ANXIETY AND SLEEP IN FIRST YEAR UNDERGRADUATE STUDENTS

GEMMA SHAXTED

PY3P01

BSc PSYCHOLOGY

ANDREW MAYERS

MAY 2008

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ABSTRACT

Students deal with many changes in their first year of university, e.g. moving away

from home, getting a job and trying to balance social activities with a heavy course

load. All of this impacts upon anxiety levels. Dahlin, Joneborg and Runeson (2005)

found first year students were more anxious than third or sixth year students. Anxiety

disrupts sleep and can be serious if it becomes insomnia. Harvey (2000) found

insomniacs have more pre-sleep cognitive activity than good sleepers. This can be

general thoughts to worries and phobias, all of which slow sleep onset rate. Based

upon previous research, this study aimed to see if there was a direct relationship

between anxiety and poor sleep in first year undergraduates using the Generalised

Anxiety Disorder Inventory (GADI) and sleep diary over one week. It was

hypothesized that the more anxious a participant was (high GADI scorer), the poorer

their sleep would be. Poor sleep was explored using three main variables – total

sleep duration, time taken for sleep onset and number of wakings. There was no

significance found for GADI scores and sleep total or sleep onset. There was

significance found for GADI and number of wakings. Anxiety was directly related to

number of wakings but not sleep total or sleep onset which does not support previous

work that showed first year’s are highly stressed (Dahlin, Joneborg and Runeson,

2005) which would subsequently affect their sleep. Further research has been

suggested in order to look more into the pre-sleep cognitive activity of students

(Harvey, 2000), to look into the gender differences reported by Dahlin, Joneborg and

Runeson, (2005) and to look at whether first year undergraduates have comparable

stress levels and sleep disruption to first year postgraduates.

INTRODUCTION

The average person sleeps for 6 ½ to 8 hours per night and Coren (1996) has

estimated that we sleep for 1 ½ hours less than we did 100 years ago as many of us

are in a constant mode of sleep deprivation. Sleep is divided into four stages of slow

wave sleep (or non-REM) sleep and REM (rapid eye movement) sleep which

appears in a cyclic fashion and Dement and Kleitman (1957) found that different

cycles and stages have different brain wave frequencies. When we are awake our

brain waves are fast and desynchronized. As our body relaxes ready to sleep our

body temperature and heart rate decreases, along with muscle tension. This is when

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alpha waves begin to appear.

Sleep stage 1 is called the hypnagogic state, where dreamlike hallucinatory images

resembling vivid photos occur. This is also when a person may get the feeling of

falling and the body can jerk awake suddenly. The alpha waves get slower and

smaller. During stage two, the brainwaves are synchronized, coming in longer and

slower. Bursts of high frequency, called sleep spindles or k-complexes, occur which

decrease the brains response to external stimuli to keep the person asleep. They

occur once every minute and are triggered by noise. Stage 3 is when slow wave

sleep (SWS) occurs. There are large and slow delta waves and sleep spindles are

less common. Heart rate, breathing rate and metabolic rate continue to fall. Stage 4

SWS is where only delta waves occur and sleep spindles are eliminated. This is

when metabolic rate is at its lowest. After all stages of SWS, REM sleep occurs. The

brain waves are similar to when we are awake (fast and desynchronized) and this is

when dreaming occurs. In this stage, a person is not easily awoken and heart rate

and breathing rate increase. Skeletal muscles are completely relaxed. There are 4 to

6 cycles per night with the REM sleep period getting longer throughout the night.

These sleep cycles can be affected by numerous factors including jet lag, shift work

and disorders such as insomnia, sleep apnoea and depression. Jet lag is more

severe when travelling west to East due to phase advance where a person loses

hours. When travelling East to West, phase delay occurs as a person is ahead of

local time. Sleeping patterns adjust after a few days; however temperature and

hormone cycles take longer. When a person is suffering jetlag, their physical and

mental performance can be affected. Czeisler et al (1982) showed that shift work not

only disrupts sleeping but also eating and social life zeitgeibers. The problem is not

the shift work; it is the changing shifts that constantly reset the biological clock

resulting in fatigue, serious sleep disorders, and increased risk of heart attack, ulcers

and a higher accident rate. When they introduced a phase delay system in a Utah

chemical plant, it was found that output increased.

