Running head: Role of Stress, Anxiety, and Alcohol in Disrupted Sleep 1
The Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Among a College Population
Julie DeBonis
This thesis is submitted in fulfillment
of the requirements of the Research Honors Program
in the Department of Psychology
Marietta College
Marietta, Ohio
April 21, 2011 2 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
This Research Honors thesis has been approved for
the Department of Psychology and
the Honors and Investigative Studies Committee by
______Dr. Ryan May______04/21/11
Faculty thesis advisor Date
______Dr. Alicia Doerflinger______04/21/11
Thesis committee member Date
3 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Acknowledgements
I would like to thank Dr. Ryan May and Dr. Alicia Doerflinger for their direction, assistance and guidance. I would especially like to thank Dr. May for his continued input and suggestions that have been invaluable to the successful completion of this study.
I would like to give special thanks as well to all those who participated in this study, for making this research possible.
4 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Table of Contents
Abstract ………………………………………………………………….Page 5
Introduction……………………………………………………………....Page 6
Method………………………………………………………………...... Page 11
Results…………………………………………………………………...Page 16
Discussion……………………………………………………………….Page 17
References……………………………………………………………….Page 21
Tables…………………………………………………………………….Page 24
Appendices……………………………………………………………….Page 30
5 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Abstract
This study examines the role of stress, anxiety, and alcohol in disrupted sleep patterns within a college population. The analysis is based upon six questionnaires administered to 64 females and
16 males from the Marietta College campus. Stress, anxiety, and alcohol use were examined in relation to their self-reported sleep disruption. The results show that stress is the largest contributing factor to sleep disruption, anxiety is a moderate predictor of sleep disruption, and alcohol use is a modest predictor of sleep disruption. In order to combat the effects that stress has on sleep habits, it is suggested that college students are provided with knowledge on how to manage stress before experiencing adverse effects on sleep habits.
6 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
The Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Among a College Population
Sleep disruption can lead to many physical, emotional, and social problems that in turn can affect peoples’ lives in an adverse manner. Short and long term sleep disruption can lead to increased irritability, increased fatigue, increased possibility of accidents, changes in appetite, lowered immune system functioning, difficulties in memory and attention, and an increased probability of a major psychological disorder such as anxiety disorders or depression developing
(Seiberling, 2011).
There are many factors that give way to sleep disruptions in people of all ages. The college age, in particular, is at risk to experience a wide variety of sleep disruptions due to the extreme fluctuations within the college setting (Lund, 2010). College is a time of transition in life, opening the doors from a sheltered high school existence to an open and unexplored world that is daunting, and guaranteed to cause a few snags as new experiences unfurl. As such, students in college may lose out on sleep in order to compensate for other life changes. College students between the ages of 18 and 24 that participated in a recent study regarding sleep differences between genders revealed that sleep latency in both genders and across all ages was compromised due to the strenuous demands of college (Tsai, 2004). Once sleep disruption developed a pattern, those students would eventually accumulate a sleep debt, raising their risk for other potential physical and psychological difficulties in their future (Tsai, 2004).
Stress is a major factor leading to sleep disruption. The lack of control that people feel when they are stressed causes them to fret about the things they cannot change which often times leads to a disruption of sleep (Drake, 2003). The emotional reactions exhibited in relation to stress are cause for concern that can lead to sleep disruption. Stress adversely affects sleep 7 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep patterns in such a way that the affected sleep can ultimately propagate additional stress. Stress and sleep patterns enter this cyclical pattern due to stress altering a person’s REM sleep cycle
(Vandekerckhove, 2010). Stress can increase or decrease the latency of REM sleep, as well as the wakening threshold that allows a person to recall dreams from REM sleep more readily. The prevalence of remembering dreams after sleep disruption can affect stress levels as well by turning the person’s attention to the content of the dream in relation to their daily stresses
(Vandekerckhove, 2010). The added stress caused by sleep disruptions’ physical and emotional effects on a person can lead the person into a pattern in which sleep disruption and stress come together as one, leading toward the highest risk of future physical and psychological health
(Vandekerckhove, 2010).
If the necessary amount of required sleep is not received, a person will not be fully restored, making them prone to increased sensitivity to emotional, and other, stimuli experienced throughout the day. This is thought to be the effect of altered REM sleep cycles which adversely affect the manner in which the prefrontal cortex functions, causing a person to be focused on the emotion aspects of events rather than on the logical or rational (Vandekerckhove, 2010).
Anxiety can also cause an increased risk of sleep disruption (Buckner 2008). Stress is the precursor to the development of anxiety within a person (McLaughlin, 2009). Repeated daily stressors, especially life events pertaining to family discord and health issues, can lead to heightened anxiety sensitivity. When a person is continually exposed to these stressful life events, they are at a higher risk of developing an anxiety disorder (McLaughlin, 2009).
According to the DSM-IV-TR, one of the six defining aspects of an anxiety disorder is the prevalence of sleep pattern alteration, in which a person has trouble falling asleep or staying asleep throughout the night (2000). Feelings of anxiousness such as fear, the inability to relax, 8 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep unsteadiness, or dizziness can all be contributing factors that lead to difficulty falling asleep
(Beck, 1993). Such feelings can be triggered by stressful life situations, as well as by a person’s naturally anxious tendencies. Those with higher tendencies toward anxiety experience stressful events as more stressful than those with lower tendencies toward anxiety, therefore creating a higher risk for anxious symptoms in some people rather than others (Kendall, 1978).
