Browse
Recent Submissions
Item Current PTSD symptomatology distorts memory for past symptoms(Elsevier, 2019-02-20) Nahleen, Sasha; Nixon, Reginald David; Takarangi, Melanie K TClinicians often rely on clients’ retrospective reports of past symptoms to diagnose and treat Posttraumatic Stress Disorder (PTSD). However, there is limited research investigating memory for past PTSD symptoms. We asked sexual assault survivors to report their PTSD symptoms and then recall them 6 months later. Overall, symptom recall was consistent with initial reports. However, after dividing participants into PTSD-positive and negative groups, we found that people who were PTSD-negative at follow-up underestimated past PTSD symptom severity while people who were PTSD-positive overestimated past symptoms. For example, 2.8% of PTSD-negative participants versus 15.9% of PTSD-positive participants recalled experiencing 20+ more points on the PCL-5 at follow-up than at initial assessment. Further, people who adjusted over time greatly underestimated past symptoms unlike those who remained PTSD-positive. Our findings have important theoretical and clinical implications because they show that current symptom severity may influence the memory reconstruction of prior levels of adjustment.Item A randomised controlled trial of guided internet-based cognitive behavioural therapy for perfectionism: Effects on psychopathology and transdiagnostic processes(Elsevier, 2019-03-30) Kothari, Radha; Barker, Chris; Pistrang, Nancy; Rozental, Alexander; Egan, Sarah J; Wade, Tracey Diane; Allcott-Watson, Hannah; Andersson, Gerhard; Shafran, RozBackground and objectives Perfectionism is a transdiagnostic process that has been associated with a range of psychopathology and also with other transdiagnostic processes. We have previously shown that guided internet-based cognitive behavioural therapy (ICBT) can reduce symptoms of dysfunctional perfectionism, however, no impact was observed on symptoms of depression and anxiety. Here we explore the impact of guided ICBT for perfectionism on symptoms of other associated psychopathology, specifically obsessive-compulsive disorder (OCD) and eating disorders, and also on other associated transdiagnostic processes (self-esteem, intolerance of uncertainty, and self-compassion). Methods Participants who presented with clinical levels of perfectionism were randomised to an experimental group that received the intervention (n = 62), or a wait list control group (n = 58). Questionnaires assessing symptoms of OCD, eating disorders, self-esteem, intolerance of uncertainty, and fear of self-compassion were completed pre-intervention, post-intervention (12 weeks), and at follow-up (24 weeks). Between group effect sizes are reported. Results The intervention led to significant decreases in symptoms of OCD (d = −0.9; CI: -1.4, −0.4) and eating disorders (d = −0.6; CI: -1.0, −0.1), and had an impact on other transdiagnostic processes resulting in increased self-esteem (d = 0.7; CI: 0.2, 1.2), decreases in intolerance of uncertainty (d = −0.9; CI: -1.4, −0.4), and fear of self-compassion (d = −0.8; CI: -1.3, −0.3). At follow-up changes were maintained in symptoms of OCD (d = −1.3; CI: -1.8, −0.8), disordered eating (d = −0.7; CI: -1.2, −0.2), intolerance of uncertainty (d = −0.8; CI: -1.2, −0.3), and fear of self-compassion (d = −1.0; CI: -1.5, −0.5). Conclusions Guided ICBT for perfectionism improves associated psychopathology and transdiagnostic processes. ClinicalTrials.gov registration no. NCT02756871.Item Predictors of outcome in cognitive behavioural therapy for eating disorders: An exploratory study(Elsevier, 2019-02-15) Pellizzer, Mia L; Waller, Glenn; Wade, Tracey DianeObjective Early decrease in symptoms is a consistent predictor of good treatment outcome across all eating disorders. The current study explored the predictive value of novel early change variables in a transdiagnostic, non-underweight sample receiving 10-session cognitive behavioural therapy. Method Participants who reported bingeing and/or purging in the week preceding baseline assessment (N = 62) were included in analyses. Early change variables were calculated for novel (body image flexibility, body image avoidance, body checking, and fear of compassion) and established predictors (behavioural symptoms and therapeutic alliance). Outcomes were global eating disorder psychopathology and clinical impairment at posttreatment and three-month follow-up. Intent-to-treat analyses were conducted using linear regression, adjusting for baseline values of the relevant outcome and early change in behavioural symptoms. Results Early improvement in body image flexibility was the most consistent predictor of good outcome. Early change in body image avoidance and the fear of expressing and receiving compassion to/from others were significant