Anxiety and stress are common sleep disrupters. Sleep can be disrupted on a variety

of levels by anxiety from mild to extreme depending on the fixation and extremity of

the stressor, for instance a trip away from home, a new job etc, but it can be

disrupted more severely by anxiety disorders such as phobias, obsessive compulsive

disorder and panic disorder

(http://sleepdisorders.about.com/cs/sleepdestroyers/a/anxiety.htm, 2006, as

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accessed on 30th April 2008)

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Anxiety in students can be induced by numerous factors, Andrews and Wilding

(2004) found, such as exam or coursework pressure, homesickness, work and future

career prospects, travel concerns and fear of not fitting in or being able to cope with

the workload, etc.

Andrews and Wilding (2004) found that the most anxiety-inducing factors within

students were financial worries and other outside pressures. In their study they

looked into whether student anxiety increased after beginning their university

courses. The effect of adverse life events and how these factors affected their exam

performance in 351 undergraduates using the Hospital Anxiety and Depression Scale

and a list of threatening experiences. They found that 20% of symptom free students

had become significantly anxious halfway through their course. Of these 36% had

recovered and relationship difficulties independently predicted anxiety. All affected

predicted a decrease in exam performance. This was the first study to highlight the

fact that British students’ anxiety levels can affect academic performance.

Dahlin, Joneborg and Runeson (2005) looked into stress and depression in medical

students using the Higher Education Stress Inventory and Meehan’s suicidal ideation

questions in first, third and sixth year students. They found that first year students

gave higher ratings to workload and feedback stressors, showing that they felt more

under pressure and were dealing with it less effectively than the third and sixth year

students who gave lower ratings. Third year students rated worries are about the

future highest and sixth year students rated highest the third year worries as well as

non-supportive climate. All rated the lack of feedback. They concluded that first year

students had the highest degree of pressure and subsequent anxiety depression than

any of the other two years looked at. There was also to be found a gender difference

with women reporting higher levels of stress than men.

Insomnia is one of the most prevalent psychological disorders which causes severe

distress in the patient and can affect many aspects of their lives including social life,

personal relationships, physical health and work life. It affects 33% of the population

in the United States (National Sleep Foundation, 1991) and Ancoli-Israel and Roth

(1999) found that it is especially prevalent in those suffering stressful life events. NHS

Direct (http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=216&sectionId=1,

accessed April 30th 2008) defines insomnia as the disturbance of a normal sleep

pattern and can last for days, months and even years.

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Symptoms include difficulty getting to sleep, waking during the night, not feeling

refreshed by sleep and inability to concentrate during the day and have physical,

psychological, physiological and pharmacological causes. Harvey (2002) modelled

the maintenance of insomnia. Insomniacs tended to be more anxious about getting

sleep and the consequences for the next day if none or very little is experienced. This

negative cognition triggers autonomic arousal and emotional distress.

Harvey (2002) proposed that this state of intense anxiety triggers selective attention

towards the internal and external sleep treat cues and continues to monitor them.

This anxious state and attention paid to internal and external cues makes the

individual overestimate the sleep deficit and its subsequent effects on daytime

performance. As time goes by, these anxiety levels rise further and disrupt sleep in a

more drastic way.

Harvey (2000) looked at pre-sleep cognitive activity in insomniacs and good sleepers.

Pre-sleep Cognitive activity such as being focused on worries, problems and noises

within the sleeping environment or being less focussed on nothing in particular keep

participants awake and therefore sleep onset if disrupted. These factors are more

pronounced in insomniacs and is a key attribute in their disrupted or lack of sleep.