External factors like alcohol can also play a role in sleep disruption, whether it is used as a sleep aid or abused in a way the sleep cannot follow its normal pattern in the body (Brower,
2003). ―National samples of college students demonstrate that nearly 85% report consuming alcohol within the past year, 70% report monthly use, and 40% report binge drinking (consuming five or more drinks in a row) within the past 2 weeks‖ (Kuther, 2003). American college students are susceptible to alcohol use as it seems to be the culture’s view that drinking in college is the
―cool‖ thing to do. Therefore, it is clear that students take their cultural ―duties‖ to heart and consume alcohol, at least in some capacity. Students in college are at the point in life where they feel the need to break rules simply because they are free from their previously structured duties now that they are a part of a college campus. Alcohol is easiest to access during college years as well, making it a convenient outlet for all students seeking to find a way to fit in as well as a way to cope with their daily problems (Kuther, 2003).
Alcohol adversely affects REM cycles in a similar manner to stress. In a study of college age males, it was found that REM cycles were suppressed during the early sleeping hours after an alcohol session, but accelerated during the later sleeping hours of the same night (Rundell,
1972). This implies that alcohol is acting as a depressant to the brain during sleep, and to combat the depressive effects, the brain tries to compensate by creating stronger and more prevalent
REM cycles in the second half of sleep. The results are consistent with the theory that sleep 9 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep patterns are contingent with the blood alcohol content in the body. However, these results showed that after repeated alcohol sessions, the sleep patterns measured leveled out over time, in which REM cycles adjusted to near normal. It is suggested that the body adapts to the effects of alcohol, including sleep patterns (Rundell, 1972). REM sleep cycles adjust in order to compensate for the effects of alcohol, but repercussions still occur in the form of lost stage 2 sleep. Stage 2 sleep is responsible for the transition between wakefulness and sleeping, in which a person can be easily roused, but if not disturbed, continually drifts into a deeper sleep (Chang,
2010). Alcohol suppressed stage 2 sleep across all alcohol sessions observed, revealing that persons consuming alcohol frequently fell asleep without transitioning into the deep sleep preceding REM sleep. Bypassing the transition period into REM sleep accounts for the feelings of fatigue and general sleepiness that a person experiences the day following an alcohol induced sleep because the traditional sleep pattern did not occur (Rundell, 1972).
The amount of alcohol consumed in an alcohol session influence sleep behavior as well
(Voinescu, 2010). In a recent study by Voinescu (2010), it was discovered that the more alcohol consumed in each alcohol session, the more sleep disturbance occurred. Persons reporting higher levels of alcohol consumption were more likely to experience symptoms of insomnia that interfered with daily life than persons reporting lower levels of alcohol consumption.
Alcohol can become a coping mechanism as well, used in order to encourage the onset of sleep when sleep becomes difficult, as often occurs for college students due to heightened stress and anxiety (Taylor, 2010). However, alcohol does not allow for a restful sleep as the student expects, but rather, disrupts the sleep cycles, providing more windows of wakefulness within the sleep pattern as well as an earlier waking time. As a result, feelings of sleepiness continue throughout the day following an alcohol induced sleep due to alcohol’s depressive 10 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep characteristics. The lack of judgment used in the decision to utilize alcohol as a sleep aid can lead to daytime sleepiness that can be as harmless as falling asleep reading or as harmful as falling asleep at the wheel and causing a traffic accident (Taylor, 2010).
Lund (2010) completed a study in which college students were administered three different sleep surveys, a mood states survey, a distress (anxiety) test, and a physical health survey in order to determine sleep patterns. The results of each survey were analyzed, revealing increased disrupted sleep-wake patterns resulting from the altered tempo of the college lifestyle, but lesser effects due to exercise, alcohol, and caffeine consumption (Lund, 2010). Other research has shown that the adolescent years are the most susceptible to sleep problems that will continue into adulthood, supporting the theory of increased sleep disruption in college age students (Dregan, 2010). Due to the frequency of sleep disruption experienced by college students, it has been suggested that college students have access to information regarding the prevention of sleep disruption in order to live a healthier lifestyle (Tsai, 2004).
The purpose of this study is to explore the time in peoples’ lives when they are especially prone to stress, anxiety, and alcohol use: the college years. The goal of this study is to predict the extent to which students’ sleep patterns are disrupted by the variables of stress, anxiety and alcohol use. This study will attempt to partially replicate Lund’s study; however, this particular study will have a specific focus on alcohol uses’ influence on sleep behavior, as well as focusing more on stress and anxiety specifically. It is expected that the results will reveal an increase in students’ sleep difficulties with the addition of the variables stress, anxiety, and/or alcohol usage.
11 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Method
Subjects
The subjects that participated in this study are Marietta College students of all class levels, totaling 80 students. Sixty four women and sixteen men took place in the study. The selection process recruited students primarily from introductory psychology courses, as well as students from upper level psychology classes, or those that have studied psychology in previous semesters as Marietta College.
Materials
Six questionnaires were utilized in this study: the Beck Anxiety Inventory (Beck, 1993), the Alcohol Use Disorders Identification Test (Babor, 2001), the College Undergraduate Stress
Scale (Renner, 1998), the Global Sleep Assessment Questionnaire (Roth, 2002), the Pittsburgh
Sleep Quality Index (Buysse, 1989), and the Pittsburgh Sleep Symptom Questionnaire (Okun,
2009).
