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Yoga for anxiety: A systematic review and meta-analysis of randomized controlled trials.
Cramer, H, Lauche, R, Anheyer, D, Pilkington, K, de Manincor, M, Dobos, G, Ward, L
Depression and anxiety. 2018;35(9):830-843
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While temporary anxiety is a natural response, excessive and prolonged anxiety can lead to a wide range of physical symptoms and behavior changes. Current treatment options include psychological approaches and medication, however many individuals experiencing anxiety choose to self-manage their condition. Yoga has become a popular approach to improve emotional well-being, and based on a recent study, yoga practitioners have reported managing stress and anxiety as one of the main reasons for practicing. The aim of this meta-analysis was to review the effectiveness and safety of yoga for anxiety. Eight studies with 319 participants were included in this systematic review. Among these studies, no effects were found for patients with anxiety disorders diagnosed by the Diagnostic and Statistical Manual (DSM) criteria, only for patients without a formal diagnosis. Based on these results, the authors conclude yoga may be beneficial in the short-term for individuals with elevated levels of anxiety, however there was no conclusive evidence for individuals when only DSM-diagnosed anxiety disorders were considered. These findings warrant further studies to better understand the connection between mindfulness practices and anxiety.
Abstract
Yoga has become a popular approach to improve emotional health. The aim of this review was to systematically assess and meta-analyze the effectiveness and safety of yoga for anxiety. Medline/PubMed, Scopus, the Cochrane Library, PsycINFO, and IndMED were searched through October 2016 for randomized controlled trials (RCTs) of yoga for individuals with anxiety disorders or elevated levels of anxiety. The primary outcomes were anxiety and remission rates, and secondary outcomes were depression, quality of life, and safety. Risk of bias was assessed using the Cochrane tool. Eight RCTs with 319 participants (mean age: 30.0-38.5 years) were included. Risk of selection bias was unclear for most RCTs. Meta-analyses revealed evidence for small short-term effects of yoga on anxiety compared to no treatment (standardized mean difference [SMD] = -0.43; 95% confidence interval [CI] = -0.74, -0.11; P = .008), and large effects compared to active comparators (SMD = -0.86; 95% CI = -1.56, -0.15; P = .02). Small effects on depression were found compared to no treatment (SMD = -0.35; 95% CI = -0.66, -0.04; P = .03). Effects were robust against potential methodological bias. No effects were found for patients with anxiety disorders diagnosed by Diagnostic and Statistical Manual criteria, only for patients diagnosed by other methods, and for individuals with elevated levels of anxiety without a formal diagnosis. Only three RCTs reported safety-related data but these indicated that yoga was not associated with increased injuries. In conclusion, yoga might be an effective and safe intervention for individuals with elevated levels of anxiety. There was inconclusive evidence for effects of yoga in anxiety disorders. More high-quality studies are needed and are warranted given these preliminary findings and plausible mechanisms of action.
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The cognitive treatment components and therapies of cognitive behavioral therapy for insomnia: A systematic review.
Jansson-Fröjmark, M, Norell-Clarke, A
Sleep medicine reviews. 2018;42:19-36
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Insomnia disorder is characterised by problems getting to sleep at bedtime, periods of being awake, or waking early and not being able to go back to sleep. This leads to problems with daytime functioning (e.g. low energy levels, mood disruptions). Diagnosis requires difficulties for 3 or more nights each week for longer than 3 months. Cognitive behavioural therapy (CBT) is considered a viable treatment for patients with insomnia and usually is made up of elements such as sleep hygiene and relaxation, addressing problematic sleep behaviours, and dealing with unhelpful beliefs. However, the effectiveness of various CBT elements is still in question. This systematic review aims to address this, and is based on 1455 subjects in 32 studies. The review concluded there was support for paradoxical intention: instructing the subject to try to remain awake as long as possible rather than aiming to sleep, and cognitive therapy: to reverse unhelpful beliefs about sleep, sleep-worry, misperceptions of sleep and using safety behaviours. It also found that some cognitive elements appear promising including behavioural experiments: planned activities that help the subject test unhelpful beliefs and cognitive refocusing: getting subjects to focus on non-arousing thoughts such as film plots or by focusing on external things like audiobooks to shift attention. However, more methodologically robust studies are needed.