Insomniacs tend to focus on not being able to sleep or getting very little or about the

day’s events. For insomniacs, this pre-sleep cognitive activity tends to be less

intentional, more occupying and lasts much longer than in good sleepers and

therefore causes more problems for sleep onset in insomniacs than in good sleepers.

Pre-sleep imagery tended to be stronger, more distressing and associated with

strong physical sensations in insomniacs than in good sleepers.

The previous research has shown that a variety of things can affect sleep, from shift

work (Czeisler et al, 1982) to depression. Students have been found to be some of

the most under pressure and anxious resulting from a variety of factors such as

finances, (Andrews and Wilding, 2004). Dahlin, Joneborg and Runeson (2005) found

that first year students dealt more poorly and felt more anxious and under pressure

than third or sixth year students. Anxiety is a known sleep disrupter and in extreme

cases can lead to insomnia (Harvey, 2002). Drawing on from previous research, it

can be seen that a study looking into a possible direct link between sleep disruption

and the level of anxiety experienced by students has not been done specifically.

Since students appear to be subject to greater stress, this may lead to greater

anxiety, which may have a negative impact on sleep.

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This study attempted look at how anxiety affects the sleep of first year

undergraduates over a week using questionnaires. First year students tend to have

higher anxiety levels due to the changes and pressures that they have to deal with

(Dahlin, Joneborg and Runeson, 2005). Sleep is quite easily affected by anxiety, it is

hypothesized that students with high anxiety levels, as measured by the GADI, would

sleep less in total, wake more during the night and take longer to get to sleep, as

there maybe a direct relationship between anxiety and poor sleep.

METHOD

Design

This study used a between groups design. It utilised the Generalised Anxiety

Disorder Inventory (GADI – see Appendix 3) (2000, Psychopharmacology Unit,

University of Bristol) and a sleep diary – see Appendix 4 (Southampton & South West

Hants LREC Ethics submission no. 234/03/w). Both were questionnaires. There were

3 main independent variables explored using the sleep diary for this study – total

sleep time in minutes, total time taken for sleep to onset in minutes and number of

wakings per night. The sleep diary also recorded time when sleep was first

attempted, how long the wakings during the night lasted in total, what time the

participant awoke and what time they got up. At the bottom was a subjective rating

scale that had 5 points scored from 0 (very good etc) to 4 (very poor) for sleep

quality, sleep ease, refreshment after sleep and whether it was enough sleep. The

dependent variable was the anxiety level as measured by the GADI. The GADI

contains 22 questions about feelings, e.g. I find it difficult to relax. All questions must

be answered with a tick in the option box that the participant feels most applies to

themselves. The options are not at all, a little, somewhat, very much and extremely

and are scored in that order from 0 to 4. A high total score indicates a high anxiety

level etc.

Participants

21 first year undergraduate students were used. 6 were male and 15 were female.

Students were recruited from within the university via solicitations before or after

lectures, word-of-mouth between students, and in the latter stages flyers were used

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to increase recruitment in last few weeks, (see appendix 5). They were left in random

places around campus e.g. cafeteria, library, law atrium and student pin-board.

Materials

Participants were each given a handout containing 2 copies of the GADI, 7 copies of

the sleep diary and a consent form (see appendix). A pen or pencil was used to

complete the questionnaires. SPSS was used to analyse the data.

Procedure

Participants were initially briefed about the nature of the experiment (see appendix)

and asked to sign a consent form. Each was given the questionnaire handout (see

appendix) and was told to complete the initial GADI prior to completing the first sleep

diary. They were to complete one sleep diary as soon after waking from the previous

nights sleep as possible for 7 days. After completing all 7 sleep diaries, Participants

were told to complete the final GADI and return for debriefing. Participants were

debriefed by informing them again that the study was looking into the link between

sleep and anxiety in first year undergraduates. They were given an email address if

they did decide to withdraw from the study after having completed the forms.

Participants were told how the research was going and what was beginning to

emerge at the time of their completion, if anything, and how it fit with the previous

research. They were also advised that if they had been affected by anything within

the study (e.g. realising how stressed they were or how little they were sleeping) or

generally that there were counsellors within the university who could help them deal

with their problems. Participants were thanked again for taking part.

