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Paradoxical intention and insomnia: An experimental investigation

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Abstract

A study by Turner and Ascher (1978) compared the efficacy of progressive relaxation, stimulus control, and paradoxical intention in ameliorating sleep onset insomnia. Results indicated that the three were equally effective. The present study is a partial replication of Turner and Ascher (1978) and focuses on the use of paradoxical intention in reducing sleep difficulties.Twenty-five individuals complaining of sleep discomfort were randomly assigned to three groups: paradoxical intention, placebo control, no treatment control. Clients in the paradoxical intention group were instructed to remain awake while lying in bed in a darkened room. The complete rationale for such a prescription was provided. Those in the placebo group received a pseudo systematic desensitization program.Results indicated that subjects exposed to the paradoxical intention procedure reported significant improvement on several measures of sleep behavior when compared with reports of subjects in either placebo or no-treatment control groups.

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... Nineteen RCTs compared a cognitive component or therapy with a more passive comparator, i.e., psychoeducation, monitoring, no treatment or a waitlist control [31e49]. Four RCTs used a psychological placebo as a comparator [33,34,36,47,50]. One RCT compared a cognitive program with biofeedback [51]. ...
... First, we present studies that have investigated the most common form of paradoxical intention administration (type A) [33]. The type A rationale is based on that sleep-related performance anxiety is likely to result in sleep difficulties, mainly sleep-onset insomnia. ...
... In the type A administration, the patient is instructed to remain awake for as long as possible under sleep-compatible conditions natural for the onset and maintenance of sleep (e.g., lights out) and not to move around or engage in behavior specifically designed to prevent sleep. In one early study [33], paradoxical intention, placebo and a no-treatment condition were compared. The findings demonstrated that paradoxical intention was superior to the other two groups on sleep onset latency, number of awakenings, and difficulty falling asleep at post-treatment. ...
Article
Since the beginning of the twenty-first century, there has been an increased focus on developing and testing cognitive components and therapies for insomnia disorder. The aim of the current review was thus to describe and review the efficacy of cognitive components and therapies for insomnia. A systematic review was conducted on 32 studies (N=1455 subjects) identified through database searches. Criteria for inclusion required that each study constituted a report of outcome from a cognitive component or therapy, that the study had a group protocol, adult participants with diagnosed insomnia or undiagnosed insomnia symptoms or reported poor sleep, and that the study was published until and including 2016 in English. Each study was systematically reviewed with a standard coding sheet. Several cognitive components, a multi-component cognitive program, and cognitive therapy were identified. It is concluded that there is support for paradoxical intention and cognitive therapy. There are also other cognitive interventions that appears promising, such as cognitive refocusing and behavioral experiments. For most interventions, the study quality was rated as low to moderate. We conclude that several cognitive treatment components and therapies can be viewed as efficacious or promising interventions for patients with insomnia disorder. Methodologically stronger studies are, however, warranted.
... Results indicated longer sleep onset times for those asked to sleep as quickly as possible. Also in clinical settings, paradoxical intention therapy is used, aiming at taking the pressure of falling asleep from subjects by telling them to stay awake (Ascher & Turner, 1979;Espie, 1987;Ladouceur & Gros-Louis, 1986;Morin et al., 1999). Thus, to influence sleep, cognitive approaches might not be easily implemented successfully and consciousness is possibly even better circumvented. ...
... Thus, changing inappropriate beliefs concerning sleep is one major target in clinical approaches to treat sleep disturbances (Morin, Blais, & Savard, 2002). However, intentionally "wanting" to fall asleep is often counterproductive; therefore, paradoxical interventions are sometimes more helpful to induce sleep (Ascher & Efran, 1978;Ascher & Turner, 1979). Thus, inducing sleep or extending SWS under hypnosis might bypass the explicit and voluntary intention, inducing subsequent sleep effects on a more subconscious level, not involving willing decision processes. ...
... The first factor describes what is prescribed, either a change or a symptom, and the second factor describes the how or the connotation of the prescription. To illustrate factor one,Ascher and Turner (1979) prescribed a symptom by instructing insomniac clients to stay awake, whereas,Feldman, Strong, and Dancer (1982) directed clients to let themselves be depressed by concentrating on negative thoughts and avoiding cheerful places. The symptom is usually experienced by the client as an uncontrollable, spontaneous occurrence of an undesirable event and the demand to bring it about deliberately creates a "be spontaneous" paradox. ...
... We believe that seeing personal problems as natural results of the contingencies within which they are embedded, and personal goals as requiring the design of, or exposure to, new contingencies (which may, of course, require new repertoires to access), is a far more hopeful stance, in which client and consultant can work together toward clearly specified goals. Given this collaborative emphasis, we also tend to avoid interventions that depend on paradox, except where the paradoxical mechanisms can be shared with the client (Ascher & Turner, 1979). ...
