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overestimated the time it took them to fall asleep and their sleep efficiency, there was agreement observed between the two measures for total sleep duration in hours and the number of night-time awakenings. This strengthens the evidence that people with FMS experience difficulties maintaining sleep quality through the night. Interventions to improve sleep quality need to focus on reducing night-time awakenings in order to improve sleep quality for people with FMS. The findings in Chapter Six also highlight the possible existence of undiagnosed sleep disorders within this population. This supports the results of previous research in FMS where sleep disorders have been found to be prevalent (Mease et al., 2009); screening for sleep disorders in people with FMS is therefore advisable. Objective Two. The Psychological Factors Affecting Sleep Quality in FMS The second aim of the thesis was to explore the psychological factors that may contribute to poor sleep quality in patients with FMS. The first study (Chapter Four) highlighted that coping did not have a significant direct effect on sleep quality, however higher levels of negative affect and lower social functioning were associated with poorer sleep quality. These findings were extended in the second study (Chapter Five) in which people with FMS were found to have higher dysfunctional beliefs about sleep need and higher perceived levels of stress than healthy controls, and that these factors were significantly associated with poorer sleep quality. The findings from Chapter Five were supported and expanded in the qualitative exploration, (Chapter Six) as participants with FMS were very aware of the role of psychological factors on their sleep quality and described how high cognitive arousal, worrying about daily stressors and expectations about their sleep, all affected the sleep quality they experienced at night. The influence of these psychological factors needs to be considered in future research and interventions focusing on improving sleep in people with FMS. Objective Three. The Effect of Sleep Quality on Symptoms and Daily Life for People with FMS In addition to describing the experience of sleep in FMS, this thesis aimed to explore how sleep quality affects patients‟ symptoms and daily lives. The first study (Chapter 153
Four) revealed that global sleep quality was significantly associated with poorer health outcomes including physical functioning, role limitations due to emotional difficulties, fatigue, well-being, social functioning and pain. Higher levels of perceived pain and poorer physical functioning were significantly associated with more frequent night- time awakenings. This supports previous research findings which found that poor sleep quality is associated with higher levels of pain (Nicassio et al., 2002) and that fatigue was only associated with worse daytime dysfunction. In the qualitative study, (Chapter Six), participants described a strong interrelationship between their sleep quality and other symptoms relating to their condition (such as pain and fatigue), with a poor nights sleep leading to higher levels of pain and fatigue the following day and high levels of pain interfering with their sleep at night. Participants also described feeling more fatigued and less able to participate in daytime activities after a poor nights sleep, supporting the quantitative findings (Chapters Four and Five). As sleep quality, pain and fatigue fluctuated over time, this caused participants with FMS significant difficulties in being able to plan activities and they often had to cancel arrangements due to a poor nights sleep. As a way of coping with their poor sleep and symptoms, participants described planning rest periods and using daytime naps, to help them to increase their energy levels over the course of the day. It was also observed that most people with FMS perceived that the onset of their sleep difficulties occurred prior to, or at the same time as, the onset of their other FMS symptoms; suggesting that sleep difficulties are not just a consequence of pain and fatigue. As shown in Chapter Five, sleep disturbance is a significant risk factor for diagnosis of FMS, and sleep appears to be a significant cause of disability and reduced social functioning in people with FMS. This supports the recent recommendations on outcome measures for clinical trials in FMS which state that sleep should be considered to be key outcome for interventional studies within this population (Mease et al., 2009). Objective Four. An Intervention to Improve Sleep Quality Lastly this study aimed to trial an intervention with the aim to improve sleep quality for patients with FMS. Drawing on the findings from the first three studies, this feasibility study explored the effect of a brief mindfulness intervention, based on the principles of acceptance of physical sensations and thoughts and thereby reducing stress and arousal on sleep quality in FMS. Although the intervention was only piloted 154
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Sick and Tired: Understanding and M
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Chapter Four. The Nature and Effect
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References ........................