predictors in some analyses. Discussion Novel early change variables were significant predictors of eating disorder outcomes in this exploratory study. Model testing is required to understand the exact mechanisms by which these variables impact on outcomes, and whether there is potential benefit of modifying existing protocols.Item Readiness to change and commitment as predictors of therapy compliance in adolescents with Delayed Sleep-Wake Phase Disorder(Elsevier, 2019-03) Micic, Gorica; Richardson, Cele; Cain, Neralie Louisa; Reynolds, Chelsea M; Bartel, Kate; Maddock, Ben; Gradisar, Michael ShaneObjectives Recent evidence indicates that adolescents' motivation to change sleep-wake patterns is low, despite significant impact of adolescent sleep problems on many areas of daytime functioning. The aim of the present study is to evaluate components of adolescents' motivation, and subsequent changes in behaviour. Methods Fifty-six adolescents, aged 13–23 (M = 15.8 ± 2.3 y; 38% m) diagnosed with Delayed Sleep-Wake Phase Disorder (DSWPD) underwent three therapy sessions involving bright light therapy to phase advance sleep patterns. Adolescents were instructed to advance wake-up times by 30-min daily. Motivation ratings of desire, ability, reason, need and commitment to change sleep patterns were taken at baseline. Sleep diaries were taken at the end of treatment session 1, with sequentially earlier wake-up times in 30-min intervals indicating compliance. Results At the outset of therapy, adolescents indicated strong desire, reasons and need, yet moderate ability and commitment to advance their sleep-wake patterns. Following therapy, sleep-onset times were significantly advanced, total sleep time increased and sleep latency decreased (all p < 0.05). Therapy lasted 6–27 days (M = 13.9 ± 4.5) and clients complied for approximately half the time (between 3 and 15 days; M = 8.8 ± 2.7). Commitment was associated with ability (r = 0.66, p < 0.001) but not desire, reason or need (all p > 0.05). Adolescents' desire to change (r = 0.30, p = 0.03) and commitment (r = 0.30, p = 0.03) were positively correlated with behaviour change, but their need, ability and reasons were not. A mediation analysis showed that ability and desire were important in predicting behaviour change, by total effects through commitment (ie, indirectly and directly). Conclusion Our findings suggest that the total effects of ability (ie, confidence) and desire to change are the best predictors of behavioural changes, thus clinicians should focus on these components of the readiness to change model when undertaking treatments with sleep-disordered adolescents.Item Media multitasking, impulsivity and dual task ability(Elsevier, 2018-11-09) Shin, Myoungju; Webb, Andrew; Kemps, Eva BerthaWith recent developments in technology, media multitasking is an ever-increasing phenomenon. Although most studies associate media multitasking with high impulsivity and poorer cognitive performance, findings in the literature have been mixed, with some studies suggesting the opposite. The aim of this study was to investigate the relationship between media multitasking and the capacity to exert inhibitory control, as well as the ability to multitask in a multisensory setting. Results showed that media multitasking was associated with high attentional impulsivity and lower initiatory self-control, but not with inhibitory self-control. Relatedly, heavy media multitaskers were slower and showed more omission errors on the go/no-go task, suggestive of inattention; however, they were better at inhibiting already initiated motoric responses in the stop signal task. Media multitasking was further associated with faster responses when a letter and a tone task were temporally separated, but not when they were presented closer in time. Taken together, the results suggest a more nuanced relationship between media multitasking, personality and cognitive ability than has previously been thought. This has important real life implications for media multitasking, showing both advantages and disadvantages.Item Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD(Elsevier, 2018-04-18) Nixon, Reginald David; Bralo, DanielleWe investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12–16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 – 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.Item Investigation of sex differences in delusion-associated cognitive biases(Elsevier, 2018-12-24) de Vos, Chloe; Leanza, Letizia; Mackintosh, Amatya; Ludtke, Thies; Balzan, Ryan P; Moritz, Steffen; Andreou, ChristinaIn the past few decades, sex differences have been identified in a number of clinical, cognitive and functional outcomes in patients with schizophrenia spectrum disorders. However, to date, sex differences in higher-order cognitive biases have not