Beck Anxiety Inventory (BAI) (Beck, 1993). The BAI is a 21-item scale that measures the severity of self-reported anxiety in adults and adolescents. It consists of descriptive statements of anxiety symptoms which are rated on a 4-point scale with the following correspondence: ―Not at all‖ (0 points); ―Mildly; it did not bother me much‖ (1); ―Moderately; it was very unpleasant, but
I could stand it‖ (2); and ―Severely; I could barely stand it‖ (3). The BAI has shown (1) Internal consistency ranged from .92 to .94 for adults (Cronbach’s alpha). The alphas for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition—Revised (DSM-III-R) anxiety disorder groups ranged from .85 to .93. (2) Test-retest reliability (1-week interval): .75. The 12 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep correlations of the BAI with a set of self-report and clinician-rated scales were all significant.
The correlation of the BAI with the revised Hamilton Anxiety Rating Scale (HARS-R) and revised Hamilton Rating Scales for Depression (HRSD-R) were .51 and .25, respectively. The correlation of the BAI with the BDI was .48. Convergent and discriminant validity to discriminate homogeneous and heterogeneous diagnostic groups were ascertained from three studies (Beck, 1993). The BAI is scored by adding the reported scores of the 21 available criteria. Scores are categorized into three levels of anxiety: low, moderate, and high. Scores between 0-21 represent low anxiety, scores in the 22-35 range represent moderate anxiety, and scores exceeding 36 represent high anxiety (Beck, 1993).
Alcohol Use Disorders Identification Test (AUDIT) (Babor, 2001). The AUDIT consists of 10 questions about recent alcohol use, alcohol dependence symptoms, and alcohol-related problems.
The median internal consistency reliability across 24 samples was .81, with a range of .59 to .91.
Results suggest that the AUDIT is capable of generating generally reliable scores across some varied sample conditions. Data suggest that the interviewer- or self-administered AUDIT have similar discriminant validity to identify hazardous-drinking and alcohol-dependent behavior.
Published reports that evaluated the psychometric properties of self-administered AUDIT found areas under receiver operating characteristic (AUROC) in the range of 0.78 to 0.99 (Babor,
2001). The AUDIT is scored by calculating the total of responses provided for the 10 questions.
The severity of alcohol use is determined by assigning the total scores to a categorized range.
Scores ranging 8-15 represent a need for advice to reduce hazardous drinking, while scores ranging 16-19 represent a need for brief substance counseling and monitoring. Reported scores exceeding 20 represent a need for evaluation for an alcohol dependency (Babor, 2001).
13 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
College Undergraduate Stress Scale (CUSS) (Renner, 1998). The CUSS consists of 51 questions that gauge how stressed a student is when asked about a variety of demographically related issues. These questions range from severe stressors such as rape to mild stressors such as not liking a class. Internal consistency was (KR-21 = .80) and the split-half reliability was .71; the
Spearman-Brown prophecy formula brings the estimated reliability up to .83. CUSS shares criterion-related validity with the Brief Mood Introspection Scale (BMIS), a brief, validated measure of state mood, scored in the positive mood direction, and Pennebaker's (1980) symptom checklist, the "PILL" (Renner, 1998). The CUSS is scored by calculating the responses and determining whether the score was relatively high or low, representing high or low stress, respectively. Scores typically range 182 to 2571, thus scores of stress levels are relative in order to account for the obtuse range (Renner, 1998).
Global Sleep Assessment Questionnaire (GSAQ) (Roth, 2002). The GSAQ is an 11 item questionnaire that rates sleep behaviors on a three-point scale, ranging from behaviors that never occur, sometimes occur, and always occur. Test–retest reliability ranged from 0.51 to 0.92.
Pearson correlation coefficients suggested that the GSAQ discriminated between diagnoses
(Roth, 2002). Scores of the GSAQ are obtained by calculating the total responses to the 11 questions. Higher responses of always and sometimes represent a greater risk of sleep disruption
(Roth, 2002).
Pittsburgh Sleep Quality Index (PSQI) (Buysse, 1989). The PSQI is a 19 item questionnaire that asks participants to report their typical sleep habits within the past month. The PSQI asks 4 open ended questions, asking participants about their typical bedtime, how long it takes them to fall asleep at night, their average time of wakefulness, and the approximate number of hours of they sleep per night. The following 7 component questions attempt to quantify the extremity of sleep 14 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep disruptions that participants experience. The questionnaire resolves with 5 items about the subject’s sleep habits from the perspective of the subject’s roommate or bed partner (if applicable) (Buysse, 1989). The component questions formulating the midsection of the questionnaire showed a reliability coefficient (Cronbach’s alpha) of .85, demonstrating a high level of internal consistency. Paired t-tests of the PSQI also showed no significant difference between two tests taken by the same participant, indicating strong test-retest reliability. Validity was established for the PSQI through comparison with polysomnography, a diagnostic test performed during sleep to measure various psychological variables (Geyer, 2010). The latency of sleep between the PSQI and polysomnography results remained consistent, and thus validated for future use (Buysse, 1989). Each question of the PSQI is assigned a value between 0 and 3, some in conjunction with other questions in the questionnaire, and some questions assigned their own value. The PSQI measures sleep duration, sleep latency, day time dysfunction due to sleepiness, the efficiency of sleep, overall sleep quality, and the need for medication to aid sleep. The overall score of the PSQI is the combined scores of each of the individual measures (ranging from 0-21), with scores less than 5 representing better sleep quality and greater than 5 representing worse sleep quality (Buysse, 1989).
