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Volume 13 No. 11
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Scientific Investigations

Free Perfectionism and Polysomnography-Determined Markers of Poor Sleep

Anna F. Johann1,2; Elisabeth Hertenstein, PhD1; Simon D. Kyle, PhD3; Chiara Baglioni, PhD1; Bernd Feige, PhD1; Christoph Nissen, MD1; Dieter Riemann, PhD1; Kai Spiegelhalder, MD, PhD1
1Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; 2Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Germany; 3Sleep and Circadian Neuroscience Institute (SCNi), Nuffield Department of Clinical Neuroscience, University of Oxford, United Kingdom

ABSTRACT

Study Objectives:

Perfectionism has been suggested to represent a predisposing factor for poor sleep. However, previous studies have relied on self-reported measures. The association between perfectionism and poor sleep measured by polysomnography (PSG) warrants further investigation.

Methods:

The current retrospective exploratory study used the Frost Multidimensional Perfectionism Scale and PSG in an unselected sample of 334 consecutive sleep laboratory patients (140 males, 194 females, 44.6 ± 15.9 years). Data were analyzed using linear regression analyses.

Results:

High levels of perfectionism were associated with PSG-determined markers of poor sleep in the first sleep laboratory night. The total Frost Multidimensional Perfectionism Scale score was significantly associated with the number of nocturnal awakenings in the first sleep laboratory night. The subscales “concern over mistakes” and “personal standards” of perfectionism were significantly associated with markers of poor sleep. In contrast, there were only a few associations between perfectionism and PSG variables of the second sleep laboratory night.

Conclusions:

This pattern of results suggests that high levels of perfectionism may predispose individuals to sleep disturbances in the context of acute stressors. Thus, the influence of perfectionism on poor sleep should be further investigated to improve treatment.

Citation:

Johann AF, Hertenstein E, Kyle SD, Baglioni C, Feige B, Nissen C, Riemann D, Spiegelhalder K. Perfectionism and polysomnography-determined markers of poor sleep. J Clin Sleep Med. 2017;13(11):1319–1326.


INTRODUCTION

Perfectionism is a personality trait that has been defined as a dispositional tendency to set excessively high standards and to evaluate one's own performance in an overly critical manner.1 Perfectionism has been linked to several mental disorders including eating, anxiety, and depressive disorders.2 In addition, perfectionism may be a predisposing factor for poor sleep.35 This may be due to the fact that the maladaptive form of perfectionism includes excessive concerns about making mistakes and is associated with worry and rumination.6 Worry and rumination at bedtime are, in turn, assumed to lead to sleep onset and sleep maintenance difficulties.7 In particular, it has been suggested that individuals with high levels of perfectionism are more concerned about the effects of acute sleep disturbances on their daytime performance.4 This may lead to increased worry and arousal at bedtime; therefore, perfectionism may contribute to the transition from acute to chronic sleep disturbances. It may be hypothesized that individuals prone to perfectionism actively attempt to force sleep initiation, a strategy called sleep effort that does not pay off and leads to sleep disturbances.3,8

In line with these theoretical considerations, previous evidence suggests that individuals who fulfill the diagnostic criteria for insomnia present with higher levels of perfectionism than good sleepers.9,10 Additionally, several studies showed that patients with insomnia strive for perfection on a behavioral level.1113 Longitudinal studies suggest that perfectionism is indeed a risk factor for insomnia symptoms.14,15 Further findings have shown that the link between insomnia symptoms and perfectionism may be mediated by emotional distress,15 stress perception, and emotion regulation16 or anxiety.17

BRIEF SUMMARY

Current Knowledge/Study Rationale: Studies on perfectionism and sleep have relied on self-reported measures of sleep. Discrepancies between subjective and objective measures of sleep have frequently been observed, especially in patients with insomnia. Subjective and objective sleep disturbances are partially independent constructs, with objective sleep disturbances being more closely associated with physiological arousal and medical morbidity. For these reasons, we investigated whether higher levels of perfectionism are linked to poor sleep, using polysomnography to measure sleep instead of self-report.