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In this paper the authors report on the early development of a cultural entity––Walden Fellowhip, Inc.––which was established “to explore and encourage the development of behavior and cultural practices which maximize reinforcement and minimize coercion over the long term for all persons in a manner consistent with the survival of the human and other species.� This voluntary organization maintains three primary streams of activity: self-education, consultation services, and cultural design research in the wider community. A major goal toward which involvement in all of these converge is the development of a mutually reinforcing social and verbal community among participants. Unlike an earlier paper in which this organization was conceptualized, this article is not fictional.
... 64 However, intentionally "wanting" to fall asleep is often counterproductive; therefore, paradoxical interventions are sometimes more helpful to induce sleep. 65,66 Thus, inducing sleep or extending SWS under hypnosis might bypass the explicit and voluntary intention, inducing subsequent sleep effects on a more subconscious level, not involving willing decision processes. In particular, the effects of the hypnotic suggestion were highly specific in our study: The suggestion to "sleep deeper" specifically extended duration of SWS, leaving other sleep stages unaffected. ...
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Study objectives: Slow wave sleep (SWS) plays a critical role in body restoration and promotes brain plasticity; however, it markedly declines across the lifespan. Despite its importance, effective tools to increase SWS are rare. Here we tested whether a hypnotic suggestion to "sleep deeper" extends the amount of SWS. Design: Within-subject, placebo-controlled crossover design. Setting: Sleep laboratory at the University of Zurich, Switzerland. Participants: Seventy healthy females 23.27 ± 3.17 y. Intervention: Participants listened to an auditory text with hypnotic suggestions or a control tape before napping for 90 min while high-density electroencephalography was recorded. Measurements and results: After participants listened to the hypnotic suggestion to "sleep deeper" subsequent SWS was increased by 81% and time spent awake was reduced by 67% (with the amount of SWS or wake in the control condition set to 100%). Other sleep stages remained unaffected. Additionally, slow wave activity was significantly enhanced after hypnotic suggestions. During the hypnotic tape, parietal theta power increases predicted the hypnosis-induced extension of SWS. Additional experiments confirmed that the beneficial effect of hypnotic suggestions on SWS was specific to the hypnotic suggestion and did not occur in low suggestible participants. Conclusions: Our results demonstrate the effectiveness of hypnotic suggestions to specifically increase the amount and duration of slow wave sleep (SWS) in a midday nap using objective measures of sleep in young, healthy, suggestible females. Hypnotic suggestions might be a successful tool with a lower risk of adverse side effects than pharmacological treatments to extend SWS also in clinical and elderly populations.
... Therapist type, training, and supervision Treatment integrity check Ascher and Turner (1979) (1) Attempt to remain awake as long as possible rather than continuing the effort to fall asleep, (2003) (1) At lights out: stay awake for as long as possible by keeping eyes open, (2) resist sleep-onset gently but persistently in an environment conducive to sleep, and (3) not engage in active methods to stay awake. the notion that decreased performance anxiety is a mechanism through which PI might work. ...
Article
Paradoxical intention (PI) has been considered an evidence‐based treatment for insomnia since the 1990s, but it has not been evaluated with modern review techniques such as meta‐analysis. The present study aimed to conduct the first systematic review and meta‐analysis of studies that explore the effectiveness of PI for insomnia on insomnia symptomatology and theory‐derived processes. A systematic review and meta‐analysis was conducted by searching for eligible articles or dissertations in six online bibliographic databases. Randomised controlled trials and experimental studies comparing PI for insomnia to active and passive comparators and assessing insomnia symptoms as outcomes were included. A random effects model was estimated to determine the standardised mean difference Hedge’s g at post‐treatment. Test for heterogeneity was performed, fail‐safe N was calculated, and study quality was assessed. The study was pre‐registered at International Prospective Register of Systematic Reviews (PROSPERO, CRD42019137357). A total of 10 trials were identified. Compared to passive comparators, PI led to large improvements in key insomnia symptoms. Relative to active comparators, the improvements were smaller, but still moderate for several central outcomes. Compared to passive comparators, PI resulted in great reductions in sleep‐related performance anxiety, one of several proposed mechanisms of change for PI. PI for insomnia resulted in marked clinical improvements, large relative to passive comparators and moderate compared to active comparators. However, methodologically stronger studies are needed before more firm conclusions can be drawn.