been systematically studied. The present study aimed to examine sex differences in jumping-to-conclusions and evidence integration impairment based on data collected in two previous studies in patients with schizophrenia spectrum disorders and healthy controls. For this purpose, data from n = 58 patients and n = 60 healthy controls on the Fish Task (as a measure of jumping to conclusions) and bias against disconfirmatory evidence (BADE; as a measure of evidence integration) task were analyzed. Results indicated a lack of sex differences in jumping-to-conclusions and evidence integration impairment both in patients with schizophrenia spectrum disorders and healthy controls. Although the present study was adequately powered to detect sex differences of a low medium effect size, larger studies are warranted to exclude differences of a smaller magnitude between men and women regarding delusion-associated cognitive biases.Item Impaired mismatch negativity to frequency deviants in individuals at ultra-high risk for psychosis, and preliminary evidence for further impairment with transition to psychosis(Elsevier, 2017-11-11) Lavoie, Suzie; Jack, Bradley N; Griffiths, Oren; Ando, Ayaka; Amminger, Paul; Couroupis, Anthony; Jago, Aidan; Markulev, Connie; McGorry, Patrick; Nelson, Barnaby; Polari, Andrea; Yuen, Hok Pan; Whitford, Thomas JBackground There is evidence to suggest that people with established psychotic disorders show impairments in the mismatch negativity induced by a frequency-deviant sound (fMMN), and that these impairments worsen with the deterioration of psychotic symptoms. This study aimed to test whether individuals at ultra-high risk (UHR) for psychosis show pre-morbid impairments in fMMN, and if so, whether fMMN continues to deteriorate with transition to psychosis. Method fMMN was recorded in a cohort of UHR individuals (n = 42) and compared to healthy controls (n = 29). Of the 27 UHR participants who returned for a second EEG session, six participants had transitioned to psychosis by 12-month follow-up (UHR-T) and were compared to the 21 participants who did not transition (UHR-NT). Results fMMN amplitude was significantly reduced, relative to healthy controls, in the UHR cohort. Furthermore, UHR-T individuals showed a significant decrease in fMMN amplitude over the period from baseline to post-transition; this reduction was not observed in UHR-NT. Conclusions These results suggest that fMMN is abnormal in UHR individuals, as has repeatedly been found previously in people with established psychotic disorders. The finding that fMMN impairment worsens with transition to psychosis is consistent with the staging model of psychosis; however, caution must be taken in interpreting these findings, given the extremely small sample size of the UHR-T group.Item Neurophysiological evidence of efference copies to inner speech(eLife Sciences, 2017-12-04) Whitford, Thomas J; Jack, Bradley N; Pearson, Daniel; Griffiths, Oren; Luque, David; Harris, Anthony; Spencer, Kevin M; Le Pelley, Mike EEfference copies refer to internal duplicates of movement-producing neural signals. Their primary function is to predict, and often suppress, the sensory consequences of willed movements. Efference copies have been almost exclusively investigated in the context of overt movements. The current electrophysiological study employed a novel design to show that inner speech – the silent production of words in one’s mind – is also associated with an efference copy. Participants produced an inner phoneme at a precisely specified time, at which an audible phoneme was concurrently presented. The production of the inner phoneme resulted in electrophysiological suppression, but only if the content of the inner phoneme matched the content of the audible phoneme. These results demonstrate that inner speech – a purely mental action – is associated with an efference copy with detailed auditory properties. These findings suggest that inner speech may ultimately reflect a special type of overt speech.Item Cross‐modal symbolic processing can elicit either an N2 or a protracted N2/N400 response(Wiley, 2016-03-26) Griffiths, Oren; Le Pelley, Mike E; Jack, Bradley N; Luque, David; Whitford, Thomas JA cross‐modal symbolic paradigm was used to elicit EEG activity related to semantic incongruence. Twenty‐five undergraduate students viewed pairings of visual lexical cues (e.g., DOG) with congruent (50% of trials) or incongruent (50%) auditory nonlexical stimuli (animal vocalizations; e.g., sound of a dog woofing or a cat meowing). In one condition, many different pairs of congruent/incongruent stimuli were shown, whereas in a second condition only two pairs of stimuli were repeatedly shown. A typical N400‐like pattern of incongruence‐related activity (including activity in the N2 time window) was evident in the condition