Study Impact: Our study shows that perfectionism is related to objective sleep disturbances. Thus, our results show that perfectionism warrants further investigation in order to further improve the treatment of insomnia.

Perfectionism is often assessed using the Hewitt and Flett Multidimensional Perfectionism Scale (MPS)18 or the Frost Multidimensional Perfectionism Scale (FMPS).1 The MPS comprises the subscales self-oriented perfectionism (SOP), socially prescribed perfectionism (SPP), and other-oriented perfectionism (OOP). The FMPS comprises 6 subscales: concern over mistakes (CM), doubts about action (DA), personal standards (PS), parental criticism (PC), parental expectations (PE), and organization (O). Studies reporting on the association between insomnia and perfectionism showed that insomnia is associated with DA,9,19 PS,9 CM,9,19 and PC.10,19 Studies reporting on the association between insomnia symptoms and perfectionism showed that insomnia symptoms are associated with DA,16,17 PS,16 CM,15,16 and PC.17 In addition, it was reported that SPP is a predictor for insomnia symptoms.14 With regard to subjective parameters of sleep, studies found that perfectionism is associated with sleep onset latency (SOL)10,14,16 and wake after sleep onset (WASO).14,16

Studies on perfectionism and sleep have relied on self-reported measures of sleep, and it has not been investigated whether higher levels of perfectionism are also linked to poor sleep as measured by polysomnography (PSG). This is particularly relevant because pronounced discrepancies between subjective and objective measures of sleep have been observed, especially in patients with insomnia.20,21 Thus, subjective and objective sleep disturbances are partially independent constructs with objective sleep disturbances being more closely associated with physiological arousal and medical morbidity.22 This study addresses this gap by analyzing objective sleep parameters (ie, sleep data from PSG), with regard to perfectionism using an explorative approach.

Research thus far on the relationship between personality traits and sleep architecture has provided mixed results. One study reported that higher percentages of REM sleep were found in participants with higher extraversion scores, but not in those with higher neuroticism scores.23 In addition, a study found that trait anxiety was associated with a smaller percentage of slow-wave sleep, a higher percentage of stage N1 sleep, more microarousals, and a lower REM density.24 Another study on trait anxiety showed that REM sleep in a low-anxiety group was shorter in the first 2 nights compared with 2 subsequent nights and that stage N2 sleep was longer during the first night than in the remaining 3 nights, whereas a high-anxiety group did not show any of these differences.25 Further evidence comes from a study on anticipatory worry, which has been shown to be negatively correlated to REM latency,26 and from a study on affect intensity in depressed men, which found that phasic REM sleep was positively associated with intensity of daytime affect.27 In contrast, 2 studies did not find evidence for a potential association between personality traits and sleep architecture.28,29 The association between perfectionism and sleep architecture has not been investigated so far. Thus, our study addresses this gap in the literature.

In the current study, we investigated the association between perfectionism and poor sleep as a transdiagnostic dimensional construct rather than the association between perfectionism and insomnia. The rationale behind this approach is based on the Research Domain Criteria (RDoC) framework, which is being promoted by the National Institute of Mental Health.30

For several reasons, this new classification framework for research on mental disorders is a departure from the current diagnostic system in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which draws on symptom-related categories. It is argued that those diagnostic categories fail to accommodate findings coming from clinical neuroscience and genetics. In addition, current diagnostic classifications suffer from not making reliable predictions about treatment response. Finally, established frameworks may not capture fundamental underlying pathophysiological mechanisms of dysfunction.30

Thus, the RDoC framework proposes to base understanding and treatment of mental disorders strictly on strong empirical evidence for constructs that are marked by a high degree of external validity and are based on neural circuits. Initially, 20 constructs have been identified, which have then been grouped into 5 domains. For example, the constructs “arousal,” “circadian rhythms” and “sleep-wakefulness” have been grouped into the domain “arousal and regulatory systems.”

