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Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia: A Quasi-Experimental Study

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Abstract

The purpose with the investigation was to examine whether improvements in pre-sleep cognitive arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors mediate the outcomes in in-person CBT-I. Fifty-eight participants with insomnia were administered either cognitive behavioral therapy or belonged to a waitlist. At pre- and post-treatment, participants completed questionnaires and sleep diaries assessing cognitive arousal, unhelpful beliefs about sleep, maladaptive sleep behaviors, insomnia severity, dysfunction, and subjective sleep parameters. Outcome measures were re-administered at a 3-month follow-up. Decreases in cognitive arousal mediated the effect on dysfunction. Reductions in unhelpful beliefs mediated the treatment effect on insomnia severity and dysfunction. Decreases in bedtime variability mediated the outcome on insomnia severity, and reductions in time in bed had a mediating effect on total wake time. Neither rise time variability nor napping mediated the improvements. A reversed model, in which the outcomes were used as mediators, showed less fit with the current data, indicating that change in the psychological processes as mediators of improvement in the outcomes was the most plausible conclusion. These findings are clearly supportive of cognitive-behavioral models of insomnia by highlighting cognitive arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research.

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References

  • Bastien, C. H., Vallieres, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2, 297–307. doi:10.1016/S1389-9457(00)00065-4.

    Article  PubMed  Google Scholar 

  • Bootzin, R. R., Epstein, D., & Wood, J. M. (1991). Stimulus control instructions. In P. J. Hauri (Ed.), Case studies in insomnia (pp. 19–28). New York: Plenum Publishing Company. doi:10.1007/978-1-4757-9586-8_2.

    Chapter  Google Scholar 

  • Borbély, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1, 195–204.

    PubMed  Google Scholar 

  • Breslau, N., Roth, T., Rosenthal, L., & Andreski, P. (1996). Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biological Psychiatry, 39, 411–418. doi:10.1016/0006-3223(95)00188-3.

    Article  CAS  PubMed  Google Scholar 

  • Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, 73–86. doi:10.1016/S0005-7916(00)00012-4.

    Article  CAS  PubMed  Google Scholar 

  • Edinger, J. D., Bonnet, M. H., Bootzin, R. R., Doghramji, K., Dorsey, C. M., Espie, C. A., et al. (2004). Derivation of research diagnostic criteria for insomnia: Report of an American academy of sleep medicine work group. Sleep, 27, 1567–1596.

    PubMed  Google Scholar 

  • Edinger, J., Kirby, A., Lineberger, M., Loiselle, M., Wohlgemuth, W., & Means, M. Duke structured interview schedule for DSM-IV-TR and international classification of sleep disorders, second edition (ICSD-2): Sleep disorder diagnoses. Unpublished manual.

  • Edinger, J. D., & Means, M. K. (2005). Cognitive-behavioral therapy for primary insomnia. Clinical Psychology Review, 25, 539–558. doi:10.1016/j.cpr.2005.04.003.

    Article  PubMed  Google Scholar 

  • Edinger, J. D., Olsen, M. K., Stechuchak, K. M., Means, M. K., Lineberger, M. D., Kirby, A., et al. (2009). Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: A randomized clinical trial. Sleep, 32, 499–510.

    PubMed Central  PubMed  Google Scholar 

  • Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Coffman, C. J., & Carney, C. E. (2007). Dose–response effects of cognitive-behavioral insomnia therapy: A randomized clinical trial. Sleep, 30, 203–212.

    PubMed  Google Scholar 

  • Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. Journal of the American Medical Association, 285, 1856–1864. doi:10.1001/jama.285.14.1856.

    Article  CAS  PubMed  Google Scholar 

  • Espie, C. A. (2002). Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology, 53, 215–243. doi:10.1146/annurev.psych.53.100901.135243.