Pittsburgh Sleep Symptom Questionnaire (PSSQ) (Okun, 2009). The PSSQ is a 13 item questionnaire addressing the severity of sleep symptoms over the past month. Five questions address the frequency of sleep symptoms throughout a week and the longevity of the symptoms affect. The remaining eight questions address the weight of the symptoms effects of the students’ daily life. Content validity and face validity were found to be excellent due to the fact that the
PSSQ questions came directly from the DSM-IV. The PSSQ has high internal consistency due to an overall reliability coefficient (Cronbach’s alpha) of 0.89 (Okun, 2009). The PSSQ is scored 15 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep by three criteria: the sleep symptom criterion, the duration criterion, and the daytime impairment criterion. The sleep symptom criterion is determined by whether responses of ―frequently‖ or
―always‖ occurred in question 1, 2, or 5 with a yes or no answer. The duration criterion is determined by whether responses of questions 1, 2, or 5 showed the duration of symptoms to be longer or equal to 4 weeks with a yes or no answer. The daytime impairment criterion is determined by whether at least one of the responses to questions 6-13 was ―quite a bit‖ or
―extremely‖ with a yes or no answer. The risk of insomnia is measured by how many yes or no responses are recorded; more yes answers representing problematic sleep behaviors and more no answers representing non-problematic sleep behaviors (Okun, 2009).
Procedures
Each participant in this study was administered the six surveys in a counterbalanced manner, thereby measuring stress, anxiety, alcohol use, and sleep patterns in all participants. The participation of any subjects was confidential as the surveys were numbered rather than labeled by a name. This information was provided to participants in an informed consent form. A power analysis was conducted; the alpha level at .05, an effect size of .15, a statistical power level of
.80 and three predictors, determining that at least 76 participants were needed. A correlation was conducted in order to determine the correlation between the variables of stress, alcohol use, and anxiety. A stepwise multiple regression was conducted in order to determine the extent to which stress, anxiety, and alcohol predict sleep difficulties as measured by each of the sleep questionnaires.
16 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Results
The overall mean scores that participants reported indicate that they experience moderate levels of stress measured by the CUSS, low levels of anxiety measured by the BAI, and low levels of alcohol use measured by the AUDIT as shown in Table 1.
Sleeping behavior; quantity and quality
Participants indicated via the PSQI an average time of falling asleep to be 12:00am with an average waking time at 7:45am, accounting for approximately 7.75 hours of sleep per night.
Total reported sleep time per night was calculated by comparing bedtime and awakening time, averaging at 7.63 (SD=1.34) hours, slightly below the suggested 8 hours of sleep that the average person requires (National Sleep Foundation, 2011). Students reported their approximate average nightly sleep as 6.46 (SD=1.19) hours, over an hour less than the amount of sleep they received according to their reported bedtime and awakening hours. The average number of minutes to fall asleep was reported as 29.9 (SD=21.59) minutes. The amount of total sleep per night ranged from 4.9 hours of sleep to Forty-two percent of students reported getting less than 6.5 hours of sleep per night and only 12.6% of students reported getting 8 or more hours of sleep per night.
Relation of stress, anxiety and alcohol
Pearson correlations were conducted between scores on the BAI, CUSS, and AUDIT.
Stress, anxiety, and alcohol use were all significantly correlated variables, as shown in Table 2.
Theses correlations suggest that the variables likely interact with one another as predictors of sleep disruption.
Global Sleep Assessment Questionnaire
In order to examine the extent to which stress, anxiety, and alcohol use predict sleep difficulties as measured by the GSAQ, a stepwise multiple regression analyses was conducted. 17 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
The results of the GSAQ regression are found in Table 3. The analyses revealed that stress, anxiety, and alcohol use were all significant predictors of sleep disruption. Anxiety was the strongest predictor of sleep disruption, accounting for 19% of the variance in sleep disturbance.
Stress and alcohol accounted for 8.1% and 3.7% of the variance, respectively, of sleep disruption.
Pittsburgh Sleep Symptom Questionnaire
The extent to which stress, anxiety, and alcohol use predict sleep difficulties as measured by the PSSQ, a stepwise multiple regression analyses was conducted. Anxiety accounted for
13% of the variance of sleep disruption and stress accounted for an additional 4.7% of the variance of sleep disruption. Alcohol use did not contribute as a predictor of sleep disruption based upon the responses recorded from the PSSQ. Table 4 shows the significance of anxiety and stress as predictors of sleep disruption.
In order to explore differences in reported levels of stress, anxiety, and alcohol use between those identified as problem or non-problem sleepers as identified by the PSSQ, a one- way analysis of variance was conducted. Results can be found in Table 5, which revealed that students reporting more disrupted sleep habits synonymous with insomnia also reported higher levels of stress and anxiety, but not alcohol usage.