... Ascher and Turner [102] found that PI-A produced a greater reduction in subjective SOL compared with PI-B, an active placebo control group (i.e., quasi-desensitization), and a passive control group. Ascher and Turner [103] also found a superior effect of PI-A on subjective SOL compared with a placebo control group (i.e., quasi-desensitization) and a passive control group. Similarly, in a third study [104], individuals who received PI-A improved more on subjective SOL than individuals in a passive control group, and this effect was still apparent after 3, 6, and 17 months. ...
Chapter
The purpose of the research programme detailed in this paper is to update the attachment control system framework that John Bowlby set out in his formulation of Attachment Theory. It does this by reconceptualising it as a cognitive architecture that can operate within multi-agent simulations. This is relevant to computational psychiatry because attachment phenomena are broad in scope and range from healthy everyday interactions to psychopathology. The process of attachment modelling involves three stages and this paper makes contributions in each of these stages. Firstly, a survey of attachment research is presented which focuses on two important attachment behavioural measures: the Strange Situation Procedure and the Adult Attachment Interview (AAI). These studies are reviewed to draw out key behavioural patterns and dependencies. Secondly, the empirical observations that are to be explained in this research programme are abstracted into scenarios which capture key behavioural elements. The value of behavioural scenarios is that they can guide the simulation design process and help evaluate simulations which are produced. Thirdly, whilst the implementation of these scenarios is still a work in progress, several designs are described that have been created and implemented as simulations. These include normative and non-pathological infant behaviour patterns observed across the first year of life in naturalistic observations and ‘Strange Situation’ studies. Future work is described which includes simulating dysfunctional infant behaviour patterns and a range of adult attachment behaviour patterns observed in the Adult Attachment Interview. In conclusion, this modelling approach is distinguished from other approaches in computational psychiatry because of the psychologically high level at which it models phenomena of interest.
... Paradoxical intention has been evaluated in six studies meeting inclusion criteria. 38,47,49,54,55,77 All six studies focused on the problem of sleep-onset insomnia. In four studies, 38,49,54,77 paradoxical intention was more effective than control conditions in reducing sleep onset latency, whereas two studies 47,55 failed to report significant differences between this treatment and a placebo or wait-list control condition at posttreatment. ...
Article
This paper reviews the evidence regarding the efficacy of nonpharmacological treatments for primary chronic insomnia. It is based on a review of 48 clinical trials and two meta-analyses conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on non-drug therapies for the clinical management of insomnia. The findings indicate that nonpharmacological therapies produce reliable and durable changes in several sleep parameters of chronic insomnia sufferers. The data indicate that between 70% and 80% of patients treated with nonpharmacological interventions benefit from treatment. For the typical patient with persistent primary insomnia, treatment is likely to reduce the main target symptoms of sleep onset latency and/or wake time after sleep onset below or near the 30-min criterion initially used to define insomnia severity. Sleep duration is also increased by a modest 30 minutes and sleep quality and patient's satisfaction with sleep patterns are significantly enhanced. Sleep improvements achieved with these behavioral interventions are sustained for at least 6 months after treatment completion. However, there is no clear evidence that improved sleep leads to meaningful changes in daytime well-being or performance. Three treatments meet the American Psychological Association (APA) criteria for empirically-supported psychological treatments for insomnia: Stimulus control, progressive muscle relaxation, and paradoxical intention; and three additional treatments meet APA criteria for probably efficacious treatments: Sleep restriction, biofeedback, and multifaceted cognitive-behavior therapy. Additional outcome research is needed to examine the effectiveness of treatment when it is implemented in clinical settings (primary care, family practice), by non-sleep specialists, and with insomnia patients presenting medical or psychiatric comorbidity.
... The first wave of psychotherapy for insomnia included single-component treatments that took a strictly behavioral focus. These treatments, which ranged from paradoxical intention [30][31][32] to stimulus control [33] to sleep restriction [34] among others, were administered as stand-alone interventions in clinical trials and were the first to gather empirical support as non-pharmacological treatments for insomnia. As the field of psychotherapy moved towards a focus on patterns of thinking during the second wave, insomnia treatments followed, with cognitive therapy for insomnia [35] emerging as a treatment specifically targeting the maladaptive beliefs about sleep and cognitive arousal commonly associated with the disorder. ...
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The development of psychological and behavioral therapies over the past several decades has led to what is termed the third wave of psychotherapy, a collection of treatments that adopt a new approach to maladaptive cognitions and target broad, contextualistic goals. Within the field of behavioral sleep medicine, treatments for insomnia have followed a similar evolution, and several emerging therapies, including mindfulness and acceptance-based therapies, have begun to accumulate evidence as effective treatments for this sleep disorder over the past several decades. This paper discusses the historical background of the third wave of psychotherapy, introduces each of the third-wave therapies that have been applied to the treatment of insomnia, and reviews the recent literature to critique the effectiveness of these treatments. Relevant controversies with the third-wave therapies are discussed to inform future directions in insomnia research.