Abstract
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.
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Investigating effective treatment factors in brief cognitive behavioral therapy for panic disorder.
Lim, JA, Lee, YI, Jang, JH, Choi, SH
Medicine. 2018;97(38):e12422
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Both standard and short-term cognitive behaviour therapy (CBT) have been shown to be effective in the treatment of panic disorder (PD). The aim of this study was to investigate the effectiveness of a mindfulness-based brief CBT, in particular, with respect to physiological symptoms, like palpitations and accelerated heart rate, and factors that may help predict treatment outcome. Treatment consisted of psychoeducation about the condition and teaching meditation/relaxation techniques. CBT was delivered once a week over a four week period (a total of four sessions). Several self-assessed scales were used to determine outcome and efficacy. The four week intervention showed statistically significant improvements on almost all scores. The results suggest that fear of cardiovascular (CV) symptoms may be an important predictor of the clinical course of PD. The authors concluded that managing fear of CV symptoms can help improve effectiveness of brief CBT and that short-term CBT may be particularly effective for patients who suffered from CV symptoms. The study was limited by the fact that there was no control group and that participants had relatively mild PD symptoms and may therefore not have been representative of the PD patient population as a whole.
Abstract
Numerous studies have provided evidence for the effectiveness of cognitive behavioral therapy (CBT) on panic disorders (PDs). There has also been growing attention on brief CBT with regard to delivering intensive treatment efficiently. This study investigated the essential parts of mindfulness-based brief CBT to optimize treatment benefits.A total of 37 patients were retrospectively enrolled in this study. They were recruited from the anxiety/panic/fear clinic of Seoul National University Hospital. The patients participated in group CBT once a week for a total of 4 sessions over a 4-week period, when they were assessed using the Panic Disorder Severity Scale (PDSS), Anxiety Sensitivity Index-Revised (ASI-R), Albany Panic and Phobia Questionnaire (APPQ), State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Yale-Brown Obsessive Compulsive Scale (Y-BOCS) before and after brief CBT. Twenty-nine patients completed the 1-month follow-up.There were significant reductions in PDSS (P < .001), ASI-R-fear of respiratory symptoms (P = .006), ASI-R-fear of publicly observable anxiety reaction (P = .002), ASI-R-fear of cardiovascular symptoms (P < .001), ASI-R-fear of cognitive dyscontrol (P = .001), ASI-R-Total (P < .001), APPQ-Agoraphobia (P = .003), APPQ-Total (P = .028), STAI-State anxiety (P < .001), STAI-Trait anxiety (P = .002), BAI (P = .003), and BDI (P < .001) scores. We also found significant associations between ASI-R-fear of cardiovascular symptoms, ASI-R-Total, and changes in PDSS scores. A stepwise multiple linear regression analysis indicated that anxiety sensitivity for fear of cardiovascular symptoms predicted an improvement in panic severity (β = 0.513, P = .004).Our findings suggested that behavioral aspects, especially physiological symptom control, needed to be considered in brief, intensive CBT for PD. The results also suggested that a mindfulness-based brief CBT approach might be particularly helpful for patients with PD who have severe cardiovascular symptoms.
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A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders.
Murawski, B, Wade, L, Plotnikoff, RC, Lubans, DR, Duncan, MJ
Sleep medicine reviews. 2018;40:160-169
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Sleep is important for good health but more than a quarter of the adult population reports poor quality sleep. This review and meta-analysis looked at cognitive and behavioural interventions in adults who report poor sleep but are not diagnosed with a clinical sleep disorder. The most commonly used interventions were stress management/relaxation, meditation, controlled breathing and stimulus control. A meta-analysis showed a medium improvement of overall sleep quality and a small but significant improvement of subjective sleep quality and duration with cognitive and behavioural interventions. The effects were bigger when sleep at baseline was worse. Effects of mode of delivery, study duration and the inclusion of a relaxation component were not assessed, due to insufficient numbers. The authors conclude that there is room for improvements of cognitive and behavioural interventions and call for more investigations into this.