using many stimuli, whereas the incongruence‐related activity in the two‐stimuli condition was confined to differential N2‐like activity. A supplementary analysis excluded stimulus characteristics as the source of this differential activity between conditions. We found that a single individual performing a fixed task can demonstrate either a protracted N400‐like pattern of activity or a more temporally focused N2‐like pattern of activity in response to the same stimulus, which suggests that the N2 may be a precursor to the protracted N400 response.Item Effects of Outcome Predictability on Human Learning(Frontiers, 2017-04-05) Griffiths, Oren; Thorwart, AnnaCue-outcome learning is a cornerstone of intelligent action. Learning that a stimulus (the cue) can be used to predict a second event (the outcome) affords adaptive decision making. If an animal can use environmental cues to predict the presence of food (an appetitive outcome) or a predator (an aversive outcome), then it can potentially act to maximize the likelihood of the former and minimize the latter. This capacity also allows for the development of complex associative webs of knowledge. For example, it allows humans to associate a visual icon with an auditory phoneme (and thus read), or to connect new information with existing knowledge. These are fundamental capacities of intelligent agents. The capacity to learn cue-outcome mental associations is crucial. However, forming mental associations may be cognitively costly, so it is important to be selective about which associations are learned, and thus to prioritize which stimuli gain access to the learning process. One way to achieve this efficiency is to leverage prior knowledge to focus primarily upon those events (cues and outcomes) that are most likely to be meaningfully associated (e.g., Mackintosh, 1975; Le Pelley, 2004, 2010; Mitchell and Le Pelley, 2010; Esber and Haselgrove, 2011). There are three logically distinguishable components of a person's prior associative knowledge that could be used to guide the selectivity of subsequent cue-outcome learning. First, there is the knowledge about specific cue-outcome associations that have already been learned (represented as associative strength, or V). Second, there is knowledge about the cueing stimuli themselves (represented as cue associability, or α). Finally, people could use prior knowledge about the outcome stimuli. The influence of the first two forms of associative knowledge in guiding subsequent learning has been extensively investigated. However, the influence of the third form (i.e., information about outcome stimuli) has been largely overlooked in the learning literature. We argue herein that this oversight of the potential role of outcome predictability in shaping learning offers fertile new ground for the science of learning. Before making this case, we first briefly note how associative strength and cue associability have been shown to guide learning.Item Outcome predictability biases cued search(American Psychological Association, 2018) Griffiths, Oren; Erlinger, May; Beesley, Tom; Le Pelley, Mike EWithin the domain of associative learning, there is substantial evidence that people (and other animals) select among environmental cues on the basis of their reinforcement history. Specifically, people preferentially attend to, and learn about, cueing stimuli that have previously predicted events of consequence (a predictiveness bias). By contrast, relatively little is known about whether people prioritize some (to-be-predicted) outcome events over others on the basis of their past experience with those outcomes (a predictability bias). The present experiments assessed whether the prior predictability of a stimulus results in a learning bias in a contingency learning task, as such effects are not anticipated by formal models of associative learning. Previously unpredictable stimuli were less readily learned about than previously predictable stimuli. This pattern is unlikely to reflect the use of strategic search processes or blocking of learning by the context. Instead we argue that our findings are most consistent with the operation of a biased learning mechanism. (PsycINFO Database Record (c) 2018 APA, all rights reserved)Item Desirable leadership attributes are preferentially associated with women: A quantitative study of gender and leadership roles in the Australian workforce(Sage Journals, 2018-09-19) Griffiths, Oren; Roberts, Lynette; Price, JoshWomen are under-represented globally in leadership roles. One theory suggests that this imbalance is due to a mismatch between the qualities women are perceived to have, and the qualities desired in business leaders. Yet, little is known about whether this incongruence remains prevalent in the Australian business environment. To this end, this study