    Article  PubMed  Google Scholar 

  • Espie, C. A., Kyle, S. D., Miller, C. B., Ong, J., Hames, P., & Fleming, L. (2014). Attribution, cognition and psychopathology in persistent insomnia disorder: Outcome and mediation analysis from a randomized placebo-controlled trial of online cognitive behavioural therapy. Sleep Medicine, 15, 913–917. doi:10.1016/j.sleep.2014.03.001.

    Article  PubMed  Google Scholar 

  • First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1997). Structured clinical interview for DSM-IV axis I disorders: Clinician version. Washington, DC: American Psychiatric Press.

    Google Scholar 

  • Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? Journal of the American Medical Association, 262, 1479–1484. doi:10.1001/jama.1989.03430110069030.

    Article  CAS  PubMed  Google Scholar 

  • Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to detect the mediated effect. Psychological Science, 18, 233–239.

    Article  PubMed Central  PubMed  Google Scholar 

  • Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869–893. doi:10.1016/S0005-7967(01)00061-4.

    Article  CAS  PubMed  Google Scholar 

  • Harvey, A. G., Sharpley, A. L., Ree, M. J., Stinson, K., & Clark, D. M. (2007). An open trial of cognitive therapy for chronic insomnia. Behaviour Research and Therapy, 45, 2491–2501. doi:10.1016/j.brat.2007.04.007.

    Article  PubMed  Google Scholar 

  • Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76, 408–420.

    Article  Google Scholar 

  • Jansson-Fröjmark, M. (2014). The work and social adjustment scale as a measure of dysfunction in chronic insomnia: Reliability and validity. Behavioural and Cognitive Psychotherapy, 42, 186–198. doi:10.1017/S135246581200104X.

    Article  PubMed  Google Scholar 

  • Jansson-Fröjmark, M., Linton, S. J., Flink, I., Granberg, S., Danermark, B., & Norell- Clarke, A. (2012). Cognitive-behavioral therapy for insomnia co-morbid with hearing impairment: A randomized controlled trial. Journal of Clinical Psychology in Medical Settings, 19, 224–234. doi:10.1007/s10880-011-9275-y.

    Article  PubMed  Google Scholar 

  • Jansson-Fröjmark, M., & Norell-Clarke, A. (2012). Psychometric properties of the Pre-Sleep Arousal Scale in a large community sample. Journal of Psychosomatic Research, 72, 103–110. doi:10.1016/j.jpsychores.2011.10.005.

    Article  PubMed  Google Scholar 

  • Jernelöv, S., Lekander, M., Blom, K., Rydh, S., Ljótsson, B., Axelsson, J., & Kaldo, V. (2012). Efficacy of a behavioral self-help treatment with or without therapist guidance for co-morbid and primary insomnia—A randomized controlled trial. BMC Psychiatry,. doi:10.1186/1471-244X-12-5.

    PubMed Central  PubMed  Google Scholar 

  • Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27. doi:10.1146/annurev.clinpsy.3.022806.091432.

    Article  PubMed  Google Scholar 

  • Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59, 877–883. doi:10.1001/archpsyc.59.10.877.

    Article  PubMed  Google Scholar 

  • Krystal, A. D., & Edinger, J. D. (2010). Sleep EEG predictors and correlates of the response to cognitive behavioral therapy for insomnia. Sleep, 33, 669–677.

    PubMed Central  PubMed  Google Scholar 

  • Lichstein, K. L., Durrence, H. H., Taylor, D. J., Bush, A. J., & Riedel, B. W. (2003). Quantitative criteria for insomnia. Behaviour Research and Therapy, 41, 427–445. doi:10.1016/S0005-7967(02)00023-2.

    Article  CAS  PubMed  Google Scholar 

  • Lichstein, K. L., Riedel, B. D., Wilson, N. M., Lester, K. W., & Aguillard, R. N. (2001). Relaxation and sleep compression for late-life insomnia: A placebo-controlled trial. Journal of Consulting and Clinical Psychology, 69, 227–239. doi:10.1037//0022-006X.69.2.227.

