新版的睡眠信念态度表（英文版 ）.pdf

SLEEP,Vol.30,No.11,20071547INTRODUCTIONCLINICAL AND RESEARCH EVIDENCE SUGGEST THAT SLEEP RELATED COGNITIONS SUCH AS FAULTY BELIEFS,WORRY,AND ATTENTIONAL BIAS PLAY AN important medi-ating role in perpetuating or even exacerbating insomnia.1-4 For in-stance,some insomnia sufferers tend to hold unrealistic expectations about their sleep requirements and to worry excessively when such requirements are not met.Others fear the potential consequences of insomnia on their daytime functioning and tend to selectively channel their attention on any evidence of such consequences.In turn,such faulty expectations,perceptions,and excessive worry are instrumental in producing emotional distress,heightening arousal,and in feeding on the vicious cycle of insomnia.5Recognizing the potential role of sleep-disruptive cognitions in insomnia,an increasing number of investigators and clinicians are incorporating cognitive therapy as a therapeutic component of psychological interventions for insomnia.6 Although the unique contribution of cognitive therapy to treatment outcome has not been assessed yet,recent clinical trials have shown that these ther-apeutic targets,including faulty beliefs and attitudes about sleep,are responsive to treatment and may actually play an important mediating role in reducing insomnia symptoms and in maintain-ing sleep improvements over time.7-9Despite increasing recognition of the importance of cognitive factors in the etiology of insomnia,there are few instruments spe-cifically designed to identify and evaluate patient-specific sleep re-lated cognitions relevant for therapy.The development of reliable and valid measures is both timely and relevant given the increasing attention devoted to insomnia in general10,11 and,more specifically to sleep cognitions as a mediating factor and a treatment target.The Dysfunctional Beliefs and Attitudes about Sleep Scale4,12 was developed to evaluate such sleep-disruptive cognitions.The origi-nal DBAS version included 30 items that were rated on 100-mm visual analog scales.This instrument has been translated into sev-eral languages(e.g.,French,Italian,German,Japanese,Swedish)and is increasingly used by clinicians and researchers throughout the world.13-20 The DBAS has been found reliable for discriminating between self-defined good and poor sleepers in both younger and older adults.2,21,22 It has also been shown sensitive to several indices of changes with insomnia treatment.7-9,21 To encourage a more wide-spread use of the DBAS among the sleep community,we examined the psychometric properties of an abbreviated version(16 items)us-ing a more user-friendly response format(0-10,Likert-type scale).METHODParticipantsThere were a total of 283 participants including 124 clinical patients evaluated/treated for insomnia at a private behavioral sleep medicine clinic(clinical sample)and 159 research partici-pants enrolled in insomnia treatment studies(research sample).Dysfunctional Beliefs and Attitudes about Sleep(DBAS):Validation of a Brief Version(DBAS-16)Charles M.Morin,PhD;Annie Vallires,PhD;Hans Ivers,MPsUniversit Laval,Qubec,CanadaValidation of the DBAS-16Morin et alDisclosure StatementThis is not an industry supported study.Dr.Morin has received research support from Sanofi-Aventis;has consulted for Sepracor,Pfizer,Neurocrine,Takeda,and Shire Biochem;and has participated in speaking engagements for Takeda,Sanofi-Aventis,and Merck.The other authors have indicated no financial conflicts of interest.Submitted for publication June,2006Accepted for publication June,2007Address correspondence to:Charles M.Morin,PhD,Universit Laval,cole de Psychologie,Pavillon F.A.S.,Quebec City,Quebec,Canada,G1K 7P4.Tel:[phone];Fax[phone];E-mail:cmorinpsy.ulaval.caINSOMNIAStudy Objective:Sleep related cognitions(e.g.,faulty beliefs and ap-praisals,unrealistic expectations,perceptual and attention bias)play an important role in perpetuating insomnia.This paper presents new psycho-metric data on an abbreviated version of the Dysfunctional Beliefs and Attitudes about Sleep Scale(DBAS-16),a 16-item self-report measure designed to evaluate a subset of those sleep related cognitions.Design:Psychometric study of a patient-reported measure of sleep re-lated beliefs based on existing clinical and research databases.Participants:A total of 283 individuals(60%women;mean age of 46.6 years old)with insomnia,including 124 clinical patients and 159 research participants.Measurements and Results:Participants completed the DBAS,Insom-nia Severity Index,Beck Depression and Anxiety Inventories,daily sleep diaries for 2 weeks,and 3 nights of polysomnography(research sample only)as part of a baseline assessment.The DBAS-16 was found to be reliable,as evidenced by adequate internal consistency(Cronbach alpha=0.77 for clinical and 0.79 for research samples)and temporal stability(r=0.83).The factor structure was similar to the original 30-item version,with 4 factors emerging and reflecting:(a)perceived