RESULTS

The initial and final GADI scores were combined and the average taken for each

participant. Averages were calculated for sleep onset, total sleep time and number of

wakings for each participant. The median was calculated for sleep onset time in

minutes (15 minutes), total sleep time in minutes (480 minutes) and number of

wakings (0 wakings). Each participant’s average score for each variable was

compared to the median and given a score of 1 for good and 2 for bad, see Appendix

7.

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The data was analysed using parametric (t-test and ANOVA) and nonparametric

(Mann Whitney U) tests due to the normality of the data.

The data was close enough to the normal to use a parametric test but a

nonparametric test was used in order to clarify the reliability. For all SPSS output, see

appendix 6.

N Mean Rank Sum of Ranks

GADI v Total Good 8 8.62 69.00

Poor 13 12.46 162.00

GADI v Onset Good 6 7.83 47.00

Poor 15 12.27 184.00

GADI v No. Of Wakings Good 10 6.80 68.00

Poor 11 14.82 163.00

Table 1. Mann Whitney U Test Mean Ranks and Sum of Ranks.

Mann Whitney U test was run due to the normality of the data and Table 1. Shows

the mean ranks and sums of ranks used for this nonparametric test. There was no

significant difference in GADI scores between the two sleep total groups, Mann

Whitney U (n1=8, n2=13) = 33, p>0.05, (two-tailed). There was no significant

difference in GADI scores between the two sleep onset groups, Mann Whitney U

(n1=6, n2=15) = 26, p>0.05, (two-tailed). There was a significant difference in GADI

scores between the two number of wakings groups, Mann Whitney U (n1=10, n2=11)

= 13, p<0.01, (two-tailed).

N Mean Std. Deviation

GADI v Total Good 8 12.44 6.13

Poor 13 24.23 21.99

GADI v Onset Good 6 11.75 6.56

Poor 15 22.93 20.71

GADI v No. Of Wakings Good 10 9.85 6.75

Poor 11 28.73 21.17

Table 2. Mean and Standard Deviations for T-Test

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Table 2. shows the means and standard deviations that were used to run the t-test.

There was no significant difference in GADI scores between the two sleep total

groups, t (19) = -1.47, p>0.05, (two-tailed). There was no significant difference in

GADI scores between the two sleep onset groups, t (19) = -1.28, p>0.05, (two-tailed).

There was a significant difference in GADI scores between the two number of

wakings groups, t (19) = -2.69, p<0.05 (two-tailed).

Two-way ANOVA was used to look for significance between the three independent

variables and the dependant variable, see Table 3.

Source Sums of Sqs df Mean Square F

Sleep Total 95.68 1 95.68 0.34

Waking No. 991.14 1 991.14 3.54

ST * WN 58.44 1 58.44 0.21

Error 4759.21 17 279.95

Sleep Total 170.11 1 170.11 0.48

Sleep Onset 87.84 1 87.84 0.25

ST * SO 1.55 1 1.55 0.00

Error 5975.42 17 351.49

Sleep Onset 201.06 1 201.06 0.73

Waking No. 978.24 1 978.24 3.56

SO * WN 47.11 1 47.11 0.17

Error 4670.52 17 274.74

Table 3. ANOVA used to detect significance between sleep total, sleep onset and

waking number against GADI scores.

There was no significant variation in GADI scores across the two sleep total groups,

(F1, 17 = 0.34, p>0.05, MSE = 279.95). The main effect of the number of wakings

was not significant, (F1, 17 = 3.540, p>0.05, MSE = 279.95). There was no significant

interaction between sleep total and number of wakings (F1, 17 = 0.21, p>0.05, MSE

= 279.95).

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There was no significant variation in GADI scores across the two sleep total groups,

(F1, 17 = 0.48, p>0.05, MSE = 351.49). The main effect of sleep onset was not

significant, (F1, 17 = 0.25, p>0.05, MSE = 351.49).