The goal of this framework is to systematically investigate all constructs on different levels including genes, molecules, cells, physiology, behavior, and self-report in order to arrive at a better understanding of a mental disorder and its underlying patho-physiological mechanisms. The RDoC framework may help to develop and provide personalized therapy based on biomarkers.

In line with the RDoC framework, we included all patients with poor sleep in our study rather than insomnia patients only. Such an approach has been explicitly suggested by Insel et al.30: “Notably, samples might include patients spanning from multiple DSM diagnoses.” In order to “…explicate the full range of a given dimension…” An example of this: “A study of fear circuitry might include all patients presenting at an anxiety clinic…”

METHODS

Participants

In line with the RDoC framework, we included all patients with poor sleep in our study rather than insomnia patients only. All patients who were investigated for 2 nights in the sleep laboratory of the Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg between November 2012 and November 2014 (n = 424) were considered to be eligible to participate in the current study. These patients were referred to our sleep disorders clinic by their primary care provider or medical specialist, and the sleep laboratory recordings were part of the routine clinical procedure. Ninety patients were excluded from analysis due to nonstandardized bedtimes (n = 48), incomplete data on perfectionism (n = 16), incomplete data on depression (n = 5), or psychoactive medication in the week prior to or during the sleep laboratory investigation (n = 21). This resulted in a sample of 334 sleep laboratory patients. All patients were required to refrain from alcohol, caffeine, and daytime naps during the recording days. All patients were investigated between 1995 and 2014. For further details on the study sample, see Table 1 and Table 2. The study was conducted in accordance with the Declaration of Helsinki. Written consent was obtained from all patients prior to the examination in the sleep laboratory, allowing us to analyze their data for research purposes. The study protocol was approved by the Institutional Review Board of the Medical Center – University of Freiburg.

Sample characteristics

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Table 1

Sample characteristics

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Polysomnography data.

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Table 2

Polysomnography data.

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Polysomnography

All patients underwent 2 consecutive nights of PSG. Sleep was recorded for approximately 8 hours from 10:07 PM ± 27 minutes until 6:07 AM ± 27 minutes adjusted to individual habitual bedtimes. All recordings included electroencephalogram (C3-A2, C4-A1), electrooculogram (horizontal and vertical), and electromyogram (submental) and were scored visually by experienced raters according to the American Academy of Sleep Medicine criteria.31 All patients were screened for apnea and periodic leg movements by monitoring abdominal and thoracic effort, nasal airflow, oximetry, and bilateral tibialis anterior electromyogram. Sleep recordings were evaluated for the following parameters of sleep continuity: total sleep time (TST); SOL—time from lights out to the first epoch of stage N2 sleep; sleep period time (SPT)—time from sleep onset to final awakening; WASO—defined as the difference between SPT and TST; number of awakenings; and arousal index (number of arousals per hour). Sleep architecture parameters were percentages of stages N1, N2, slow wave sleep (SWS), and REM sleep in reference to SPT.

Psychometric Assessment

Perfectionism was assessed using the FMPS,1 a 35-item, 5-point, Likert-type (disagree strongly to agree strongly) questionnaire with total scores ranging from 29 to 145 points. The FMPS is the most widely used scale for measuring perfectionism and has demonstrated good internal consistency and reliability as well as good convergent and discriminatory validity.1,32,33 The FMPS comprises 6 subscales: concern over mistakes (CM), doubts about action (DA), parental expectation (PE), parental criticism (PC), personal standards (PS), and organization (O). The last subscale (O; containing 6 items) is not included in the total score and was not used in the current study. In addition to the FMPS, all patients were asked to fill in the Pittsburgh Sleep Quality Index (PSQI)34 and the Beck Depression Inventory (BDI).35