Discussion
The results showed that certain aspects of sleep were affected by the variables of stress, anxiety, and alcohol use. Both the Pittsburgh Sleep Symptom Questionnaire and the Global
Sleep Assessment Questionnaire showed that anxiety and stress affected sleep habits in a damaging manner. It is apparent from the results gained from the PSSQ and the GSAQ that the participants’ feelings and behavior associated with sleep disruption were most likely to be 18 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep affected by stress or anxiety. The GSAQ alone showed that alcohol use was a predictor of sleep disruption. The third sleep questionnaire, the Pittsburgh Sleep Quality Index, showed no significant relation to stress, anxiety, or alcohol use. The lack of significance suggested that the amount of time sleeping and external physical factors, such as a roommate, were not as likely to occur due to stress, anxiety, or alcohol.
Stress
Stress levels were moderate in students as found by the College Undergraduate Stress
Scale, and were significant predictors of sleep disruption across all sleep questionnaires. Stress was a significant predictor of sleep disruption as reported from the Pittsburgh Sleep Symptom
Questionnaire’s raw scores as well as the criterion scores. The GSAQ asked questions based upon sleeping behaviors and their frequency of occurrence, focusing on the behavior rather than feelings about sleep or external forces that influence sleep. Stress predicted a negative impact on sleep behaviors, as reported in the Global Sleep Assessment Questionnaire. According to the results, stress predicted behaviors that alter sleep and the feelings that students had toward their sleep patterns. This is consistent with previous findings of the relationship between sleep and stress.
Anxiety
The Beck Anxiety Inventory revealed that students reported a generally low level of anxiety. However, anxiety was a significant predictor of sleep disruption overall. Anxiety predicted that the reported sleep behaviors of the Global Sleep Assessment Questionnaire would be negatively affected. Sleep disruptions were also predicted by anxiety in relation to the
Pittsburgh Sleep Symptom Questionnaire; predicting an increase in the frequency, prevalence, and feelings associated with sleep disruptions. The PSSQ measured the frequency of less specific 19 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep sleep disruptions, as well as how persons felt about their sleep habits and the effects that sleep habits had on their daily lives. The beliefs that persons had about their sleep habits were predictors of how much anxiety said persons experienced. Although the overall anxiety levels reported were low, sleep behaviors and feelings associated with sleep disruptions were the most likely to be predicted by anxiety.
Alcohol Use
The Alcohol Use Disorders Identification Test (AUDIT) revealed that students’ drinking habits were not threatening. Regardless of the students’ reports of non-risk drinking, alcohol use still proved to be a predictive factor of sleep disruption. The sleep behaviors described in the
Global Sleep Assessment Questionnaire were susceptible to alteration by the use of alcohol. The use of alcohol did not seem to affect students’ views of their sleep habits, nor did it affect the amount of sleep that students reported. Alcohol was only likely to predict a change in the behaviors that were associated with sleep and its typical disrupters.
Limitations
The results of this study must be interpreted in light of the sample population. The participants consisted of college students attending a liberal arts school from a small geographic range. The participants were chosen from a narrow pool, including only those students that have taken or are currently enrolled in a psychology course at the college. This may or may not account for inconsistencies based upon students’ knowledge about the topics of sleep, stress, anxiety, or alcohol use. Due to the narrow population involved in this study, the results may not be relatable to other settings or representative of all college students’ sleep habits and disruptions. It should be taken into consideration as well that this study was a one-time event. By limiting the study to a one-time event, participants’ sleeping behaviors may have been reported 20 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep in relation to specific events causing stress, anxiety, or alcohol use rather than long-term sleep habits. Future research should consider utilizing a broader population of participants, the inclusion of additional demographic information, and possibly a longitudinal model to account for changes in sleep habits between semesters.
Recommendations
The results show that stress is the largest contributing factor to sleep disruption in college age students. These findings are consistent with the results from Lund’s study, which this study is modeled after (2010). Lund found that 24% of variance in sleep was predicted by stress and tension (anxiety) and this study found that 27.1% and 17.7% of variance in sleep disruption was predicted by stress and anxiety according to the GSAQ and PSSQ respectively. However, Lund’s study did not find that alcohol was a significant predictor of sleep difficulty (2010), while this study found that alcohol accounted for 3.7% of variance in sleep disruption. Upon examination of the study’s results, providing information related to stress management to students may be the most effective way to encourage students to retain healthy sleep habits and avoid future sleep disruption that can lead to other physical and psychological harm.
21 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
References
Babor, T.F.; Higgins-Biddle, J.C.; Saunders, J.B.; Monteiro, Maristela G. (2001). The Alcohol
Use Disorders Identification Test: Guidelines for Use in Primary Care. World Health
Organization. Department of Mental Health and Substance Dependence: 2,1-41.
Beck, A.T.; Epstein, N.; Brown, G.; Steer, R.A (1988). An inventory for measuring clinical
anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56(6),
893-897.
Brower, K.J. (2003). Insomnia, alcoholism and relapse. Sleep Medicine Reviews. 7(6),523-539.
Buckner, J.D.; Bernert, R.A.; Cromer, K.R.; Joiner, T.E.; Schmidt, N.B. (2008). Social anxiety
and insomnia: the mediating role of depressive symptoms. Depression and Anxiety,
25(2), 124 – 130.
Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The
Pittsburgh Sleep Quality Index (PSQI): A new instrument for psychiatric research
and practice. Psychiatry Research, 28(2), 193-213.
Chang, L. (2010). Stages of Sleep: REM and Non-REM Sleep. Retrieved 22 March, 2011.
―Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision.‖ American
Psychiatric Association; Washington, DC, 2000.