    Article  CAS  PubMed  Google Scholar 

  • Lichstein, K. L., Taylor, D. J., McCrae, C. S., & Thomas, S. J. (2011). Relaxation for insomnia. In M. L. Perlis, M. Aloia, & B. Kuhn (Eds.), Behavioral treatments for sleep disorders: A comprehensive primer of behavioral sleep medicine interventions (practical resources for the mental health professional (1st ed., pp. 45–54). New York: Academic Press.

    Chapter  Google Scholar 

  • Lichstein, K. L., Wilson, N. M., & Johnson, C. T. (2000). Psychological treatment of secondary insomnia. Psychology and Aging, 15, 232–240. doi:10.1037//0882-7974.15.2.232.

    Article  CAS  PubMed  Google Scholar 

  • Lundh, L. G., & Broman, J. E. (2000). Insomnia as an interaction between sleep-interfering and sleep-interpreting processes. Journal of Psychosomatic Research, 49, 299–310. doi:10.1016/S0022-3999(00)00150-1.

    Article  CAS  PubMed  Google Scholar 

  • McEnany, G., & Lee, K. A. (2000). Owls, larks, and the significance of morningness/eveningness rhythm propensity in psychiatric-mental health nursing. Issues in Mental Health Nursing, 21, 203–216.

    Article  CAS  PubMed  Google Scholar 

  • Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford Publications.

    Google Scholar 

  • Morin, C. M. (2006). Cognitive-behavioral therapy of insomnia. Sleep Medicine Clinics, 1, 375–386. doi:10.1016/j.jsmc.2006.06.008.

    Article  Google Scholar 

  • Morin, C. M., & Benca, R. (2012). Chronic insomnia. The Lancet, 379, 1129–1141. doi:10.1016/S0140-6736(11)60750-2.

    Article  Google Scholar 

  • Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: An update of recent evidence (1998–2004). Sleep, 29, 1398–1414.

    PubMed  Google Scholar 

  • Morin, C. M., Vallières, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep: Validation of a brief version. Sleep, 30, 1547–1554.

    PubMed Central  PubMed  Google Scholar 

  • Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. H. (2002). The work and social adjustment scale: A simple measure of impairment in functioning. British Journal of Psychiatry, 180, 461–464. doi:10.1192/bjp.180.5.461.

    Article  PubMed  Google Scholar 

  • Nicassio, P. M., Mendlowitz, D. R., Fussell, J. J., & Petras, L. (1985). The phenomenology of the pre-sleep state: The development of the Pre-Sleep Arousal Scale. Behavior Research and Therapy, 23, 263–271. doi:10.1016/0005-7967(85)90004-X.

    Article  CAS  Google Scholar 

  • NIH. (2005). National Institutes of Health state of the science conference statement: Manifestations and management of chronic insomnia in adults. Sleep, 28, 1049–1057.

    Google Scholar 

  • Nock, M. K. (2007). Conceptual and design essentials for evaluating mechanisms of change. Alcoholism, Clinical and Experimental Research, 31, 4–12. doi:10.1111/j.1530-0277.2007.00488.x.

    Article  Google Scholar 

  • Ohayon, M. M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97–111. doi:10.1053/smrv.2002.0186.

    Article  PubMed  Google Scholar 

  • Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in simple and multiple mediator models. Behavior Research Methods, Instruments, and Computers, 40, 879–891.

    Article  Google Scholar 

  • Roth, T., & Ancoli-Israel, S. (1999). Daytime consequences and correlates of insomnia in the United States: Results of the 1991 National Sleep Foundation Survey. II. Sleep, 22, 354–358.

    Google Scholar 

  • Rucker, D. D., Preacher, K. J., Tormala, Z. L., & Petty, R. E. (2011). Mediation analysis in social psychology: Current practices and new recommendations. Social and Personality Psychology Compass, 5(6), 359–371.