... Paradox, as it is used within the context of marriage and family therapy, attempts to address conflictual relationships between parents and children or husbands and wives. In addition, there is a growing list of somatic problems that have been treated with therapeutic paradox as an integral part of the treatment: insomnia (2,6,19); urinary retention (1); migraine headache (11); adolescents with such chronic illnesses as end-stage renal disease and kidney transplantation, congenital heart defects and disease, juvenile rheumatoid arthritis, insulin-dependent diabetes mellitus, intractable asthma, and systemic lupus erythematosis (8); asthma (14); adults with endstage renal disease, diabetes, or chronic pain (16); alcoholism (20); and anorexia nervosa (14). Paradoxical modes of intervention have not been used to treat generalized, free-floating anxiety with its consequent somatic distress and patient complaints. ...
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Discusses the management of patients who persist in whining and complaining about somatic symptoms that do not appear to be associated with organic pathology. A paradoxical behavioral technique is described. Four cases treated by the technique (4 males aged 45, 57, 58, and 61 yrs) are described, as is a 1-yr follow-up. Results in symptom alleviation appeared to persist and generalize to other life areas. (20 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
... Após três semanas de intervenção foi observada uma significativa redução na latência do sono (de 62 para 29 minutos), tendo os autores concluído que esse método era efetivo para facilitar o início do sono. 18 Um outro estudo avaliou a eficiência da terapia de controle dos estímulos para o tratamento da insônia crônica. Os resultados demonstraram uma redução significativa no tempo acordado após o início do sono o que sugere que a terapia de controle dos estímulos é um bom método para consolidar o sono dos pacientes. ...
Article
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The purpose of this manuscript is to briefly describe the main modalities of non-pharmacological therapy and its utilization on the chronic insomnia treatment. Insomnia is the most frequent sleep disorder and that is more associated with psychiatry disorders. The pharmacotherapy is the most frequent treatment, but the nonpharmacologic therapy has been studied. The most common therapy modalities include behavioral approaches, stimulus control, sleep restriction, paradoxical intention, sleep hygiene, progressive muscle relaxation and biofeedback and, more recently, physical exercise practices. At first behavioral therapy aimed to improve sleep quality, however, recent studies have been emphasizing the effect of behavioral and cognitive approaches on quality of life, on decrease of dosage and frequency of drugs intake. Since insomnia is a chronic condition, long-term and safe treatments are warranted.
... [18] Paradoxical intention procedure is effective on several measures of sleep behavior as compared to either placebo or no treatment. [42] Pharmacological interventions Drug therapy can be effective for short-term alleviation of insomnia but may not be sufficient for long-term management of chronic insomnia [ Table 1]. Behavioral therapy, on the other hand, yields the most durable improvements in sleep patterns. ...
Article
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Chronic insomnia is a fairly common condition affecting one-fourth of the clinical population. It has been variously defined and is related to a large number of conditions. A thorough assessment of the patient presenting with chronic insomnia is of vital importance for the treatment. Treatment consists of modifying sleep habits to reduce autonomic and cognitive factors and education about healthier sleep practice. Drug treatment should be reserved for the short-term alleviation of insomnia. Appropriate treatment of chronic insomnia improves the quality of life. The prevention of insomnia consists of a balance of rest, recreational exercise in combination with stress management and a healthy diet.
... Addressing the "racing mind": learning how to cope or deal with worries and thought that prevent the person from falling asleep Paradoxical intention: trying to stay awake instead of falling asleep [12] Additive Relaxation: relaxation and breathing techniques to teach persons to unwind [13] Mindfulness: using techniques from mindfulness to teach persons to unwind [14] Lichstein et al. [20] Kuhn et al. [21] Therapist-guided dCBT Automated dCBT with guidance and tailoring supported by human therapists Partly Lancee et al. [22] Van Straten et al. [23] Blom et al. [24] Fully automated dCBT Fully automated and tailored dCBT without in-person clinical support Fully Ritterband et al. [25] Vincent et al. [26] Espie et al. [27] the program is offered without any human support. Personalization is built into the automated program using algorithms to tailor all aspects of the program, including personalized feedback and a tailored treatment program. ...