Drake, C.L.; Roehrs, T.; Roth, T. (2003). Insomnia causes, consequences, and therapeutics: An
overview. Depression and Anxiety, 18(4), 163–176.
Dregan, A.; Armstrong, D. (2010). Adolescence Sleep Disturbances as Predictors of
Adulthood Sleep Disturbances—A Cohort Study. Journal of Adolescent Health, 46(5),
482-487. 22 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep
Geyer, J.D.; Carney, P.R.; Payne, T. (2010). Atlas of Polysomnography. Lippincott, Williams,
and Wilkins: Philadelphia.
Kendall, P.C. (1978). Anxiety: States, traits--situations? Journal of Consulting and
Clinical Psychology, 46(2), 280-287.
Kuther, T.L.; Timoshin, A. (2003). A Comparison of Social Cognitive and Psychosocial
Predictors of Alcohol Use by College Students. Journal of College Student Development,
44(2), 143-154.
Lund, H.G.; Reider, B.D.; Whiting, A.B.; Prichard, J.R. (2010). Sleep Patterns and Predictors of
Disturbed Sleep in a Large Population of College Students. Journal of Adolescent Health,
46(2), 124-132.
McLaughlin, K.A.; Hatzenbuehler, M.L. (2009). Stressful Life Events, Anxiety, Sensitivity, and
Internalizing Symptoms in Adolescents. Journal of Abnormal Psychology, 118(3), 659-
669.
How Much Sleep Do We Really Need? (2011). National Sleep Foundation: Virginia. Retrieved
20 March, 2011. sleep-do-we-really-need> Okun, M.L., Kravitz, H.M., Sowers, M.F., Moul, D.E., Buysse, D.J., & Hall, M. (2009). Psychometric evaluation of the Insomnia Symptom Questionnaire: A self-report measure to identify chronic insomnia. Journal of Clinical Sleep Medicine, 5(1), 41-51. Roth, T.; Zammit, G.; Kushida, C.; Doghramji, K.; Mathias, S.D..; Wong, J.M.; Buysse, D.J. (2002). A new questionnaire to detect sleep disorders. Sleep Medicine, 3(2), 99-108. 23 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Rundell, O.H.; Lester, B.K.; Griffiths, W.J.; Williams, H.L. (1972). Alcohol and sleep in young adults. Psychopharmacologia, 26(3), 201–218. Seiberling, I. (2011). ―Restless? You're not alone.‖ The Montreal Gazette. Retrieved 21 March, 2011. Taylor, D.J.; Bramoweth, A.D. (2010). Patterns and Consequences of Inadequate Sleep in College Students: Substance Use and Motor Vehicle Accidents. Journal of Adolescent Health, 46(6), 610-612. Tsai, L.; Li, S. (2004). Sleep patterns in college students: Gender and grade differences. Journal of Psychosomatic Research, 56(2), 231-237. Vandekerckhove, M.; Cluydts, R. (2010). The emotional brain and sleep: An intimate relationship. Sleep Medicine Reviews, 14(4), 219-226. Voinescu, B.; Coogan, A.; Orasan, R.; Thome, J. (2010). Alcohol consumption: links between sleep and diurnal preference. European Psychiatry, 25, 1679. 24 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep List of Tables Table 1. Mean scores of CUSS, BAI and AUDIT scales. Table 2. Correlations of BAI, CUSS, and AUDIT Table 3. Regression of GSAQ with BAI, CUSS, and AUDIT Table 4. Regression of PSSQ total scores with BAI and CUSS Table 5. ANOVA of PSSQ criteria 25 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Table 1 Mean scores of CUSS, BAI and AUDIT scales Measure Mean (SD) Stress (CUSS) 1331.60 (417.14) Anxiety (BAI) 16.94 (9.96) Alcohol (AUDIT) 5.15 (5.53) 26 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Table 2 Correlations of BAI, CUSS, and AUDIT Measures BAI CUSS AUDIT BAI 1 .350*** .269* CUSS .350*** 1 .412*** AUDIT .269* .412*** 1 *p<.05, **p<.01, ***p<.001 27 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Table 3 Regression of GSAQ with BAI, CUSS, and AUDIT Model b SE b β p R² Change 1 (Constant) 15.94 .595 .000 Anxiety (BAI) .130 .030 .435 .000 .190 2 (Constant) 13.60 .980 .000 Anxiety (BAI) .098 .031 .329 .002 Stress (CUSS) .002 .001 .305 .004 .081 3 (Constant) 13.89 .972 .000 Anxiety (BAI) .089 .031 .298 .005 Stress (CUSS) .002 .001 .227 .040 Alcohol (AUDIT) .115 .057 .214 .047 .037 Significance determined when p < .05. 28 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Table 4 Regression of PSSQ total scores with BAI and CUSS Model b SE b β p 1 (Constant) 15.69 2.54 .000 Anxiety (BAI) .447 .129 .364 .001 2 (Constant) 8.37 4.29 .055 Anxiety (BAI) .348 .135 .283 .012 Stress (CUSS) .007 .003 .231 .039 Significance determined when p < .05. 29 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Table 5 ANOVA of PSSQ criteria Measures N Mean SD p Anxiety (BAI) Non-problem sleep 44 14.89 9.50 Problem sleep 36 19.44 10.06 Total 80 16.94 9.96 .041* Alcohol (AUDIT) Non-problem sleep 44 4.70 4.73 Problem sleep 36 5.69 6.39 Total 80 5.15 5.53 .429 Stress (CUSS) Non-Problem Sleep 44 1230.59 361.28 Problem Sleep 36 1455.06 451.56 Total 80 1331.60 417.14 .016* 30 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendices Appendix A. Beck Anxiety Inventory (BAI) Appendix B. Alcohol Use Disorders Identification Test (AUDIT) Appendix C. College Undergraduate Stress Scale (CUSS) Appendix D. Global Sleep Assessment Questionnaire (GSAQ) Appendix E. Pittsburgh Sleep Quality Index (PSQI) Appendix F. Pittsburgh Sleep Symptom Questionnaire (PSSQ) 31 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendix A Beck Anxiety Inventory Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom. Not Mildly but it Moderately - it Severely – it At All didn’t bother wasn’t pleasant bothered me a lot me much. at times Numbness or tingling 0 1 2 3 Feeling hot 0 1 2 3 Wobbliness in legs 0 1 2 3 Unable to relax 0 1 2 3 Fear of worst happening 0 1 2 3 Dizzy or lightheaded 0 1 2 3 Heart pounding/racing 0 1 2 3 