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There was no significant interaction between sleep total and sleep onset (F1, 17 =

0.00, p>0.05, MSE = 351.49).

There was no significant variation in GADI scores across the two sleep onset groups,

(F1, 17 = 0.73, p>0.05, MSE = 274.74). The main effect of number of wakings was

not significant, (F1, 17 = 3.56, p>0.05, MSE = 274.74). There was no significant

interaction between sleep onset and number of wakings (F1, 17 = 0.17, p>0.05, MSE

= 274.74).

DISCUSSION

There was found to be no significance between GADI scores, sleep onset and sleep

total. This suggests that there is little or no interaction between these variables which

means that sleep onset and sleep total are not affected by anxiety in this study. This

contradicts the general finding that anxiety affects sleep and can lead to insomnia

(http://sleepdisorders.about.com/cs/sleepdestroyers/a/anxiety.htm, 2006, as

accessed on April 30th 2008).

The scores for the GADI were low across the board and suggests that the students

were not that anxious. This does not support Dahlin, Joneborg and Runeson (2005)’s

results which found that first year students tended to be very anxious. This could be

the reason why there was no significance found linking sleep total with the GADI

scores. As anxiety is a common sleep disrupter, a participant needs to be anxious in

order to have their sleep disrupted. As the GADI scores are low, meaning participants

were not very anxious, it is not surprising then that sleep is not affected. If the GADI

scores were higher then it would have been presumed that total sleep time would be

lower and that the data would have shown a significant effect for a direct relationship

between poor sleep and anxiety. For instance looking at the data in Appendix 7,

Participant 12 had an average GADI score of 66 with average sleep duration of 455

minutes sleep per night and participant 16 had a GADI average score of 74 with an

average 227 minutes sleep per night. Both of these participants have a high GAD

score and have a poor sleep total rating. Participant 16 does appear to conform to

the hypothesis that the higher the GADI score, the poorer sleep is, however

participant 12 has a high anxiety level yet sleeps longer per night that participant 6

who has an anxiety score of 33.

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This shows that the data as a whole as analysed by t-test, ANOVA and Mann

Whitney and more specifically when looking at individual participant data, does not

show a significant relationship between anxiety and sleep disruption for this study.

The relationship between the GADI score and the number of wakings is significant for

the t-test and Mann Whitney. This means that the anxiety score affects the number of

times a person wakes during the night. It can be said that the higher the level of

anxiety as measured by the GADI, the more times a person will wake throughout the

night. This means that an anxious student is more likely to get a more disrupted

night’s sleep.The ANOVA does not show significance for number of wakings,

however it is close to significance. It is more of a trend in ANOVA than a significant

relationship as found in t-tests and Mann Whitney. This lack of significance in

ANOVA could be down to the normality of the data which is only very slightly skewed

but would still have an effect on the outcome. It would be a good idea for further

research to look at whether the length of the wakings was also significant when

compared to the GADI scores.

Due to the lack of significance of a direct relationship between anxiety and sleep total

or sleep onset time, but does show significance for the number of wakings per night,

it is important to consider the limitations of this study and the factors that may have

influenced the outcome. It is also important to reflect upon what could be altered if

this study was to be replicated in the future or to be a source of information for any

similar studies.

This study used the GADI at the beginning of the sleep diary period and upon

completion of the sleep diary period. The averages were taken and used for the

analysis. However if the anxiety level had changed over this period it was not taken

into account and the reasons behind the change were not explored. As some of the

anxiety levels did decrease or increase and the average score was used, it may have

meant that the scores were not an accurate depiction of the anxiety level of the

participant and may have confounded the results. It was not necessary to take two

scores unless they were used separately. If this study was to be replicated in the

future it would only be necessary to take one GADI score.

Another irrelevant source of data in this study were the subjective ratings of sleep

quality, sleep ease, feeling of refreshment and whether it was enough sleep.

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These ratings were not explored explicitly within the study as they were not

specifically relevant to the hypotheses that were being tested and due to the

constraints of time and resources. Rather than changing the scales of the rating

system as was done prior to data collection, the ratings should have been eliminated.

