Sleep quality predicts treatment outcome in CBT for social anxiety disorder

Abstract

Background: Sleep quality may be an important, yet relatively neglected, predictor of treatment outcome in cognitive-behavioral therapy (CBT) for anxiety disorders. Specifically, poor sleep quality may impair memory consolidation of in-session extinction learning. We therefore examined sleep quality as a predictor of treatment outcome in CBT for social anxiety disorder and the impact of d-cycloserine (DCS) on this relationship.

Methods: One hundred sixty-nine participants with a primary diagnosis of DSM-IV generalized social anxiety disorder were recruited across three sites. Participants were enrolled in 12 weeks of group CBT. Participants randomly received 50 mg of DCS (n = 87) or pill placebo (n = 82) 1 hr prior to sessions 3-7. Participants completed a baseline measure of self-reported sleep quality and daily diaries recording subjective feelings of being rested upon wakening. Outcome measures including social anxiety symptoms and global severity scores were assessed at each session.

Results: Poorer baseline sleep quality was associated with slower improvement and higher posttreatment social anxiety symptom and severity scores. Moreover, patients who felt more "rested" after sleeping the night following a treatment session had lower levels of symptoms and global severity at the next session, controlling for their symptoms and severity scores the previous session. Neither of these effects were moderated by DCS condition.

Conclusions: Our findings suggest that poor sleep quality diminishes the effects of CBT for social anxiety disorder and this relation is not attenuated by DCS administration. Therapeutic attention to sleep quality prior to initiation of CBT and during the acute treatment phase may be clinically indicated.

Trial registration: ClinicalTrials.gov NCT00633984.

Keywords: cognitive behavioral therapy; d-cycloserine; psychotherapy; sleep quality; social anxiety disorder; social phobia.

Conflict of interest statement

Conflict of Interest: Dr. Zalta declares no conflicts of interest. Dr. Dowd reported receiving grant support from NIMH, Neuronetics, Cervel Neurotech, Otsuka, and the Research Foundation for Mental Hygeine and is a consultant for Cervel Neurotech. Dr. Rosen-field reported receiving grant funding from NIMH and consulting for the University of Miami. Dr. Smits reported receiving royalties from various book publishers unrelated to this study. Dr. Otto noted serving as a consultant for MicroTransponder Inc. and reported receiving royalties from multiple publishers, including Routledge, the publisher of the CBT manual used in this study. Dr. Simon reported receiving grant support from the American Foundation for Suicide Prevention, Forest Laboratories, NIMH, and the Department of Defense; consulting for the Massachusetts General Hospital Psychiatry Academy; and having stock options in Elan, Dandreon, G Zero, and Gatekeeper. Dr. Meuret reported receiving grant support from NIH and serving as a consultant for Palo Alto Health Sciences Inc. Dr. Marques reported consulting for the Massachusetts General Hospital Psychiatry Academy and receiving payment for manuscript preparation for Hazelden Publishing and Harvard Health Publications. Dr. Hofmann reported serving as a consultant for Merck-Schering/Plough, receiving grant support from NIMH, and receiving royalties from multiple publishers, including Routledge, the publisher of the CBT manual used in this study. Dr. Pollack noted the following disclosures for the preceding 36 months: Advisory Boards and Consultation: Corcept, Eli Lilly, Johnson and Johnson, Ironwood Pharmaceuticals, Medavante, Merck, Otsuka, Targia Phamaceuticals, and Transcept Research; Grants and Grants Pending: NIDA, NIMH, NCCAM, Bristol Myers Squibb, Euthymics, Forest Laboratories, GlaxoSmithKline, and Eli Lilly; Equity: Doyen Medical, Medavante, Mensante Corporation, Mindsite, Targia Pharmaceuticals; Royalty/patent: SIGH-A, SAFER interviews.

© 2013 Wiley Periodicals, Inc.

Figures

Figure 1

Slope of change in LSAS for participants high or low in baseline sleep quality. High PSQI represents 1 standard deviation above the mean. Low PSQI represents 1 standard deviation below the mean.

Figure 2

Slope of change in CGI-S for participants high or low in baseline sleep quality. High PSQI represents 1 standard deviation above the mean. Low PSQI represents 1 standard deviation below the mean.