Statistical Analysis

All analyses were carried out using the statistical software package R (http://www.R-project.org/). Descriptive presentation of the data includes mean values and standard deviations. The association between perfectionism and PSG-determined sleep continuity and sleep architecture parameters was analyzed using a series of linear regression models. This approach was chosen because of the retrospective exploratory study design. For each combination of perfectionism-related variable (FMPS total and subscale scores; independent variable) and PSG parameter (see “Polysomnography” in Methods; dependent variable), a linear regression analysis was conducted with age, sex, BDI scores, and somatic sleep disorders (sleep apnea syndrome, restless legs syndrome / periodic leg movement disorder, organic insomnia, non-rapid eye movement parasomnia, circadian rhythm sleep disorder, narcolepsy, and idiopathic hypersomnia) as covariates. BDI scores were used as covariates in all analyses because depression levels have been linked to both poor sleep36 and perfectionism levels.2 To investigate the association between perfectionism and subjective sleep, the same analyses have been performed with PSQI scores as dependent variable. Due to multiple testing (114 tests), the alpha level was set at P < .01 (two-tailed) for all analyses. Values of P ranging from .01 to .05 were considered to be statistical trends.

RESULTS

Sample Characteristics

The characteristics of the study sample are presented in Table 1. Descriptive statistics of the PSG measures are presented in Table 2.

The Association Between Perfectionism and Sleep

The results of the linear regression analyses investigating the association between FMPS total scores and PSG parameters are presented in Table 3. The total FMPS score was significantly associated with the number of nocturnal awakenings in the first sleep laboratory night (t = 4.42, P < .001, Figure 1). Moreover, there were statistical trends for the association between the total FMPS score and other parameters of the first sleep laboratory night, namely TST (t = −2.17, P = .031), arousal index (t = 2.43, P = .016), WASO (t = 2.28, P = .023), and REM sleep (t = −2.05, P = .042). No significant associations were found between the total FMPS score and sleep parameters of the second sleep laboratory night. However, there was a statistical trend for the association between the total FMPS score and the arousal index (t = 2.22, P = .027).

Association between FMPS total score, subscale scores (CM, DA) and polysomnography parameters.

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Table 3

Association between FMPS total score, subscale scores (CM, DA) and polysomnography parameters.

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Association between perfectionism and number of awakenings in the first sleep laboratory night.

P < .001 in the linear regression analysis with age, sex, and Beck Depression Inventory (BDI) scores as covariates. FMPS = Frost Multidimensional Perfectionism Scale, PSG = polysomnography.

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Figure 1

Association between perfectionism and number of awakenings in the first sleep laboratory night.

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The results of the linear regression analyses investigating the association between PSQI scores and FMPS total and sub-scale scores revealed that there were no significant associations between PSQI scores and FMPS total and subscale scores.

The results of the analyses of the association between FMPS subscales and sleep parameters are presented in Table 3 (CM, DA) and Table 4 (PE, PC, PS). With regard to the first sleep laboratory night, both CM and PS were significantly associated with TST (CM: t = −2.88, P = .004; PS: t = −3.18, P = .002) and the number of nocturnal awakenings (CM: t = 3.32, P < .001; PS: t = 3.09, P = .002). Moreover, PE (t = 4.54, P < .001) and PC (t = 3.77, P < .001) were also significantly associated with the number of nocturnal awakenings, CM was significantly associated with the arousal index (t = 2.84, P = .005), and PS was significantly associated with WASO (t = 2.65, P = .009). Statistical trends were observed for the association between CM and WASO (t = 2.51, P = .013), CM and REM sleep (t = −2.14, P = .033), PS and the arousal index (t = 2.29, P = .019), and the association between PS and REM sleep (t = −2.10, P = .037).

Association between FMPS subscale scores (PE, PC, PS) and polysomnography parameters.

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Table 4

Association between FMPS subscale scores (PE, PC, PS) and polysomnography parameters.