It was not clear at the beginning of the study that they would not be used which is

why they were kept on the sleep diary. However, it could be said that sleep ease was

looked at loosely in the form of the variable sleep onset, just not in the subjective

manner of the rating syste,. As these results were collected they should have been

explored, even if it was only quickly to see if there was any relationship between

them and anxiety measured by the GADI score. It could have possibly shown

significance between anxiety and one or more of the variable. However, this was not

the case and should be the focus if the study is replicated in the future in case they

did provide any significant results. This is a severe criticism of this study as it is

ignoring potentially significant data.

Although this study went on from the work of Dahlin, Joneborg and Runeson (2005)

where it was found that first year students had a higher level of stress than third or

sixth year students, it could have been a bit limited. If the study was broadened to

include first year postgraduates, who may be under greater, equal to or less pressure

than first year undergraduates, the results may have indicated more significance in

the results. First year postgraduates have survived undergraduate study however the

pressure that is heaped upon postgraduate students is probably very similar to first

year undergraduates. By including first year postgraduates it would have also made

the sample population larger which may have increased the ease of participant

recruitment and made for a larger sample. This would be a good comparison to

undertake at a later date. It could be possible that even though the postgraduate

students are under more pressure to perform and succeed, they may be able to deal

with it better as they have been through undergraduate schooling and learnt to deal

with it and subsequently sleep better.

If the study had been carried out in a similar manner to Dahlin, Joneborg and

Runeson (2005), where different university years were compared against each other,

the study may have produced more conclusive results regarding the hypotheses

being tested. It may have been that although first year students are under pressure, it

may not have been to the extent to which third year students who are doing

dissertations are under, but more so than second year students.

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For future work it would be a good idea to replicate their study parameters between

the different years of university students whilst studying and applying the results to

the effect this anxiety has on sleep.

Harvey (2000) looked into the pre-sleep cognitive activity of insomniacs and the types

of worries that took place at this time. The more activity in this pre-sleep stage, the

more sleep was affected in a negative manner. As sleep onset was a key variable in

this study it would have been a good idea to look at the sorts of things that run

through the minds of the participants in this sleep onset stage. This could have been

important as Harvey (2000) had already recognised that this pre-sleep activity posed

problems especially in insomniacs more than it did for good sleepers. It would have

indicated who had merely problems with switching off at the end of the day and those

who could possibly have insomnia. The participants that scored poorly on the sleep

onset variable may have had higher levels of pre-sleep cognitive activity than those

who had good sleep onset scores. This should be something to be explored in a

future study into anxiety and sleep disruption.

Data collection was quite challenging as there were similar studies running at the

same time which affected the number of participants that were willing to take part in

the study and was also the reason why flyers had to be resorted to in the last few

weeks. If this was a stand alone study then it may have been easier to recruit

participants and therefore a larger sample could have been used. A larger sample

may have affected the outcome of the study in either direction.

Ages of the participants were not taken. This was not thought to be an important

factor at the beginning of the study; however it may have had some effect on the end

result. If this study was to be carried out in the future it would be a good idea to look

at age’s effect on anxiety and the subsequent sleep disruption. For instance, it may

be possible that the older the undergraduate student is, the more able they are to

cope with the stressors that they face much better, which could mean that as they are

more able to deal with the stress, and their sleep will be less disrupted.

Dahlin, Joneborg and Runeson (2005) found that there was a gender difference

between men and women in reporting stress levels. It would be a good idea to re-

examine or to replicate this study with an aim of trying to see if this data correlates

with their finding as this was not something that was taken into account in this study.

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The study hypothesised that the more anxious a student was (as shown by a high

GADI score), the less and poorer sleep they would get in total per night, the more

wakings they would have per night and the longer it would take to get to sleep per

night. However the results showed that there was no significant relationship between

level of anxiousness and sleep total or sleep onset. There was only a significant

relationship between level of anxiousness and the number of wakings per night.

