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
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
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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
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.
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

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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
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
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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.

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

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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).

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.

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
13
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

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

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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

15
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.

16
Appendix 2. Consent Form

Study Title: Anxiety and Sleep in First Year Undergraduates

Please cross out

as 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:

17
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 A little Somew Very Extremel
all bit hat much y
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

Southampton & South West Hants LREC Ethics Submission No. 234/03/w
19
Appendix 5. Recruitment Flyer

FIRST YEAR
UNDERGRADUATES
NEEDED
For 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:

litchickuk@o2email.co.uk

Thank you For Your Participation In Advance

20
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 1.0
2 16.0 2.0 2.0 2.0
3 19.0 2.0 2.0 2.0
4 13.0 2.0 2.0 2.0
5 9.0 1.0 1.0 1.0
6 29.0 2.0 2.0 2.0
7 21.0 1.0 2.0 2.0
8 2.0 2.0 2.0 1.0
9 11.0 2.0 2.0 2.0
10 12.0 1.0 2.0 1.0
11 0.0 2.0 2.0 1.0
12 66.0 2.0 2.0 2.0
13 20.0 2.0 2.0 1.0
14 27.0 2.0 2.0 2.0
15 6.5 1.0 1.0 1.0
16 74.0 2.0 2.0 2.0
17 7.5 1.0 1.0 1.0
18 20.0 2.0 2.0 1.0
19 18.0 2.0 1.0 2.0
20 7.5 1.0 1.0 1.0
21 22.0 1.0 1.0 2.0

21