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List of Tables Table 1. Participant
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Co-authored Works Although the stud
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Acknowledgments This thesis would n
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Intellectual Property Rights There
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Confidential Material No participan
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The role of sleep in FMS appears to
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little information was available as
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Psychophysiologic insomnia which is
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and are less able to inhibit the pa
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widely applied in clinical practice
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of fewer tender points; usually bet
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Current Management Strategies The t
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also likely to depend on a number o
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deep sleep (stages three and four)
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Although sleep moves through the sl
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Figure 3. The Integrative Model of
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However, conducting a blood test is
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As sleep is a complex process invol
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Sleep Diaries Sleep diaries are a k
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pain). Lentz et al (1999) revealed
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These results have also been suppor
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(McCracken & Iverson, 2002) which s
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Figure 4. Conceptual model of the d
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Clinical Implications Despite the p
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Chapter Three. Sleep in FMS As high
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& Penzien, 2003), although alpha wa
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pauses in breathing indicative of s
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Relationships between Sleep and Pai
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Managing Sleep Disturbance in FMS D
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may be possible to help patients im
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person to initiate an action (such
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and Nicassio et al (1995) only expl
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1) Poor sleep quality, defined by t
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elow 0.7 are acceptable. Therefore
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heart disease (Epstein et al., 1999
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In order to explore the links betwe
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questionnaire 78 (77.2%) of the par
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efficiency, suggesting that partici
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Older age and longer length of illn
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Table 2. Correlations between demog
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Logistic Regression As 97% of the s
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in bed, participants may have devel
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Relationship between Negative Affec
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participants, who may be less likel
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emotional problems, increased pain
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eactions are most likely to be detr
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It has been suggested that the auto
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For both groups, participants were
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with and without chronic medical co
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As previously described on page 61,
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Figure 7. Scree plot for the explor
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Figure 8. Scree plot for the explor
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Table 6. Participant characteristic
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Table 7. Measures of central tenden
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CON = DBAS-10 Dysfunctional beliefs
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The Exp (B) values revealed that hi
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Page 121 and 122: It became clear, through the analys
Page 123 and 124: interventions. With this in mind, t
Page 125 and 126: The philosophy of phenomenology was
Page 127 and 128: Methods Participants were given a w
Page 129 and 130: Table 11. Interview schedule for th
Page 131 and 132: Rigour The interview transcripts we
Page 133 and 134: “The main symptom is this overwhe
Page 135 and 136: Theme Two. Inter-relationship betwe
Page 137 and 138: where I live, so I don‟t know, I
Page 139 and 140: Participants also described how the
Page 141 and 142: “XXXX (name of person) planned a
Page 143 and 144: A strong theme that emerged in this
Page 145 and 146: conducted at several time points, w
Page 147 and 148: Chapter Seven. Investigating the Ef
Page 149 and 150: activities because they no longer f
Page 151 and 152: Therefore as this was a feasibility
Page 153 and 154: Self-reported sleep quality was ass
Page 155 and 156: The progressive muscle relaxation (
Page 157 and 158: Exploring the baseline data, there
Page 159 and 160: Consequently, univariate analysis w
Page 161 and 162: There was no significant correlatio
Page 163 and 164: people with FMS (Perlis, Giles, Men
Page 165 and 166: The aim of this study was to explor
Page 167 and 168: observed in perceived overall sleep
Page 169: elaborated on in Chapter Six, which
Page 173 and 174: Modifications to the Call-Schmidt a
Page 175 and 176: MBSR programme in people with FMS (
Page 177 and 178: diagnostic criteria for these sleep
Page 179 and 180: comprehensive measures to look at t
Page 181 and 182: References Abad, V. C., Sarinas, P.
Page 183 and 184: Brand, S., Gerber, M., Beck, J., Ha
Page 185 and 186: Crofford, L. J., & Demitrack, M. A.
Page 187 and 188: Goldenberg, D. L., Kaplan, K. H., N
Page 189 and 190: Johns, M. W. (2002). Sleep propensi
Page 191 and 192: Leung, Y. Y., Ho, K. W., Zhu, T. Y.
Page 193 and 194: Mease, P. J. (2005). Fibromyalgia s
Page 195 and 196: symptoms in healthy subjects; Corre
Page 197 and 198: approach with illustration to the h
Page 199 and 200: Thomas, E. N., & Blotman, F. (2010)
Page 201 and 202: Yunus, M. B., Masi, A. T., & Aldag,
Page 203 and 204: Appendices Appendix A: Search Strat
Page 205 and 206: Sleep and Fibromyalgia Syndrome Con
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Page 209 and 210: The following questions relate to y
Page 211 and 212: There are lots of ways to try to de
Page 213 and 214: 42. I try hard to prevent other thi
Page 215 and 216: During the past month have you had
Page 217 and 218: Appendix E: Published paper of Stud
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Sleep and Fibromyalgia Syndrome Con
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Appendix H: Participant Questionnai
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Below are 10 statements reflecting
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The questions in this scale ask you
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Appendix I. Published Paper for Stu
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Appendix K. Information Sheet and C
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Sleep in Fibromyalgia Syndrome Cons
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Appendix L: Letter of Ethical Appro
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Appendix M. Letter to GPs for Study
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What are the side effects of any tr
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Appendix O: Poster Advertising Stud
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Appendix Q: Participant Questionnai
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HAD Scale Read each item and place
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During the past month have you had
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Appendix R. Letter from Dr Mark Cro
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PUBLICATIONS Peer Reviewed Journal
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and panic-like episodes, Faculty of
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