Article
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Purpose of Review Digital cognitive behavioral therapy (dCBT) has been available for over a decade. We reviewed the evidence that accumulated over the past 5 years and discuss the implications for introducing dCBT into standard healthcare. Recent Findings Studies have consistently supported the use of dCBT to treat insomnia. Evidence is now demonstrating large short-term effects and smaller long-term effects up to 1.5 years after treatment across populations with various co-occurring health problems. The effects also extend into a range of psychological well-being factors. Mediators and moderators have been studied to understand mechanisms and create new opportunities to enhance effectiveness and reduce dropout. Incorporating personalized guidance in dCBT may further enhance effectiveness. Summary The evidence for dCBT for insomnia is strong and suggests that dCBT is ready for application in standard healthcare. Further research, digital innovation, and development of effective implementation methods are required to ensure dCBT fulfills its potential.
... Ascher and Turner [102] found that PI-A produced a greater reduction in subjective SOL compared with PI-B, an active placebo control group (i.e., quasi-desensitization), and a passive control group. Ascher and Turner [103] also found a superior effect of PI-A on subjective SOL compared with a placebo control group (i.e., quasi-desensitization) and a passive control group. Similarly, in a third study [104], individuals who received PI-A improved more on subjective SOL than individuals in a passive control group, and this effect was still apparent after 3, 6, and 17 months. ...
... En esta línea, las investigaciones subsecuentes se enfocaron a disminuir los componentes fisiológicos de los pacientes con insomnio, analizando la eficacia de la relajación a través de auto reportes de estudio de caso (Weil y Goldfried, 1973), retroalimentación biológica (Biofeedback) (Borkovec y Weerts, 1976;Borkovec et al., 1979) técnicas de relajación muscular en combinación con drogas sedantes (Borkovec y Fowles, 1973) o con otras técnicas terapéuticas como la intención paradójica (Nicassio y Bootzin, 1974;Geer y Katkin, 1966;Ascher y Turner, 1979). ...
Article
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Los trastornos de sueño son una problemática recurrente en la actualidad. A pesar de los múltiples estudios sobre intervenciones eficaces, es poca su difusión en la literatura hispanohablante. A partir de esta necesidad, el objetivo del presente artículo es dar a conocer las intervenciones con mayor efectividad sobre los trastornos del sueño, como son el Insomnio, Síndrome de Apnea-Hipopnea Obstructiva de Sueño (SAHOS) y Narcolepsia. Se revisó: características del sueño, criterios diagnósticos con base en la clasificación internacional de trastornos de sueño y las intervenciones psicológicas para cada uno los trastornos antes mencionados.
... Paradoxical intention essentially requires participants to get into bed and purposefully stay awake. In other words, this module prescribes the symptom as part of the solution; something that has been shown to improve sleep quality (Ascher & Turner, 1979;DeBord, 1989;Perlis et al., 2010). The rationale behind paradoxical intention assumes that problems falling asleep are, in part, maintained by anxieties around the act of falling asleep itself. ...
Article
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Background: Sleep and mental health go hand-in-hand, with problems sleeping being associated with a variety of mental health difficulties. Recently, insomnia has been linked with the experience of paranoia, a relationship that is likely to be mediated by negative affect. Given these links, the present research aimed to test whether a self-help intervention designed to improve sleep can also improve negative affect and paranoia. Method: Participants were recruited from a mailing list of University staff and were randomly allocated to one of three conditions; a wait-list control group, an active control group who completed a sleep diary each day for 6 weeks, and an experimental group who received an online self-help intervention targeting sleep problems alongside the same sleep diary. Levels of insomnia, negative affect, and paranoia were measured at baseline, immediately post-intervention, and 4- and 18-weeks post-intervention. Results: There were no significant differences between the groups on levels of insomnia, negative affect, and/or paranoid thinking at post-intervention, 4-weeks, or the 18-week follow-up. However, a relatively large number of participants dropped out of the study, particularly in the intervention group, which meant that the primary analysis was underpowered. Conclusion: Due to a high level of participant dropout, the findings from the present research are inconclusive, and suggest that retaining participants in trials of online interventions is a significant challenge that needs to be addressed in future research.
Article
The aim of this study was to investigate the effects of intention to fall asleep on sleep quality in good sleepers using polysomnographic and subjective nap parameters. We hypothesized that high intention to sleep would lead to arousal, worsening sleep quality. A counterbalanced 2 × 2 experimental design with one intra-individual (neutral versus motivating instruction) and one inter-individual (instruction sequence) variable was used. Thirty-three good sleepers (22 females; mean age: 24.1 ± 8.4 years) each attended two 1-h daytime polysomnographic recording sessions in the laboratory. When providing motivating instruction, the experimenter insisted on the importance of falling asleep as quickly as possible and promised a financial reward. Compared with neutral instruction, motivating instruction was associated with increased waking after sleep onset, number of awakenings and arousal index during napping. No relationship between instruction and subjective nap appraisal was found. The effect of high intention on sleep fragmentation remained significant after controlling for habitual napping, depression, anxiety and sleepiness. Thus, our findings suggest that high intention to fall asleep worsened sleep quality, especially in terms of sleep fragmentation, in good sleepers.