investigated gender stereotypes and desired leadership attributes in 1885 participants from 25 companies using a priopietary measure developed by a local diversity consulting company. Participants ranked the attributes that they believed were most important for leadership and rated the degree to which each attribute was associated with men or women. Men were more strongly associated with some agentic traits, whereas women were more strongly associated with a diverse range of both agentic and communal traits. Desired leadership qualities included both agentic and communal qualities, but generally favoured traits associated with women.Item Compound Stimulus Presentation Does Not Deepen Extinction in Human Causal Learning(Frontiers, 2017-02-09) Griffiths, Oren; Holmes, Nathan; Westbrook, R FredModels of associative learning have proposed that cue-outcome learning critically depends on the degree of prediction error encountered during training. Two experiments examined the role of error-driven extinction learning in a human causal learning task. Target cues underwent extinction in the presence of additional cues, which differed in the degree to which they predicted the outcome, thereby manipulating outcome expectancy and, in the absence of any change in reinforcement, prediction error. These prediction error manipulations have each been shown to modulate extinction learning in aversive conditioning studies. While both manipulations resulted in increased prediction error during training, neither enhanced extinction in the present human learning task (one manipulation resulted in less extinction at test). The results are discussed with reference to the types of associations that are regulated by prediction error, the types of error terms involved in their regulation, and how these interact with parameters involved in training.Item Do meta-cognitive beliefs affect meta-awareness of intrusive thoughts about trauma?(Elsevier, 2016-10-24) Takarangi, Melanie K T; Nayda, Diane; Strange, Deryn; Nixon, Reginald DavidBackground and Objectives People exposed to trauma often experience intrusive thoughts and memories about that event. Research examining people's responses to trauma assumes that people can accurately notice the occurrence of symptoms. However, we know from the broader cognitive literature on ‘mind-wandering’ that people are not always aware of their current focus of attention. That lack of awareness has implications for our theoretical and practical understanding of how trauma survivors recover from their experience. In the current study we investigated whether people's meta-cognitive beliefs about controlling trauma-related intrusions influenced the occurrence and meta-awareness of those intrusions. Methods We recruited participants who scored high (strong beliefs) or low (weak beliefs) on beliefs regarding the importance of controlling intrusive thoughts. Participants viewed a trauma film then—during a subsequent reading task—reported any film-related intrusions they noticed. We also intermittently asked half the participants to report what they were thinking at that particular moment, to “catch” intrusions without meta-awareness. Results People are not always aware of their trauma intrusions, and importantly, people with strong beliefs are more likely to notice trauma related intrusions both with and without meta-awareness than people with weak beliefs. Limitations We used an analogue trauma, and focused on a particular metacognitive belief, both of which somewhat limit generalizability. We also cannot definitively rule out demand effects. Conclusions Our data add to existing research showing people may lack meta-awareness of trauma-related thoughts, and suggest that survivors with particular metacognitive characteristics may be more vulnerable to ‘mind-wandering’ about trauma without awareness.Item Meta-awareness and the involuntary memory spectrum: Reply to Meyer, Otgaar, and Smeets (2015)(Elsevier, 2015-03-30) Takarangi, Melanie K T; Lindsay, D. Stephen; Strange, DerynIn their commentary, Meyer, Otgaar, and Smeets (2015) raise several important issues about the definitions, characteristics and applications of various involuntary cognitive phenomena. Here we respond to the comments of Meyer et al. in ways that we hope will advance understanding of these issues, and inform future research. In particular, we have focused on the characteristics of involuntary phenomena—particularly in relation to meta-awareness—and the clinical relevance of mind-wandering.Item Trauma-related versus positive involuntary thoughts with and without meta-awareness(Elsevier, 2016-10-07) Green, Deanne M; Strange, Deryn; Lindsay, D. Stephen; Takarangi, Melanie K TIn earlier work, we asked subjects to report involuntary thoughts relating to a trauma film and also probed subjects periodically. Subjects often