Abstract
Many adults without a diagnosed sleep disorder report poor sleep health, which is defined by dissatisfactory levels of sleep duration, sleep quality, or the timing of sleep. No previous review has summarized and described interventions targeting poor sleep health in this population. This meta-analysis aimed to quantify the efficacy of behavioral and cognitive sleep interventions in adults with poor sleep health, who do not have a sleep disorder. Electronic databases (Medline, Embase, PsycInfo, Cinahl) were searched with restrictions for age (18-64 y) and English language full-text, resulting in 18,009 records being screened and 592 full-texts being assessed. Eleven studies met inclusion criteria, seven of which reported a measure of overall sleep health (Pittsburgh sleep quality index [PSQI]). Following appraisal for risk of bias, extracted data were meta-analyzed using random-effects models. Meta-analyses showed interventions had a medium effect on sleep quality (Hedge's g = -0.54, [95% confidence interval (CI)] -0.90 to -0.19, p < 0.01). Baseline sleep health was the only significant effect moderator (p = 0.01). The most frequently used intervention components were stress management and relaxation practice, stimulus control, sleep hygiene, and exercise. Interventions targeting cognitive and behavioral self-regulation improve sleep quality in adults without clinical sleep disorder.
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Circadian Rhythms, Metabolism, and Chrononutrition in Rodents and Humans.
Johnston, JD, Ordovás, JM, Scheer, FA, Turek, FW
Advances in nutrition (Bethesda, Md.). 2016;7(2):399-406
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Chrononutrition is an emerging field that links the body’s metabolism to its endogenous circadian rhythm. It is now recognised that numerous circadian clocks are found within all major tissues and most cells of the body. This complex network of clocks influences a wide range of biological processes including neuronal, endocrine, metabolic and behavioural function. When there is a disruption in a single circadian clock, whole-organism homeostasis can be impacted, potentially resulting in the development of disease. This review explains the potential mechanisms by which circadian clocks influence biological processes through transgenic animal studies, and how they are being translated to human genetics and metabolomics. The principles of chrononutrition are clinically significant factors that should be considered when managing and treating metabolic disease, as well as maintaining health in the general population.
Abstract
Chrononutrition is an emerging discipline that builds on the intimate relation between endogenous circadian (24-h) rhythms and metabolism. Circadian regulation of metabolic function can be observed from the level of intracellular biochemistry to whole-organism physiology and even postprandial responses. Recent work has elucidated the metabolic roles of circadian clocks in key metabolic tissues, including liver, pancreas, white adipose, and skeletal muscle. For example, tissue-specific clock disruption in a single peripheral organ can cause obesity or disruption of whole-organism glucose homeostasis. This review explains mechanistic insights gained from transgenic animal studies and how these data are being translated into the study of human genetics and physiology. The principles of chrononutrition have already been demonstrated to improve human weight loss and are likely to benefit the health of individuals with metabolic disease, as well as of the general population.
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Sleep restriction increases the neuronal response to unhealthy food in normal-weight individuals.
St-Onge, MP, Wolfe, S, Sy, M, Shechter, A, Hirsch, J
International journal of obesity (2005). 2014;38(3):411-6
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Sleep patterns influence eating behaviour and the body’s response to food. Previous studies suggest that short sleep duration leads to increased caloric intake and a desire for high-fat foods, however the specific neural mechanisms explaining how sleep restriction modulates this response is unknown. The aim of this study was to determine whether a specific area of the brain is activated in response to unhealthy compared with healthy foods. 25 participants were included, all of which were normal weight and had normal sleeping patterns. Each participant was tested after five nights of either 4 or 9 hours in bed by functional magnetic resonance imaging (fMRI). The test was performed while the participant was shown healthy and unhealthy food photos in the fasted state. This study found that after a period of restricted sleep compared with habitual sleep, unhealthy foods led to greater activation in brain regions associated with reward compared with healthy foods. This finding provides a model of neuronal mechanisms relating short sleep duration to obesity and cardio-metabolic risk factors and warrants further investigation.