    Article  Google Scholar 

  • Rybarczyk, B., Lopez, M., Benson, R., Alsten, C., & Stepanski, E. (2002). Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychology and Aging, 17, 288–298. doi:10.1037//0882-7974.17.2.288.

    Article  PubMed  Google Scholar 

  • Rybarczyk, B., Stepanski, E., Fogg, L., Barry, P., Lopez, M., & Davis, A. (2005). A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults. Journal of Consulting and Clinical Psychology, 73, 1164–1174. doi:10.1037/0022-006X.73.6.1164.

    Article  PubMed  Google Scholar 

  • Schwartz, D. R., & Carney, C. E. (2012). Mediators of cognitive-behavioral therapy for insomnia: A review of randomized controlled trials and secondary analysis studies. Clinical Psychology Review, 32, 664–675. doi:10.1016/j.cpr.2012.06.006.

    Article  PubMed  Google Scholar 

  • Smith, M. T., Huang, M. I., & Manber, R. (2005). Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25, 559–592. doi:10.1016/j.cpr.2005.04.004.

    Article  PubMed  Google Scholar 

  • Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10, 541–553.

    CAS  PubMed  Google Scholar 

  • Spoormaker, V. I., Verbeek, I., van den Bout, J., & Klip, C. (2005). Initial validation of the SLEEP-50 questionnaire. Behavioral Sleep Medicine, 3, 227–246. doi:10.1207/s15402010bsm0304_4.

    Article  PubMed  Google Scholar 

  • Tremblay, V., Savard, J., & Ivers, H. (2009). Predictors of the effect of cognitive behavioral therapy for chronic insomnia comorbid with breast cancer. Journal of Consulting and Clinical Psychology, 77, 742–750. doi:10.1037/a0015492.

    Article  PubMed  Google Scholar 

  • Vincent, N., & Walsh, K. (2013). Hyperarousal, sleep scheduling, and time awake in bed as mediators of outcome in computerized cognitive-behavioral therapy (cCBT) for insomnia. Behaviour Research and Therapy, 51, 161–166. doi:10.1016/j.brat.2012.12.003.

    Article  CAS  PubMed  Google Scholar 

  • Vitiello, M. V., McCurry, S. M., & Rybarczyk, B. D. (2013). The future of cognitive behavioral therapy for insomnia: What important research remains to be done? Journal of Clinical Psychology, 69, 1013–1021. doi:10.1002/jclp.21948.

    Article  PubMed  Google Scholar 

  • Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Sleep Medicine, 5, 355–362.

    Google Scholar 

  • Webb, W. B. (1988). An objective behavioral model of sleep. Sleep, 11, 488–496.

    CAS  PubMed  Google Scholar 

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Acknowledgments

We would like to express our appreciation to Steven J. Linton, Berth Danermark and Sarah Granberg for study design, to Ida K. Flink and Annika Norell-Clarke for working as therapist in the project, to Sparbankstiftelsen Nya for funding and to the two audiology clinics in Örebro and Karlstad for recruitment.

Conflict of Interest

Rikard Sunnhed and Markus Jansson-Fröjmark declare that they have no conflict of interest.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (national and institutional). Informed consent was obtained from all individual subjects participating in the study.

Animal Rights

No animals were used in the current investigation.

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Authors and Affiliations

  1. Department of Psychology, Stockholm University, 106 91, Stockholm, Sweden

    Rikard Sunnhed & Markus Jansson-Fröjmark

  2. Center for Health and Medical Psychology (CHAMP), School of Law, Psychology, and Social Work, Örebro University, Örebro, Sweden

    Markus Jansson-Fröjmark

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  1. Rikard Sunnhed
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Correspondence to Markus Jansson-Fröjmark.

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Sunnhed, R., Jansson-Fröjmark, M. Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia: A Quasi-Experimental Study. Cogn Ther Res 39, 841–852 (2015). https://doi.org/10.1007/s10608-015-9698-0

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