Article
The diverse and complex field of paradoxical psychotherapy is introduced by interpreting a programme for anorexic patients in terms of several common paradoxical procedures. The techniques of symptom prescription, retraining, restraining, written messages and positive interpretations are outlined and discussed together with Frankl's logotherapeutic techniques of paradoxical intention and dereflection. It is noted that various schools of therapy have contributed to the use of these techniques. Several theoretical and conceptual issues pertinent to the utilization of paradoxical interventions in psychotherapy are briefly discussed. The notions of client resistance and the double bind seem central to most paradoxical manoeuvres, and possible difficulties with these are commented upon. It is suggested that a clarification of paradoxical procedures could be aided by a consideration of non-paradoxical explanations and by distinguishing between a focus on systems versus individuals. An attempt is made to define paradoxical interventions as a class by concentrating on fundamental components. Finally, the current status of paradoxical psychotherapy is summarized and possible future developments noted.
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Forty patients suffering from persistent psychophysiological Disorders of Initiating and Maintaining Sleep (DIMS) were assigned to one of the following groups: (1) EMG-biofeedback training; (2) cognitive modification treatment, combining paradoxical instructions, cognitive restructuring and thought stopping; (3) stimulus control and progressive relaxation treatment; (4) waiting list (control). Each active treatment consisted of six sessions over a period of 2 weeks. After treatment, the patients in the three treatment groups showed shorter sleep onset latency (37%), shorter wake time after sleep onset (50%), and more positive evaluations of sleep quality and restedness on awakening in the morning. The waiting-list group did not show any changes. Benefits were maintained and further increased during the 1 and 3 year follow-ups. Results did not suggest substantial differences, among the three treatments, in amount and/or stability of benefits. The 3 year follow-up revealed seven failures, as against 23 successes. The initial variables differentiating the failures were shorter sleep time and higher scores on the P scale of the Eysenck Personality Questionnaire.
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Insomnia is a condition characterized by subjective complaints of insufficient sleep and poor daytime functioning. Objective measures of sleep and daytime functioning, however, seldom show evidence of a similar degree of dysfunction. Most insomniacs, for example, do not suffer from sleep deprivation or daytime sleepiness. This discrepancy between subjective and objective measures of sleep and daytime functioning suggests that cognitive factors may play a central role in persistent insomnia. In particular, it is argued that fears about insufficient sleep and its adverse daytime consequences tend to interfere with sleep, thereby causing a vicious cycle which serves to maintain the insomnia. It is also argued that perfectionist standards and other dysfunctional beliefs may predispose people to these kinds of fears. Finally, existing models for cognitive-behavioural treatment of insomnia are criticized for being almost exclusively focused on the night-time aspects of insomnia. If insomnia is maintained by various kinds of vicious cycles involving fears, beliefs, and standards with regard to daytime functioning, these daytime aspects of insomnia should receive more attention in cognitive-behavioural treatment.
Article
This article discusses the use of paradoxical interventions in counseling psychology and surveys the research literature to date. After a description of the historical background of paradoxical interventions, current schools of therapy using paradox are presented, including the psychotherapy of Milton Erickson, the Palo Alto group founded by Gregory Bateson, the Milan School, and the Ackerman Brief Therapy Project. The theoretical and definitional underpinnings of paradoxical interventions are then discussed,"with particular attention paid to the concept of the double bind. A categorization and description of the different paradoxical strategies is described in detail, with guidelines and caveats for the therapeutic management of paradox in counseling. The article concludes with a summary of the research on paradoxical interventions including both case studies and experimental investigations and with recommendations for future research.