Unsteady 0 1 2 3 Terrified or afraid 0 1 2 3 Nervous 0 1 2 3 Feeling of choking 0 1 2 3 Hands trembling 0 1 2 3 Shaky / unsteady 0 1 2 3 Fear of losing control 0 1 2 3 Difficulty in breathing 0 1 2 3 Fear of dying 0 1 2 3 Scared 0 1 2 3 Indigestion 0 1 2 3 Faint / lightheaded 0 1 2 3 Face flushed 0 1 2 3 Hot/cold sweats 0 1 2 3 Column Sum 32 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendix B The Alcohol Use Disorders Identification Test Your answers will remain confidential so please be honest. Place an X in one box that best describes your answer to each question. Questions 0 1 2 3 4 1. How often do you have a Never Monthly 2-4 times a 2-3 times 4 or more drink containing alcohol? or less month a week times a week 2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or more alcohol do you have on a typical day when you are drinking? 3. How often do you have six or Never Less than Monthly Weekly Daily or more drinks on one occasion? Monthly almost daily 4. How often during the last year Never Less than Monthly Weekly Daily or have you found that you Monthly almost daily were not able to stop drinking once you had started? 5. How often during the last Never Less than Monthly Weekly Daily or year have you failed to do Monthly almost daily what was normally expected of you because of drinking? 6. How often during the last year Never Less than Monthly Weekly Daily or have you needed a first drink Monthly almost daily in the morning to get yourself going after a heavy drinking session? 7. How often during the last year Never Less than Monthly Weekly Daily or have you had a feeling of guilt Monthly almost daily or remorse after drinking? 8. How often during the last year Never Less than Monthly Weekly Daily or have you been unable to remem- Monthly almost daily ber what happened the night before because of your drinking? 9. Have you or someone else No Yes, but Yes, during been injured because of not in the the last year your drinking? last year 10.Has a relative, friend, doctor, No Yes, but Yes, during or other health care worker been not in the the last year concerned about your drinking last year or suggested you cut down? Total 33 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendix C College Undergraduate Stress Scale Place an ―X‖ in the last column for any item that has happened to you in the last year. Event Ratings Your Score Being Raped 100 Finding out that you are HIV-positive 100 Being accused of rape 98 Death of a close friend 97 Death of a close family member 96 Contracting a sexually transmitted disease (other than AIDS) 94 Concerns about being pregnant 91 Finals Week 90 Concerns about your partner being pregnant 90 Oversleeping for an exam 89 Flunking a class 89 Having a boyfriend or girlfriend cheat on you 85 Ending a steady dating relationship 85 Serious illness in a close friend or family member 85 Financial Difficulties 84 Writing a major term paper 83 Being caught cheating on a test 83 Drunk driving 82 Sense of overload in school or work 82 Two exams in one day 80 Cheating on your boyfriend or girlfriend 77 Getting married 76 Negative consequences of drinking or drug use 75 Depression or crisis in your best friend 73 Difficulties with parents 73 Talking in front of a class 72 Lack of Sleep 69 Change in housing situation (hassles, moves) 69 Competing or performing in public 69 Getting in a physical fight 66 Difficulties with roommate 66 Job changes (applying, new job, work hassles) 65 Declaring a major or concerns about future plans 65 A class you hate 62 Drinking or use of drugs 61 Confrontations with professors 60 Starting a new semester 58 Going on a first date 57 Registration 55 34 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Maintaining a steady relationship 55 Commuting to campus or work, or both 54 Peer pressures 53 Being away from home for the first time 53 Getting sick 52 Concerns about your appearance 52 Getting straight As 51 A difficult class that you love 48 Making new friends 47 Fraternity or sorority rush 47 Falling asleep in class 40 Attending an athletic event 20 Total 35 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendix D Global Sleep Assessment Questionnaire Question 1. Do you have difficulty falling asleep, staying asleep or Never Sometimes Usually do you feel poorly rested in the morning? Always 2. Do you fall asleep unintentionally or fight to stay Never Sometimes Usually awake during the day? Always 3. Do sleep difficulties or daytime sleepiness interfere Never Sometimes Usually with your daily activities? Always 4. Do work or other activities prevent you from getting Never Sometimes Usually enough sleep? Always 5. Do you snore loudly? Never Sometimes Usually Always 6. Do you hold your breath, have breathing pauses or Never Sometimes Usually stop breathing in your sleep? Always 7. Do you have restless or "crawling" feelings in your Never Sometimes Usually legs at night that go away if you move your legs? Always 8. Do you have repeated rhythmic leg jerks or leg Never Sometimes Usually twitches during your sleep? Always 9. Do you have nightmares or do you scream, walk, Never Sometimes Usually punch or kick in your sleep? Always 10. Do the following things disturb you in your sleep: Never Sometimes Usually pain, other physical symptoms, worries, medications Always or other (specify)? 