consequences of insomnia,(b)worry/helplessness about insomnia,(c)sleep expectations,and(d)medication.DBAS total scores were significantly correlated with other self-report measures of insomnia severity,anxiety,and depression,but not with specific sleep parameters.Conclusion:The psychometric qualities of this abbreviated DBAS-16 version seem adequate.This patient-reported measure should prove a useful instrument to evaluate the role of sleep related beliefs and attitudes in insomnia and to monitor change on this cognitive variable as a potential moderator of treatment outcome.Keywords:Insomnia,assessment,beliefs,attitudes,sleep,measure,evaluation.Citation:Morin CM;Vallires A;Ivers H.Dysfunctional Beliefs and At-titudes about Sleep(DBAS):Validation of a Brief Version(DBAS-16).SLEEP 2007;30(11):1547-1554.SLEEP,Vol.30,No.11,20071548All participants had a primary complaint of insomnia;research participants met DSM-IV criteria for chronic primary insomnia,23 whereas clinical patients could present primary insomnia or in-somnia comorbid with another medical or psychiatric disorder(mostly anxiety and depression).Participants from the research sample but not the clinical sample had to be free of any sleep or other psychotropic medication interfering with sleep at least one month prior to treatment.Additional exclusion criteria for the re-search sample were the presence of another sleep disorder(e.g.,sleep apnea,restless legs syndrome/periodic limb movements dur-ing sleep),presence of a major psychiatric disorder(e.g.,major affective disorder,psychosis),evidence that insomnia was related to a medical condition,and currently in psychotherapy.SampleThe total sample(N=283)was composed predominantly of women(59.5%);the average age was 46.6 years old(SD=10.4,range 20 to 71 years old),and the mean number of years of edu-cation was 14.9 years(SD=3.7).The average insomnia duration was 14.3 years(SD=12.5)with a mean age of insomnia onset at 32.5 years old(SD=13.1).Overall,7.6%presented sleep-onset insomnia,20.0%sleep-maintenance insomnia,1.4%terminal insomnia,and 71.0%mixed sleep onset and maintenance insom-nia.Comparisons between clinical and research samples yielded some significant differences.Specifically,clinical participants were younger(M=42.0 years)than research participants(M=47.3),t266=-4.16,P 0.001,they were more likely to re-port sleep-onset insomnia(18.5%vs.2.8%for research sample)but less likely to report sleep-maintenance insomnia(12.3%vs.23.5%for research sample),2(3,N=210)=17.46,P 0.001,and their average insomnia duration was shorter(10.0 years)compared to that of the research sample(13.9 years),t262=-2.62,P=0.009.There were also more clinical than research patients with a current psychiatric disorder(29.3%vs.15%,2(1,N=266)=7.89,P 0.005)and using hypnotic medications either currently or in the past year(67%vs.39.9%,2(1,N=264)=18.65,P 0.001).No significant difference was found on gen-der,education,and age at insomnia onset.ProcedureAll participants completed the DBAS,with several other self-report measures,as part of a baseline assessment.In addition,they underwent a clinical evaluation including a semi-structured sleep history interview to diagnose insomnia4 and the Structured Clini-cal Interview for DSM-IV24(research sample only)to evaluate the presence of psychiatric disorders.A medical history and physical examination was conducted for research participants.All partici-pants kept daily sleep diaries for 2 weeks.Seventy-three par-ticipants from the research sample completed the DBAS a second time,approximately 2 weeks after the first completion,to assess temporal stability.MeasuresDysfunctional Beliefs and Attitudes about Sleep Scale The original DBAS4 is a 30-item self-report questionnaire designed to identify and assess various sleep/insomnia-related cognitions(e.g.,beliefs,attitudes,expectations,appraisals,attri-butions).The initial pool of items was derived from clinical ex-perience with insomnia patients and from psychological concep-tualizations of insomnia.They were selected to sample a broad domain of beliefs,thoughts,appraisals,and concerns expressed by patients with insomnia.The nature of these beliefs clustered around 5 conceptually derived themes:(a)misconceptions about the causes of insomnia(e.g.,“I believe insomnia is essentially the result of a chemical imbalance”);(b)misattribution or amplifica-tion of its consequences(e.g.,“I am concerned that chronic in-somnia may have serious consequences on my physical health”);(c)unrealistic sleep expectations(e.g.,“I must get 8 hours of sleep to feel refreshed and function well the next day”);(d)diminished perception of control and predictability of sleep(e.g.,“When I sleep poorly on one night,I know it will disturb my sleep sched-ule for the whole week”);and(e)faulty beliefs about sleep-pro-moting practices(e.g.,“When I have trouble sleeping,I should stay in bed and try harder”).Earlier validation of the 30-item version showed adequate psychometric