Article
Paradoxical intention has been shown to improve sleep performance in chronic insomniacs, presumably by interrupting their overly anxious sleep efforts. It was hypothesized that instructions to simply give up such sleep intentions—without trying to stay awake—could have a similar effect. Giving-up instructions framed as a paradoxical sleep-improvement method ("try giving up") were compared with giving up presented as a way to improve nighttime comfort and morning restedness without any sleep improvement ("give up trying"), along with a placebo-attention (self-monitoring) treatment. The 3 treatments were embodied in a printed booklet delivered by mail and evenly distributed among 33 20–56 yr old chronic insomniacs recruited from the general community. All 3 treatment groups improved in daily sleep estimates ("sleep efficiency") after treatment, but only the giving-up groups improved on a self-report measure of sleep performance anxiety. It is suggested that such a reduction in performance anxiety may be an important therapeutic outcome, with or without sleep improvement. (43 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Psychologische und psychotherapeutische Behandlungstechniken sind ein unverzichtbarer Teil der Therapie von Insomnien, da sie darauf abzielen, (1) sowohl das Symptom Schlaflosigkeit als auch zugrunde liegende nichtorganische Ursachen effektiv zu behandeln und (2) nicht mit den Nachteilen einer Behandlung mit Schlafmitteln wie Substanzmißbrauch oder Medikamentenabhängigkeit verknüpft sind. Effektive Behandlungstechniken wie die Patientenaufklärung und -beratung, Schlafhygiene, Stimuluskontrolle und Entspannungsverfahren sollte jeder Therapeut und auch der Allgemeinmediziner kennen, der diese Verfahren vorwiegend bei akut erkrankten Patienten mit Ein- oder Durchschlafproblemen einsetzen kann. Andere verhaltenstherapeutische Techniken mit nachgewiesener Effektivität wie die Schlafrestriktion oder kognitive Therapie sowie tiefenpsychologisch orientierte Psychotherapien sind den dafür ausgebildeten Therapeuten vorbehalten. Patienten mit chronischer Insomnie bedürfen zumeist eines Therapeuten mit schlafmedizinischer Erfahrung. Multimodale Therapien kombinieren therapeutisch erfolgreiche Therapieelemente in strukturierten Konzepten und werden überwiegend von Spezialabteilungen der Schlafmedizin angeboten. Jede Hypnotikabehandlung eines Insomniepatienten sollte immer von basalen Elementen nichtpharmakologischer Therapie begleitet werden.
Article
Psychological treatments for sleep-maintenance insomnia have received little attention in the literature. Problems with staying asleep are commonplace, however, especially in the older age groups, and there is a need to develop effective management alternatives to night-time sedation. This single case report describes the sequential application of two cognitive interventions with treatment effects being evaluated by means of time series analysis. The mental overarousal model of sleep disturbance is discussed.
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O objetivo deste artigo é descrever, resumidamente, quais são as terapias não farmacológicas e também a atualização do uso destas para o tratamento da insônia crônica. Além da insônia ser o mais prevalente distúrbio do sono, ela está diretamente associada aos transtornos psiquiátricos. Embora o tratamento farmacológico seja o mais comumente utilizado, as terapias não farmacológicas vêm sendo amplamente estudadas, em particular as relacionadas às mudanças de comportamento. Entre estas estão a cognitiva; a higiene do sono; a do controle de estímulos; a de restrição do sono; a do relaxamento muscular; a da intenção paradoxal e, mais recentemente, a prática regular de exercícios físicos. Inicialmente, o principal objetivo dos estudos realizados com as intervenções comportamentais foi o de melhorar a qualidade do sono dos pacientes. No entanto, alguns estudos recentes têm sido desenvolvidos com o objetivo de avaliar o efeito de tais terapias auxiliando à redução da dose e da freqüência de uso de medicamentos utilizados, bem como à melhora da qualidade de vida dos pacientes. Como a insônia é um problema crônico, os tratamentos de longo prazo têm sido alvos de estudos e de uso comum entre os clínicos.
Article
In a previous study, Ascher and Turner (1980) accounted for differential results of two types of paradoxical intention administrations by suggesting that in one case subjects were encouraged to follow the explicit demands of the instructions which adversely effected performance. It was the purpose of the present study to determine the effect of employing a procedural component to emphasize the explicit demands of paradoxical intention instructions. Two groups received identical paradoxical intention instructions. One was required to present “objective” data along with their subjective sleep report—the other had only to present the subjective data. Two control groups were included in the design which employed sleep onset latency as a dependent variable. As hypothesized, results indicated that the paradoxical intention group submitting “objective” data reported latencies which were significantly longer than those of the no-treatment control, while the paradoxical intention group that was not required to submit “objective” data reported sleep onset latencies which were significantly shorter than those of the no-treatment control group.(Received December 1981)
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Background: Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. Objectives: To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers. Search methods: In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. Selection criteria: We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment . Data collection and analysis: Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model). Main results: We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. Authors' conclusions: We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.
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Approaches to interpersonal helping continue to proliferate with literally hundreds of overlapping and competing models currently on the clinical scene. Although therapists, researchers, and clinicians have striven diligently to identify which models may be best suited for which clients, problems, and so forth, these efforts have as yet produced little that is definitive, at least little that is backed by persuasive evidence. These developments have sparked a continuing movement toward eclecticism in practice as well as the rise of “integrative” practice models. The essential function of integrative models is to provide ways of synthesizing this diversity for purposes of practice, training, and research. Although the syntheses they offer are inevitably partial and selective, they can present theoretical horizons and technical combinations not found in single models.