11. Do you feel sad or anxious? Never Sometimes Usually Always 36 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendix E PITTSBURGH SLEEP QUALITY INDEX INSTRUCTIONS: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions. 1. During the past month, what time have you usually gone to bed at night? Bed time ____ 2. During the past month, how long (in minutes) has it usually taken you to Number of fall asleep each night? minutes _____ 3. During the past month, what time have you usually gotten up in the Getting up time morning? _____ 4. During the past month, how many hours of actual sleep did you get at Hours of sleep per night? (This may be different than the number of hours you spent in bed.) night _____ For each of the remaining questions, check the one best response. Please answer all questions. 5. During the past month, how often have you had trouble sleeping because you . . . a.Cannot get to sleep within 30 Not during the Less than Once or Three or more minutes past month once a week twice a times a week week b.Wake up in the middle of the Not during the Less than Once or Three or more night or early morning past month once a week twice a times a week week c.Have to get up to use the Not during the Less than Once or Three or more bathroom past month once a week twice a times a week week d.Cannot breathe comfortably Not during the Less than Once or Three or more past month once a week twice a times a week week e.Cough or snore loudly Not during the Less than Once or Three or more past month once a week twice a times a week week f.Feel too cold Not during the Less than Once or Three or more past month once a week twice a times a week week g.Feel too hot Not during the Less than Once or Three or more past month once a week twice a times a week week h.Had bad dreams Not during the Less than Once or Three or more past month once a week twice a times a week week i.Have pain Not during the Less than Once or Three or more past month once a week twice a times a week week j.Other reason(s), please Not during the Less than Once or Three or more describe past month once a week twice a times a week week 37 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep 6. During the past month, how Very good Fairly good Fairly bad Very bad would you rate your sleep quality overall? 7. During the past month, how Very good Fairly good Fairly bad Very bad often have you taken medicine to help you sleep (prescribed or ―over the counter‖)? 8. During the past month, how Very good Fairly good Fairly bad Very bad often have you had trouble staying awake while driving, eating meals, or engaging in social activity? 9. During the past month, how No problem Only a very Somewhat of a A very much of a problem has it been at all slight problem problem big for you to keep up enough problem enthusiasm to get things done? 10. Do you have a bed partner No bed Partner/room Partner in same Partner in or roommate? partner or mate in other room, but not same bed roommate room same bed If you have a room mate or bed partner, ask him/her how often in the past month you have had . . . a.Loud snoring Not during the Less than Once or Three or more past month once a week twice a times a week week b. Long pauses between breaths Not during the Less than Once or Three or more while asleep past month once a week twice a times a week week c. Legs twitching or jerking Not during the Less than Once or Three or more while you sleep past month once a week twice a times a week week d. Episodes of disorientation or Not during the Less than Once or Three or more confusion during sleep past month once a week twice a times a week week e. Other restlessness while you Not during the Less than Once or Three or more sleep; please describe past month once a week twice a times a week week 38 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep Appendix F Pittsburgh Sleep Symptom Questionnaire Instructions: Below is a list of common sleep complaints. During the past month, how many nights or days per week have you had, or been told you had, the following symptoms? If you have experienced any of these symptoms please indicate how long it has lasted in weeks, months, or years. During the past Never Do Rarely Sometimes Frequently Always How long has the month… not (less (1-2 times (3-4 times (5-7 symptom lasted? Know than per week) per week) times (# of weeks, once per months or years) per week) week) 1. Difficulty falling 0 1 2 3 4 5 Weeks asleep Months Years ______2. Difficulty staying 0 1 2 3 4 5 Weeks asleep Months Years ______3. Frequent 0 1 2 3 4 5 Weeks awakenings from Months sleep Years ______4. Feeling that your 0 1 2 3 4 5 Weeks sleep is not sound Months Years ______5. Feeling that your 0 1 2 3 4 5 Weeks sleep is unrefreshing Months Years ______ Instructions: If you have experienced any sleep symptoms during the past month, please circle the appropriate number to let us know how your sleep is affecting your daily life. Not at all A Little Bit Moderately Quite a bit Extremely 6. How much do your sleep 0 1 2 3 4 problems bother you? 7. Have your sleep difficulties 0 1 2 3 4 affected your work? 8. Have your sleep difficulties 0 1 2 3 4 affected your social life? 9. Have your sleep difficulties 0 1 2 3 4 affected other important parts of your life? 10. Have your sleep difficulties 0 1 2 3 4 made you feel irritable? 39 Role of Stress, Anxiety, and Alcohol in Disrupted Sleep 11.Have your sleep problems 0 1 2 3 4 caused you to have trouble concentrating? 12.Have your sleep difficulties 0 1 2 3 4 made you feel fatigued? 13.How sleepy do you feel 0 1 2 3 4 during the day?