These results could have been affected by the low GADI scores of the participants,

as well as other confounding factors. If this study was to be replicated there are a

variety of things that should be taken into account or modified. A larger sample would

be a good place to start and there are other populations that could have been taken

into account that may have provided a more significant result.

REFERENCES

Ancoli-Israel, S., & Roth, T. (1999). Characteristics of insomnia in the United States:

Results of the 1991 National Sleep Foundation Survey I. Sleep, 22 (Suppl. 2), S347–

S353.

Andrews, B. And Wilding, J.M. (2004). The relation of depression and anxiety to life-

stress and achievement in students. British Journal of Psychology, 95, pp. 509-21

Coren, S. (1996). Sleep Thieves. New York: Free Press

Czeisler, C.A., Moore-Ede, M.C. and Coleman, R.M. (1982). Rotating shift work

schedules that disrupt sleep are improved by applying circadian principles. Science,

217, pp.460-3

Dahlin, M., Joneborg, N., and Runeson, B. (2005). Stress and depression among

medical students: a cross-sectional study. Blackwell Publishing Ltd, Medical

Education, 39, pp. 594-604

Dement, W. And Kleitman, N. (1957). Cyclic variations in EEG during sleep and their

relation to eye movements, body motility and dreaming. Electroencephalography and

Clinical Neurophysiology, 9, pp.673-90

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Harvey, A.G. (2000). Pre-sleep cognitive activity: A comparison of sleep-onset

insomniacs and good sleepers. British Journal of Psychology, 39, 275-286

Harvey, A.G. (2002). A Cognitive Model of Insomnia. Behaviour Research and

Therapy, 40, 869-893

Harvey, A.G. (2003). Catastrophic Worry in Primary Insomnia. Journal of Behaviour

Therapy and Experimental Psychiatry, 34, 11-23

Psychopharmacology Unit. (2000). G.A.D Assessment Inventory. University of Bristol

http://sleepdisorders.about.com/cs/sleepdestroyers/a/anxiety.htm (2006) Anxiety and

Sleep, accessed on April 30th 2008

http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=216&sectionId=1 Health

Encyclopaedia: Insomnia, accessed April 30th 2008

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Appendix 1. Briefing Sheet

Thank you for considering taking part in this research (into the relationship between sleep perceptions and anxiety levels). The information that you give will be completely anonymous and will not be passed onto anyone else. It will not be used for diagnostic purposes and your answers cannot be linked to you. You are free to refuse to participate, or to withdraw at any time. This is without prejudice. It is not compulsory to take part. You do not have to give any reason for withdrawal, and it will not reflect on you personally. However, your participation may help provide information that could lead to improved treatment of sleep problems and depression.

There are two types of form to complete; a sleep diary and a G.A.D Assessment Inventory. Please complete one diary every morning over the next seven days, starting tomorrow morning (reporting your sleep from the previous night). It is vital that this is done daily and not left for too long after waking, as you will remember more this way. They are very short and only take a few moments to complete. Please answer as accurately and honestly as possible. You should answer every question. Before you start to fill in the sleep diaries please complete the initial GAD questionnaire - this will give a baseline of your anxiety levels, to be compared with the final one completed at the end of the week.

At the end of that week, please complete the final G.A.D. The questionnaire measures your general anxiety level and the questions are answered either by ticking the relevant box, or placing a mark along a scale. Please answer all the questions. However, should you feel uncomfortable answering any of the questions, please disregard that question and go on to the next one. The inventory measures your current anxiety level and is answered by circling the response that you feel describes you best. Your diaries and questionnaires will be collected from you in one week or the sleep diaries and inventories emailed back and the consent mailed to the address given.

If you are happy to proceed, please sign the attached consent form and hand it to the investigator.

Thank you once more for your assistance.

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Appendix 2. Consent Form

Study Title: Anxiety and Sleep in First Year Undergraduates

Please cross outas necessary

Have you read the Information Sheet? Yes / No

Have you had an opportunity to ask questions and discuss this study? Yes / No

Have you received satisfactory answers to all your questions? Yes / No

Have you received enough information about the study? Yes / No

Do you understand that you are free to withdraw from the study?