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Insomnien entstehen aus einem Mißverhältnis zwischen Schlafbedürfnis und Schlafvermögen. Sie stellen einen Mangel an Schlafqualität oder Schlafquantität dar. Sie sind auch ein subjektives Phänomen und damit die individuelle Wahrnehmung eines gestörten Schlafs (ASDC 1979; Soldatos et al. 1979; Kales u. Kales 1984; Parkes 1985; APA 1987; ASDA 1990; Buysse u. Reynolds 1990).
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Sleep taken at regular intervals has been an indispensable part of human and virtually all mammalian life. Yet its ephemeral and delicate nature remains poised to introduce the pain of insomnia when strained by momentous, but more often, trivial irritants. An extra sip of coffee, an awkward glance by a supervisor, or a barely audible noise in the home at bedtime may steal sleep from us. Left in its place is frustration and the nagging heritage of inadequate sleep that haunts us the next day.
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Describes 2 techniques of logotherapy, paradoxical intention and dereflection, utilizing a number of case reports. The first attempts to break a self-sustaining vicious circle involving anticipating anxiety: a symptom evokes a phobia and the phobia provokes the symptoms, which reinforces the phobia. In phobic cases patients display fear of fear, while obsessive-compulsive patients show fear of themselves. Phobics attempt to flee from the fear, while obsessives try to fight against their obsessions and compulsions. Paradoxical intention is a process whereby the patient is encouraged to do the things he fears or to wish for them to happen. The use of this technique by behavioral therapists is discussed. Dereflection has been developed for persons with sexual disorders (impotence and frigidity), in which the patient's fight for sexual pleasure becomes an obstacle to achieving it. The therapist advises against intercourse and breaks the vicious circle of expectation of pleasure, striving, and disappointment. (67 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Assessed the effectiveness of treatment programs based on progressive relaxation, stimulus control, and paradoxical intention in the context of sleep difficulties for 50 volunteer Ss. The results indicate that each of the therapeutic procedures significantly reduced sleep complaints in contrast to placebo and waiting list control groups. No differences were observed among the 3 active techniques. (1½ p ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Although most cases of psychogenic urinary retention can be ameliorated by a program composed of various behavioral techniques, there is a small percentage of cases which resists the behavioral treatment of choice. The present multiple case paper focused on the treatment of several resistant cases of functional urinary retention. Following a two week baseline period, each individual was exposed to eight weekly behavioral sessions. Whereas most cases of urinary retention have significantly improved by this time, the five individuals chosen for the present study were dissatisfied with their progress. Thus, following the eighth week, paradoxical intention was employed. Within six weeks treatment for the urinary problem was terminated as all clients were comfortable with this aspect of their daily behavior. It was hypothesized that cases of psychogenic urinary retention which resist behavioral techniques are possibly exacerbated by performance anxiety. Such anxiety can be efficiently handled by paradoxical intention.
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PHYSIOLOGICAL, PERSONALITY, AND EEG SLEEP PATTERNS OF 16 POOR-SLEEP GROUP (PSG) SS WERE COMPARED WITH 16 GOOD-SLEEP GROUP (GSG) SS. COMPARED WITH GOOD SLEEPERS, POOR SLEEPERS HAD LESS SLEEP TIME, A HIGHER PROPORTION OF STAGE 2 SLEEP, MARKEDLY LESS REM SLEEP DESPITE A SIMILAR NUMBER OF REM PERIODS, MORE AWAKENINGS, AND REQUIRED MORE TIME TO FALL ASLEEP. SIGNIFICANT PHYSIOLOGICAL DIFFERENCES BETWEEN THE GROUPS WERE OBSERVED DURING ALL STAGES OF SLEEP AND DURING A PRESLEEP PERIOD. PERSONALITY TEST RESULTS CLEARLY INDICATED A MUCH HIGHER PROBABILITY OF SYMPTOMATIC COMPLAINTS AMONG POOR SLEEPERS AS WELL AS A STRONG POTITIVE RELATIONSHIP BETWEEN DREAMING AND INDEXES OF PSYCHOPATHOLOGY. THIS STUDY DID NOT RESOLVE CAUSE AND EFFECT RELATIONSHIPS AMONG PHYSIOLOGICAL VARIABLES, PERSONALITY MEASURES, AMOUNT OF DREAMING, AND GOOD AND POOR SLEEP; HOWEVER, SIGNIFICANT EEG, PHYSIOLOGICAL, AND PSYCHOLOGICAL DIFFERENCES WERE DEMONSTRATED. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Paradoxical intention as a component in the behavioral treatment of sleep onset insomnia: A case study
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Paradoxical intention
  • Ascher