reported involuntary thoughts in response to probes, suggesting they lacked meta-awareness of those thoughts. But it is possible that some or all probe-detected thoughts were continuations of thoughts subjects had spontaneously reported, leading us to overestimate involuntary thoughts lacking meta-awareness. It is also unclear whether failures in meta-awareness occur for other emotional events. We exposed subjects to a negative or positive film. Subsequently, they reported involuntary film-related thoughts and responded to probes that distinguished new from continuing thoughts. Many (54%) but not all probe-caught thoughts were thought continuations. This result supports our earlier finding that people can lack meta-awareness for trauma-related thoughts, but suggests caution in how meta-awareness is assessed. We also found that self-caught negative and positive involuntary thoughts occurred at a similar frequency, with different characteristics.Item Explaining Memory Amplification: Is It All About the Test Format?(Sage Journals, 2017-12-08) Takarangi, Melanie K T; Oulton, Jacinta M; Strange, DerynTrauma-exposed people commonly exhibit a “memory amplification” effect, endorsing exposure to more traumatic events over time. Studies reporting this phenomenon have typically relied on checklists, where participants read event descriptions and indicate (yes/no) their exposure. We examined whether that approach is vulnerable to response biases and memory errors. In two experiments, participants viewed negative photos and completed an Old-New recognition test. In Experiment 1, participants completed either a photo recognition test or description test—composed of written descriptions of negative photos. In Experiment 2, we measured analogue PTSD symptoms and participants completed the description test twice, 24 hr apart. Those in the description test condition performed worse on the memory test and were more biased to endorse negative photos compared with the photo test condition. Furthermore, this bias to endorse negative photos increased over time and was related to analogue PTSD symptoms. Overall, our findings suggest that test format plays a role in memory amplification.Item Self-report may underestimate trauma intrusions(Elsevier, 2014-06-30) Takarangi, Melanie K T; Strange, Deryn; Lindsay, D. StephenResearch examining maladaptive responses to trauma routinely relies on spontaneous self-report to index intrusive thoughts, which assumes people accurately recognize and report their intrusive thoughts. However, “mind-wandering” research reveals people are not always meta-aware of their thought content: they often fail to notice shifts in their attention. In two experiments, we exposed subjects to trauma films, then instructed them to report intrusive thoughts during an unrelated reading task. Intermittently, we asked whether they were thinking about the trauma. As expected, subjects often spontaneously reported intrusive thoughts. However, they were also “caught” engaging in unreported trauma-oriented thoughts. The presence and frequency of intermittent probes did not influence self-caught intrusions. Both self-caught and probe-caught intrusions were related to an existing tendency toward intrusive cognition, film-related distress, and thought suppression attempts. Our data suggest people may lack meta-awareness of trauma-related thoughts, which has implications for theory, research and treatment relating to trauma-related psychopathology.Item Insomnia and mortality: A meta-analysis(Elsevier, 2018-11-11) Lovato, Nicole; Lack, Leon ColburnThe purpose of this review was to evaluate the strength of evidence for a relationship between risk of mortality and frequent and ongoing insomnia using a meta-analytic strategy. Seventeen studies, including a total of 36,938,981 individuals followed up for a mean of 11.6 y, reporting the investigation of the association between mortality and frequent (≥3 nights/wk), ongoing (≥1 mo) insomnia were identified. There was no difference in the odds of mortality for those individuals with symptoms of insomnia when compared to those without symptoms (OR = 1.06, 95%CI = 0.61–1.84, p = .84). This finding was echoed in the assessment of the rate of mortality in those with and without symptoms of insomnia using the outcomes of multivariate models, with the most complete adjustment for potential confounders, as reported by the individual studies included in this meta-analysis (HR = 1.07, 95%CI = .96–.1.19, p = .22). Additional analyses revealed a tendency for an increased risk of mortality associated with hypnotic use. The current evidence reinforces the use of cognitive therapy, within a CBTi framework, as a frontline non-pharmacological treatment for insomnia to reassure patients their longevity will not be impacted as a consequence of suffering from insomnia.