Abstract
CONTEXT Sleep restriction alters responses to food. However, the underlying neural mechanisms for this effect are not well understood. OBJECTIVE The purpose of this study was to determine whether there is a neural system that is preferentially activated in response to unhealthy compared with healthy foods. PARTICIPANTS Twenty-five normal-weight individuals, who normally slept 7-9 h per night, completed both phases of this randomized controlled study. INTERVENTION Each participant was tested after a period of five nights of either 4 or 9 h in bed. Functional magnetic resonance imaging (fMRI) was performed in the fasted state, presenting healthy and unhealthy food stimuli and objects in a block design. Neuronal responses to unhealthy, relative to healthy food stimuli after each sleep period were assessed and compared. RESULTS After a period of restricted sleep, viewing unhealthy foods led to greater activation in the superior and middle temporal gyri, middle and superior frontal gyri, left inferior parietal lobule, orbitofrontal cortex, and right insula compared with healthy foods. These same stimuli presented after a period of habitual sleep did not produce marked activity patterns specific to unhealthy foods. Further, food intake during restricted sleep increased in association with a relative decrease in brain oxygenation level-dependent (BOLD) activity observed in the right insula. CONCLUSION This inverse relationship between insula activity and food intake and enhanced activation in brain reward and food-sensitive centers in response to unhealthy foods provides a model of neuronal mechanisms relating short sleep duration to obesity.
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Dietary intake following experimentally restricted sleep in adolescents.
Beebe, DW, Simon, S, Summer, S, Hemmer, S, Strotman, D, Dolan, LM
Sleep. 2013;36(6):827-34
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Obesity in adolescents and adults has become a well recognised public health hazard. In this study the relationship of restricted sleep and consumption of high glycemic index foods, in particular sweets and desserts, was measured in adolescents. A 3-week experimental sleep manipulation protocol was designed. The order of experimental conditions was counterbalanced across participants in a randomised crossover design. All participants sleep time was in their home setting and was monitored via a daily sleep diary. No instructions were given regarding diet except to limit caffeine and energy drinks. Data was collected through sleep watches and the teens were instructed to wear the watch only during sleep time and throughout the night. A 24-hour diet recall was done at the end of each week. The results of the study showed that there was increased consumption of desserts and sweets during restricted sleep. The diets of adolescents after several nights of sleep restriction were characterised by higher glycemic index and glycemic load, as well as a trend toward high consumption of calories and carbohydrates. Sleep restriction may lead to to changes in dietary choices and dietary behaviour that may have long term negative impact on health.
Abstract
STUDY OBJECTIVE To examine the relationship between sleep and dietary intake in adolescents using an experimental sleep restriction protocol. DESIGN Randomized crossover sleep restriction-extension paradigm. SETTING Sleep obtained and monitored at home, diet measured during an office visit. PARTICIPANTS Forty-one typically developing adolescents age 14-16 years. INTERVENTIONS The 3-week protocol consisting of a baseline week designed to stabilize the circadian rhythm, followed randomly by 5 consecutive nights of sleep restriction (6.5 hours in bed Monday-Friday) versus healthy sleep duration (10 hours in bed), a 2-night washout period, and a 5-night crossover period. MEASUREMENTS Sleep was monitored via actigraphy and teens completed validated 24-hour diet recall interviews following each experimental condition. RESULTS Paired-sample t-tests examined differences between conditions for consumption of key macronutrients and choices from dietary categories. Compared with the healthy sleep condition, sleep-restricted adolescents' diets were characterized by higher glycemic index and glycemic load and a trend toward more calories and carbohydrates, with no differences in fat or protein consumption. Exploratory analyses revealed the consumption of significantly more desserts and sweets during sleep restriction than healthy sleep. CONCLUSIONS Chronic sleep restriction during adolescence appears to cause increased consumption of foods with a high glycemic index, particularly desserts/sweets. The chronic sleep restriction common in adolescence may cause changes in dietary behaviors that increase risk of obesity and associated morbidity.