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With respect to the association between FMPS subscales and sleep parameters of the second sleep laboratory night, a significant association between CM and arousal index was observed (t = 2.72, P = .007). There was a statistical trend for the association between CM and stage N1 sleep (t = 2.43, P = .015), CM and SWS (t = −2.05, P = .041), DA and the arousal index (t = 2.07, P = .039), and PS and the arousal index (t = 1.97, P = .050).

DISCUSSION

The results of this study support the notion that high levels of perfectionism are associated with PSG-determined markers of poor sleep in the first sleep laboratory night. This is particularly true for the CM and PS subscales of the FMPS. In contrast, there were very few significant associations between perfectionism and PSG variables of the second sleep laboratory night. Strengths of the study include the use of state-ofthe-art measures of perfectionism and sleep and the relatively large sample size.

The first night in the sleep laboratory is an unpleasant experience for many, probably due to the discomfort of the electrodes and the unfamiliar environment. As a consequence, individuals sleep worse, a phenomenon called the first-night effect, which led to the common practice of recording at least 2 nights in sleep laboratory research. A recent analysis of data from our sleep disorders clinic suggests that the subjective TST is reduced by approximately 20 minutes in the first sleep laboratory night compared to at-home sleep in good sleepers.37 The current results suggest that perfectionism contributes to the first-night effect. This leads to the more general hypothesis that perfectionism is an important factor for the development of objective sleep disturbances in response to acute stressors. Put differently, it may be speculated that perfectionism is important for sleep reactivity, which refers to the tendency to exhibit sleep disturbances in response to stressful events, which, in turn, is a risk factor for developing chronic sleep disturbances.38 However, it has to be stressed that data about the feeling of heightened stress during the first sleep laboratory night is missing. Thus, future studies should assess stress in the first sleep laboratory night.

With regard to subjective measures of sleep quality, we have analyzed whether perfectionism is associated with the PSQI. There were no significant associations between PSQI scores and FMPS total and subscale scores. Against that background, we looked into the 7 studies that found an association between perfectionism and subjective sleep parameters. Indeed, most studies did not use the PSQI to assess sleep. Lundh et al. (1994)9 used a clinical interview, Brand et al. (2015)16 and Akram et al. (2015)17 used the Insomnia Severity Index, Jansson-Fröjmark and Linton (2007)15 used the Basic Nordic Sleep Questionnaire and the Uppsala Sleep Inventory, and Azevedo et al. (2010)14 and Akram et al. (2017)19 used screening questions to assess sleep. Only Vincent and Walker (2000)10 used the PSQI to assess sleep. They used 2 multi-dimensional perfectionism scales, namely the MPS18 and the FMPS. They found no association between perfectionism and SOL, TST and sleep quality measured by the PSQI for the MPS.18 Using the FMPS, only 1 out of 5 subscales was associated with SOL, but not with TST and sleep quality. Moreover, this association was not supported by sleep diary data. To summarize, a potential explanation might run along the following lines: there is evidence that suggests an association between perfectionism and poor sleep measured by subjective sleep parameters; however, the PSQI may not be the most suitable measure to investigate that association.

In line with some of the results reported in previous investigations,9,10,15 CM and PS were the perfectionism subscales that were primarily related to poor sleep. As outlined in the Introduction, individuals who are more concerned about making mistakes and who have higher personal standards may be more prone to excessively worry about the effects of transient sleep loss on daytime performance and they may anticipate stronger effects. Both are dysfunctional beliefs commonly accepted to contribute to poor sleep.39 Moreover, individuals with high personal standards may experience sleep onset or sleep maintenance difficulties in the first sleep laboratory night as a performance failure. Consequently, they may increase sleep effort which also contributes to poor sleep.3,8

In the current study, significant associations between perfectionism and sleep were only found for measures of sleep continuity but not for measures of sleep architecture. This fits well with previous findings showing that acute psychological stress is primarily related to sleep continuity disturbances in patients with insomnia,40 whereas sleep architecture changes are rather common in the context of chronic psychiatric conditions.36

