The face of tiredness in insomnia from the self‐perspective: A focus on attentional and interpretative biases

The extent to which an individual has slept may influence how their physical appearance is perceived by others and oneself. The poor nature of one’s sleep can be observed through a number of dermatological characteristics (e.g., wrinkles/fine lines and bags around the eyes, dropped corners of the mouth and heavy eyes) pertaining to tiredness (Knoll, Attkiss, & Persing, 2008; Sundelin et al., 2013). Further, research concurs that facial photographs of sleep-deprived individuals are rated as less attractive, less healthy, more tired and less sociable when compared to well-rested (Axelsson et al., 2010; Sundelin, Lekander, Sorjonen, & Axelsson, 2017). As such, it appears that limited sleep may lead to dermatological changes in the face which subsequently may influence the perception of others, potentially leading to psychosocial implications relating to partner and workplace interaction(s) and with health care providers (Gupta, Gupta, & Knapp, 2015). There may be a number of mechanisms promoting these physiological changes; for example, tiredness can result in the relaxing of the muscles, which would inherently alter one’s facial expression (Enoka & Stuart, 1992). Moreover, sleep promotes blood flow to the skin and changes in skin blood coloration occur with lack of sleep, leading the face to appear paler (Kr€auchi & Wirz-Justice, 2001), which could act as a contributing factor to an increased perception of tiredness (Sundelin et al., 2013). Insomnia, by definition, encompasses subjective reports of poor sleep (American Psychiatric Association, 2013), and while the experience of tiredness is reported commonly (Balter & Uhlenhuth, 1991), this population often displays objectively better sleep than that reported subjectively (Perlis, Merica, Smith, & Giles, 2001; Tang & Harvey, 2004, 2006; Van Den Berg et al., 2008). Considering the aforementioned research, which focuses largely upon studies of extreme sleep deprivation, it would be reasonable to assume that those with insomnia might not actually appear physically tired to the same extent, perhaps falling somewhere between sleep-sated and sleep-deprived. As such, people with insomnia may not necessarily be judged as negatively by others as may be a person who has experienced a transient bout of severe sleep-deprivation. However, a different picture emerges if we examine how individuals with insomnia perceive themselves. In an article published in the Journal of Sleep Research, data from our group demonstrated that when using a visual task where participants indicated when a continuously morphing image of their face, varying in degrees of tiredness and alertness, represented their current level of tiredness, individuals with insomnia displayed an interpretive bias such that they misperceived their own face as appearing more tired than they physically were (Akram, Ellis, Myachykov, & Barclay, 2016a). Conversely, this bias did not extend to the perception of other people’s faces which were more accurately perceived (Akram, Ellis, Myachykov, & Barclay, 2016b). When asked to explore and examine their own and other people’s faces, a follow-up study in the Journal of Sleep Research (Akram, Ellis, Myachykov, & Barclay, 2017) determined that people with insomnia were quicker to direct initial attention to and maintain overall attention towards areas of the face associated with tiredness (Knoll et al., 2008; Nguyen, Isaacowitz, & Rubin, 2009; Sundelin et al., 2013). Further, it has also been evidenced that the self-reported severity of insomnia symptoms is related to reduced ratings of expression intensity for tired facial photographs of other people (Akram, Sharman, & Newman, 2017). It is relevant to note, however, that these studies used samples of a relatively young age (compared with other research in insomnia). While this was to account for changes to sleep continuity and increased sensitivity to early signs of skin ageing (Akram et al., 2017), these outcomes cannot be extrapolated to older adults experiencing insomnia. Despite this, it seems that while individuals with insomnia display an equivalent level of attention towards both their own and other people’s facial features relating to tiredness (Akram et al., 2017), only their own facial attributes of tiredness are interpreted in a manner consistent with the physical presence of an objective sleep disturbance (Akram et al., 2016a, 2016b). This may be explained from a cognitive perspective, specifically in terms of biases of attention, which may consequently influence interpretation. Individuals with insomnia report selectively attending to, and monitoring, bodily sensations on waking and throughout the day for signs of a poor night’s sleep, fatigue and tiredness (i.e., sore head, heavy eyes, poor facial complexation), which has been evidenced as mediated by the extent of sleep-related monitoring on awakening (Akram, 2017; Semler & Harvey, 2004). As the face is used in social perception to portray one’s internal state to others (Allison, Puce, & McCarthy, 2000), we may theorize that those with insomnia attend to other people’s facial attributes of tiredness, evaluating these features and drawing comparisons to their own. Certainly, if this is the case, comparisons of this nature (e.g., ‘I look exhausted compared with everybody else’) may serve to heighten pre-existing worry, arousal and distress as described in cognitive models of insomnia (Espie, Broomfield, Macmahon, Macphee, & Taylor, 2006; Harvey, 2002). From a clinical perspective, one must ask two questions: first, can we correct these biases of attention and interpretation; and secondly, would this alter reported insomnia symptomology? Tentatively, research suggests that providing feedback regarding the accuracy of how individuals with insomnia perceive their own faces in terms of tiredness served to positively influence subsequent interpretations, Received: 8 November 2017 | Accepted: 12 December 2017 DOI: 10.1111/jsr.12657