinical populations, with objective measures, is also warranted.
5. Conclusion The present findings suggest that a decreased responsiveness to rewards and a heightened sensitivity to aversive stimuli may predispose for difficulties regulating emotions. Accordingly, ERD lead to greater depression, anxiety and stress symptoms, which then worsen in the presence of poor SQ. Future research investigating self-regulatory mechanisms and personality dimensions within the context of poor SQ holds promise for improving treatments and understanding the mechanisms underlying the development and maintenance of psychopathology.
Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i
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Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.psychres.2013.06. 004.
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Please cite this article as: Markarian, S.A., et al., A model of BIS/BAS sensitivity, emotion regulation difficulties, and depression, anxiety, and stress symptoms in relation to sleep quality. Psychiatry Research (2013), http://dx.doi.org/10.1016/j.psychres.2013.06.004i