properties as evidenced by good internal consistency(Cronbach Alpha=0.80),moderate item-total correlations(mean rs=0.37),and adequate conver-gent and discriminant validity.12,14,22 Additional psychometric data on the original 30-item version,or of altered versions,have also been reported by other investigators.7,15,21Scoring and Interpretation Guidelines For each statement,the person rates his or her level of agree-ment/disagreement on a 100-mm visual analog scale anchored at one end by“strongly disagree”and at the other by“strongly agree.”In order to facilitate scoring of the instrument,the re-sponse format was altered during the course of data collection with the research sample from a visual analog scale(i.e.,straight 100 mm line)to a Likert-type scale requiring participants to circle a number from 0(strongly disagree)to 10(strongly agree)with the same continuous 100-mm line in the background.The visual analogue scale version was completed by 52 participants and the Likert scale version was completed by 107 participants.Although there is no absolute right or wrong answer for any single item,their dysfunctional nature is reflected by the degree with which patients endorse a particular item.For example,the belief that 8 hours of sleep is needed to function adequately dur-ing the day may be valid for most people,yet too strong an en-dorsement of this statement could potentially trigger some worry and concern when such requirement is not met and contribute to perpetuate insomnia.Thus,the results are quantified in terms of strength of endorsed beliefs.Except for item 23(on the 30-item version)for which the score is reversed,a higher score indicates more dysfunctional beliefs and attitudes about sleep.The total score is based on the average score of all items.Subscale scores can be computed by adding the sum of scores for the items and dividing by the number of items making up each subscale.The same scoring procedure is recommended for the revised 16-item version,i.e.,adding scores for all 16 items and dividing by 16 for an average total score.Sleep Measures Participants completed daily sleep diaries during 2 weeks as part of their baseline assessments before initiating treatment.Sleep vari-Validation of the DBAS-16Morin et alSLEEP,Vol.30,No.11,20071549ables derived from the diary included Sleep-Onset Latency(SOL),Wake after Sleep Onset(WASO;time awake from initial sleep on-set to last awakening),Total Wake Time(TWT;SOL+WASO+last awakening before arising),Total Sleep Time(TST),and Sleep Ef-ficiency(SE;ratio of total sleep time divided by time spent in bed and multiplied by 100).Sleep variables were coded each night and weekly means were computed.Research participants completed 3 nights of polysomnographic(PSG)recording as part of their base-line evaluation.Means from the second and third night of record-ings were used for the present analyses.Additional measures Several additional patient-reported measures were used to ex-amine convergent and discriminant validity.The Insomnia Se-verity Index4 is a 7-item scale evaluating the perceived insomnia severity.Ratings on a 0 to 4 point scale were obtained on the per-ceived severity of sleep-onset,sleep-maintenance,early morning awakening problems;satisfaction with current sleep pattern;in-terference with daily functioning,noticeably of impairment attrib-uted to the sleep problem;and level of distress caused by the sleep problem.The total score ranges from 0 to 28,and higher scores indicate more severe insomnia.The ISI has adequate psychomet-ric properties and has been shown to be sensitive to changes in clinical trials of insomnia.14,25,26 The Beck Depression Inventory27 and the Beck Anxiety Inventory28 were also administered to as-sess depression and anxiety symptoms.Psychometric properties of those questionnaires are well documented.RESULTSAnalyses of the Original 30 Items of the DBASSeveral analyses were computed on the original 30 items to guide the decision-making process in reducing the number of items for the final abbreviated scale.In addition to examining in-ternal consistency of the original items,those analyses sought to identify items that were sensitive to floor effect(i.e.,low mean and low variance)and items with high rate of missing data.The objective was to reduce the scale to about 16 items(i.e.,half of the original scale length)without compromising its psychometric properties or the scope of the sampled domains.Descriptive statistics(means,standard deviations,range of scores),for the 30 original items are presented in Table 1.These data show that 3 items,14(insomnia as the result of aging),15(afraid of dying in sleep)and 26(alcohol as a solution),exhibited low mean and variance,suggesting the presence of a floor effect(i.e.,low sensitivity to individual differences).In addition,item 13(should sleep as well as bed partner)was not answered by 5%of participants,probably those who did not have a bed partner.Item 2(need less sleep because of aging)had a lo