Health Anxiety as a Risk for Insomnia in Breast Cancer

Institution: University of California, San Diego
Investigator(s): Michelle Rissling, M.S. -
Award Cycle: 2009 (Cycle 15) Grant #: 15GB-0024 Award: $72,976
Award Type: Dissertation Award
Research Priorities
Community Impact of Breast Cancer>Sociocultural, Behavioral, and Psychological Issues: the human side

Initial Award Abstract (2009)

Breast cancer patients often complain of sleep disturbance and daytime sleepiness before, during and after chemotherapy and have a high incidence of anxiety and depression and insomnia which increase with age. Insomnia has a host of debilitating consequences that include: tiredness, negative mood, inability to enjoy family and social relationships and increased severity of pain and poor health. The risk factors for insomnia in breast cancer patients are poorly understood, but women with breast cancer are at a higher risk for insomnia because, in addition to the physical symptoms and an increase in anxiety and depression, the risk for insomnia and mood disorders is also greater in women.

Two cognitive models have been developed that explain the relationship between acute stressors (e.g., diagnosis of breast cancer) and the development of insomnia. In particular, research has shown that individuals with insomnia report uncontrollable worries and rumination in addition to compensatory behaviors that interfere with a return to normal sleep. However, cognition has not been investigated in relationship to insomnia in breast cancer. In addition, anxiety about specific health concerns in chronic illness has also been associated with insomnia, but has not been investigated in breast cancer. Specifically, 20 women with stage I-III breast cancer and 20 controls (women with no history of any cancer) will be studied as part of a larger longitudinal study of fatigue and cognitive deficits in breast cancer patients. Patients will be seen prior to the start of chemotherapy and after cycle 4 of chemotherapy. Control women will follow the same protocol as the nominating patient. At both time points, participants will complete questionnaires on sleep, health anxiety, cognitive arousal, compensatory sleep effort, depression, anxiety, menopausal symptoms and will wear an “actigraph” (activity recorder) for three days. Information about sleep quality and insomnia will be extracted from standardized questionnaires and from the sleep/wake cycle information provided by the actigraph. The data analysis will use multivariate general linear model to investigate differences between groups and between the two time points.

We anticipate that this research will identify the key psychosocial factors in health anxiety in breast cancer patients that can be utilized to address the critical quality of life issues associated with insomnia.

Final Report (2011)

Although the treatment of breast cancer has made large strides over the course of this project, sleep disturbances continue to be a significant health and quality of life issue in women receiving chemotherapy for breast cancer. Research into health or illness-related anxiety has also shown an increased risk of sleep disturbances in patient populations, however, this type of anxiety remains unstudied in women with breast cancer.

We investigated whether women with breast cancer experience more sleep-interfering thoughts and behaviors either before or during chemotherapy and whether these thoughts and behaviors increase the likelihood of having insomnia at the end of four cycles of treatment. We collected information on sleep, mood and health anxiety in a sample of women recently diagnosed with breast cancer both after diagnosis but before chemotherapy and after chemotherapy. We also collected the same information in a sample of demographically similar women without breast cancer that did not receive chemotherapy, but were studied at the same time as the matching breast cancer patient. We were successful in recruiting and studying 23 women with breast cancer before chemotherapy and 21 women with breast cancer after chemotherapy. We were also successful in recruiting and studying 30 demographically-similar women without breast cancer. Our final sample consists of 20 women with breast cancer individually matched with a demographically similar woman without breast cancer for whom we have collected information at both time points.

Two-factor ANOVA revealed that both groups reported similar levels of insomnia in addition to health anxiety, pre-sleep cognitive arousal and compensatory sleep effort. Actigraphic sleep and menopausal symptoms were also similar. Linear regression-based mediation analyses revealed that both groups demonstrated an association between health anxiety, compensatory sleep effort and insomnia. At C4, both groups demonstrated an association between compensatory sleep effort, pre-sleep cognitive arousal and insomnia. Additionally, compensatory sleep effort mediated links between health anxiety and insomnia, and pre-sleep cognitive arousal and insomnia. The results validate cognitive models of insomnia and provide support for targeting health anxiety, pre-sleep cognitive arousal and compensatory sleep effort as risk factors for insomnia in women with and without breast cancer.

We plan to finalize the exploratory analyses and submit manuscripts for peer-review and publication in the upcoming year.

Symposium Abstract (2010)

Michelle Rissling,1 Loki Natarajan,3 Sue Lawton,2 Monique Cornejo,2 Sonia Ancoli-Israel 1,2
1 SDSU/UCSD Joint Doctoral Program in Clinical Psychology
2 Department of Psychiatry, University of California, San Diego
3 Department of Family and Preventive Medicine

Chronic insomnia is prevalent in breast cancer patients both during and following chemotherapy. Psychophysiological models of insomnia suggest that pre-sleep cognitive arousal due to sleep effort and cognitive activity may be both a precipitating and perpetuating factor. Furthermore, psychophysiological arousal resulting from health-related anxiety may also precipitate both pre-sleep cognitive arousal and insomnia. This study examined this theory in recently-diagnosed breast cancer patients. We present preliminary analyses on data collected after diagnosis but before the start of chemotherapy.

Twelve women (mean age=50.5 yrs, SD=9.5, range: 36-63) diagnosed with stage I–III breast cancer and 11 yoked, age- and education matched healthy controls (mean age=52.7 yrs, SD=10.9, range: 38-77) were studied both before (BL) and after 4 cycles of chemotherapy (C4). The Short Health Anxiety Inventory (SHAI), Glasgow Sleep Effort Scale (GSES), the Glasgow Content of Thoughts Inventory (GCTI) and the Insomnia Severity Index (ISI) were administered at both time points. We present preliminary analyses using independent t-tests (α= 0.05) conducted on BL data.

At BL, patients reported significantly higher health anxiety (SHAI; mean= 12.47, SEM=1.58) and insomnia symptoms (ISI; mean=13.11, SEM=2.04) as compared to healthy women (SHAI: mean=8.76, SEM=0.83; ISI: mean=8.08, SEM=1.22) (SHAI: t=-2.19, df=19, P=0.04, d=0.69; ISI: t=-2.23, df=19, P=0.04, d=0.96). Although not statistically significant, patients also reported higher sleep effort (GSES; mean=5.60, SEM=1.1) than controls (mean=3.73, SEM=0.76) and higher pre-sleep cognitive activity (GCTI) at BL (mean=55.10, SEM=5.28) than controls (mean=45.33, SEM=3.06) at BL.

Preliminary results of this small sample suggest that breast cancer patients may experience more health anxiety and insomnia symptoms compared to healthy women. In addition they may also experience increased sleep effort and pre-sleep cognitive activity prior to the start of chemotherapy, but larger sample sizes are needed to confirm these findings. These results suggest that breast cancer patients may have increased vulnerability to health-related anxiety, sleep-interfering cognitions and insomnia symptoms during this period.