Clinical Implications

As we have suggested previously,13 cognitive behavioral treatment programs for perfectionism, which have been developed in the context of eating disorders,41 may be investigated in terms of their effects on sleep and associated negative sequelae of sleep disorders (eg, deficits in overnight memory consolidation).42,43 Moreover, in light of the current findings and given that perfectionism is a transdiagnostic feature of many psychiatric disorders,2 it may also be a factor contributing to the increased risk of developing psychiatric disorders in those with insomnia.4446 In addition, perfectionism has been linked to physiological arousal47 and may also play a role in the association of sleep disorders with cardiometabolic diseases.48,49

Limitations

Five limitations of the current study should be acknowledged. First, a number of statistical tests were conducted without Bonferroni correction. However, the alpha level was set at a conservative P < .01 and the observed number of statistically significant findings clearly exceeded the number that would have been expected by chance (10 findings versus 1 finding in 108 statistical tests). Second, we did not control for psychiatric diagnoses of the patients as a potential confounder in our analyses. However, this approach was chosen on purpose following the RDoC framework of the National Institute of Mental Health. Third, it has to be noted that this study did not include a control group. Thus, we could not investigate the full range from normal to abnormal with respect to the association between perfectionism and objectively determined sleep. Fourth, we only used the FMPS. A more complete picture of the association between perfectionism and PSG measures could be achieved by using both the FMPS and the MPS.18 The MPS is not available in a validated German version. Finally, because this was a retrospective exploratory study, findings should be tested in confirmatory studies.

CONCLUSIONS

In summary, the results of the current study support the hypothesis that perfectionism mediates the development of PSG-determined poor sleep in response to acute stressors. Future studies should further elucidate the role of perfectionism in the transition from good sleep to acute sleep disturbances as well as in the transition from acute to chronic sleep disturbances employing longitudinal designs. Furthermore, the role of perfectionism in the development of sleep disturbance needs to be validated in more ecological settings and with more mundane stressors.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. This was not an industry-supported study. Christoph Nissen has received speaker honoraria from Servier. Anna F. Johann, Elisabeth Hertenstein, Simon D. Kyle, Chiara Baglioni, Bernd Feige, Dieter Riemann, and Kai Spiegelhalder declare no conflicts of interest.

ABBREVIATIONS

AI

arousal index

AHI

apnea-hypopnea index

BDI

Beck Depression Inventory

CM

concern over mistakes (FMPS subscale)

DA

doubts about action (FMPS subscale)

FMPS

Frost Multidimensional Perfectionism Scale

MPS

Hewitt and Flett Multidimensional Perfectionism Scale

NOA

number of awakenings

O

organization (FMPS subscale)

OOP

other-oriented perfectionism (MPS subscale)

PC

parental criticism (FMPS subscale)

PE

parental expectation (FMPS subscale)

PS

personal standards (FMPS subscale)

PSG

polysomnography

PSQI

Pittsburgh Sleep Quality Index

RDoC

Research Domain Criteria

REM

rapid eye movement

SOL

sleep onset latency

SOP

self-oriented perfectionism (MPS subscale)

SPP

socially-prescribed perfectionism (MPS subscale)

SPT

sleep period time

SWS

slow wave sleep

TST

total sleep time

WASO

wake after sleep onset

ACKNOWLEDGMENTS

Author contributions: AFJ: study design, data analysis, interpretation of results, preparation of the manuscript; EH: interpretation of results, preparation of the manuscript; SDK: interpretation of results, preparation of the manuscript; CB: interpretation of results, preparation of the manuscript; BF: data collection, data analysis; CN: interpretation of results, preparation of the manuscript; DR: interpretation of results, preparation of the manuscript; KS: study design, data analysis, interpretation of results, preparation of the manuscript

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