Abstract

Introduction: Sleep disturbances are complex, encompassing a range of disruptions to quality, quantity, and timing (Altman, Knauert & Pisani, 2017; Cormier, 1990). A well-established bidirectional relationship exists between poor sleep and mental health issues, with psychological distress increasingly recognised as impacting sleep health (Brindle et al., 2019). Hence, sleep issues are common among those with psychosis, where trauma exposure is prevalent (Kamphuis et al., 2013). However, little research has explored the relationship between life experiences and sleep among this population (Greenwood, 2020). The current study, therefore, explored the nature of sleep disturbances in psychiatric patients at a high-secure forensic mental health hospital in the UK.

Materials and methods: Semi-structured interviews, informed by measures such as the Pittsburgh Sleep Quality Index (Buysse et al., 1989) and the Morning Eveningness Questionnaire (Horne & Östberg, 1976), were conducted with 30 psychiatric inpatients with both active and residual psychosis symptoms. Participants discussed sleep patterns, preferences, and behaviours, as well as past experiences and night-time cognitions. Interviews were recorded and transcribed using Winscribe and thematically analysed using NVivo software.

Results: Five major themes emerged from the data, emphasising sleep behaviours characteristic of this population. Firstly, participants consistently reported evening chronotypes, alongside delayed sleep patterns, highlighting the impact of misaligned circadian rhythms on unhealthy behaviours, such as poor diet and disrupted routines. Secondly, negative night-time cognitions, such as ruminations of past violence and regrets, were common, often causing physical distress and pre-sleep arousal, further driving sleep disturbances. Thirdly, there was a persistent overlap between nightmares and trauma flashbacks, with participants discussing the two interchangeably, emphasising the impact of intrusion symptoms on sleep. Another prevalent theme was a long history of sleep issues, with participants identifying a ‘tipping point’ where both sleep and psychosis symptoms had significantly worsened. This appeared to be used as a reference point from which current sleep perceptions were measured. Finally, trauma therapies, such as eye-movement desensitisation and reprocessing (EMDR), were praised for improving sleep outcomes by reducing post-trauma nightmares and psychological distress.

Conclusions: Overall, findings highlight the relationship between trauma and sleep in those with psychosis, suggesting that circadian misalignment, negative cognitions, such as rumination, and intrusion symptoms, drive sleep disturbances. These findings emphasise the importance of exploring patient perspectives, recognising trauma as a target for improving sleep outcomes across secure settings.

Acknowledgments: I would like to thank Professor Jane Louise Ireland and Dr. Simon Chu for their continued guidance and support throughout my PhD project. I would also like to acknowledge the support from my colleagues at The University of Central Lancashire and Ashworth Research Centre, as well as the patients themselves at Ashworth Hospital.