At any time?

Without having to give a reason for withdrawing? Yes / No

Do you agree to take part in this study? Yes / No

Signed: Date:

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Appendix 3. G.A.D Assessment Inventory (GADI)

G.A.D. ASSESSMENT INVENTORY

Please make sure you answer all the questions, by putting a tick in the box that best describes how you have felt over the last week.

Do not spend too much time on any one question; there are no right or wrong answers. Please tick only one box for each question.

0 1 2 3 4

Not at all

A little bit

Somewhat

Very much

Extremely

1. I am anxious on most days

2. I tire easily

3. I worry about everyday events

4. I find it difficult to relax

5. I feel “on edge”

6. I am wakeful at night

7. I experience hot flushes or cold chills

8. I am distressed by my anxiety

9. I suffer from a dry mouth

10. I fear losing control, passing out, or going crazy

11. I am troubled by restlessness

12. I suffer from dizzy spells

13. I am troubled by trembling and shaking

14. I have difficulty getting off to sleep

15. I suffer with tense or aching muscles

16. I am troubled by difficulty breathing

17. I am easily startled

18. I have difficulty concentrating

19. I have difficulty controlling my anxiety

20. I am troubled by tingling feelings or numbness

21. I worry excessively

22. I am irritable

2000 Psychopharmacology Unit, University of Bristol.

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Appendix 4. Sleep diary

SLEEP DIARY

Please complete this diary every morning.

Date: (please note the date for last night)

Please answer the following questions as accurately as possible

1 At what time did you first attempt sleep last night _____________

2 How long did it take you to get to sleep? _____________

3 How many times did you wake during the night? _____________

4 How long did these awakenings last in total? _____________

5 How long did you sleep in total? _____________

6 At what time did you wake this morning? _____________

7 At what time did you get up? _____________

Please answer the following questions by checking the box that most reflects how you felt about last nights sleep episode (e.g. very good, good, average, poor, very poor) (a ‘sleep episode’ refers to the time from when you first attempted sleep to when you finally got up)

8 How would you rate your sleep quality last night?Very Good Very Poor

9 How easily did you fall asleep?Very Easily Not at All Easily

10 How well refreshed did you feel when you woke up?Very Refreshed Not Very

Refreshed

11 Did you get enough sleep last night?Just Right Not at All

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Southampton & South West Hants LREC Ethics Submission No. 234/03/w

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Appendix 5. Recruitment Flyer

FIRST YEAR UNDERGRADUATES

NEEDEDFor 3rd Year Dissertation Study Concerning Sleep and

Anxiety

Study Utilizes a 5 Minute Daily Questionnaire to Be Completed For 7 Days

If You Are Interested In Participating In This Exciting Study Or Would Like More Information, Then Email:

l itchickuk@o2email.co.uk

Thank you For Your Participation In Advance

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Appendix 7. Data sheet with the GADI scores and scores to the median for

sleep total, sleep onset and waking number.

Participant GADI Sleep Total Sleep Onset Waking No.

1 14.0 1.0 2.0 1.02 16.0 2.0 2.0 2.03 19.0 2.0 2.0 2.04 13.0 2.0 2.0 2.05 9.0 1.0 1.0 1.06 29.0 2.0 2.0 2.07 21.0 1.0 2.0 2.08 2.0 2.0 2.0 1.09 11.0 2.0 2.0 2.010 12.0 1.0 2.0 1.011 0.0 2.0 2.0 1.012 66.0 2.0 2.0 2.013 20.0 2.0 2.0 1.014 27.0 2.0 2.0 2.015 6.5 1.0 1.0 1.016 74.0 2.0 2.0 2.017 7.5 1.0 1.0 1.018 20.0 2.0 2.0 1.019 18.0 2.0 1.0 2.020 7.5 1.0 1.0 1.021 22.0 1.0 1.0 2.0

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