To Örebro University

Depression is a common and debilitating disorder in adolescence. Sleep disturbances and depression often co-occur with sleep disturbances frequently preceding depression. The current study investigated whether catastrophic worry, a potential cognitive vulnerability, mediates the relationship between adolescent sleep disturbances and depressive symptoms, as well as whether there are gender differences in this relationship. High school students, ages 16–18, n = 1,760, 49 % girls, completed annual health surveys including reports of sleep disturbance, catastrophic worry, and depressive symptoms. Sleep disturbances predicted depressive symptoms 1-year later. Catastrophic worry partially mediated the relationship. Girls reported more sleep disturbances, depressive symptoms, and catastrophic worry relative to boys. The results, however, were similar regardless of gender. Sleep disturbances and catastrophic worry may provide school nurses, psychologists, teachers, and parents with non gender specific early indicators of risk for depression. Several potentially important practical implications, including suggestions for intervention and prevention programs, are highlighted. 

People with sleep-onset problems often experience neuroticism. To what extent the one problem leads to the other is unknown. We used self-reported data from a Swedish longitudinal project to examine developmental links between neuroticism and sleep-onset problems. A sample of 212 people, followed from birth to midlife, was part of a cohort study spanning 37 years. Adolescent neuroticism was measured at age 16 with the High School Personality Questionnaire (HSPQ, Form A) and in midlife at age 37 with the Eysenck Personality Questionnaire (EPQ). Sleep-onset problems were measured at ages 15 to 17, 25, and 37 with items developed for the Solna Project. Adolescent neuroticism failed to predict sleep-onset problems. Instead, sleep-onset problems in adolescence and young adulthood predicted midlife neuroticism. We found that sleep-onset problems during adolescence were a direct risk for midlife neuroticism, as well as, an indirect risk through continuance of sleep-onset problems into adulthood. This study provides longitudinal support for adolescent sleep-onset problems as a potent risk factor for heightened neuroticism in midlife.

Background: Neurophysiological research implicates sleep deprivation in emotion dysregulation. Less is known about the effects of partial sleep deprivation on the emotions and on emotion regulation of otherwise healthy people. An experimental, randomized pretest-posttest study design was used to examine the differential effects of partial sleep deprivation on emotion experience and implicit emotion regulation following emotion elicitation.

Methods: We randomized 81 healthy adults (44 females) into a sleep deprivation or rested condition. Sleep deprivation was defined as 3-nights with 5-hours total time in bed. Scores on positive and negative emotion markers measured emotions. Mixed between-within subjects analyses of variance were used to examine group differences in emotion following the sleep condition and after the emotion elicitation procedures and test.

Results: Sleep deprived people reported significantly less positive emotions, and more fatigue, irritability, and hostility compared to people who were rested following the sleep condition. There were negligible differences between groups in implicit emotion regulation following emotion elicitation.

Conclusions: These findings suggest that partial sleep deprivation is a potent stressor in emotion dysregulation through reductions in positive emotions. It also appears that implicit emotion regulation works equally well following strong negative emotional events, regardless of sleep condition. From a clinical perspective, sleep deprivation and ensuing reductions in positive affect and emotion may provide clinicians with viable targets in depression treatment. Keywords: Experimental, sleep deprivation, affect, emotions, emotion regulation, emotion elicitation.

This dissertation focused on the role of psychological mechanisms in the development of insomnia and the effectiveness of an early cognitive-behavioral intervention for insomnia. The first aim was to examine whether distress, worry, and dysfunctional beliefs and attitudes about sleep were related to the development of insomnia. The findings from study I indicated that distress (anxiety and, to some extent, depression) was related to the development of insomnia. In study II, the relationship between sleep-related worry and subjective sleep perception was demonstrated to intensify over time, indicating that sleep-related worry was also linked to the development of insomnia. This indicates that both distress and sleep-related worry may be mechanisms that can be regarded as two of several pathways to insomnia. While distress was related to developing an onset of insomnia, worry was linked to the early development of insomnia. In study IV, dysfunctional beliefs and attitudes about sleep were not related to clinical improvement following cognitive behavior therapy for early insomnia. However, reductions in dysfunctional beliefs and attitudes about sleep were consistently linked to improvements in daytime symptoms, but not to sleep improvements. Instead of implying that such beliefs and attitudes are less important than distress and worry in the development of insomnia, it may rather suggest that dysfunctional beliefs and attitudes about sleep play a slightly different role in insomnia than previously envisioned.

The second aim of this dissertation was to compare the effects of cognitive-behavioral therapy for insomnia with self-help information in patients with a short history of insomnia. In study III, the results showed that an early cognitive-behavioral intervention was effective for individuals with insomnia. To the benefit of the patients with insomnia and to society, cognitive behavior therapy may have a deserving and vital role as an early intervention for patients with insomnia.

Taken together, the results in this dissertation indicate that psychological mechanisms play an important role in the development of insomnia. The findings might thus add to the elaboration of cognitive-behavioral models of insomnia. While most previous research has examined insomnia only in its persistent form, the focus of this dissertation was to study insomnia in its early phase. An approach where insomnia is studied in its early phase of development has not only heuristic value to the development of cognitive-behavioral models of the condition, but might also have implications for how cognitive-behavioral therapy for insomnia can be elaborated in future research and integrated in clinical settings.

A randomized controlled design was used with a 1-yr follow-up. The purpose was to compare the effects of two early interventions, a cognitive-behavioral group intervention and a self-help information package, in patients with insomnia. In sum, 165 individuals seeking care for insomnia of 3–12 months duration were randomized to either a group receiving a CBT intervention or a group receiving a self-help information package. At the 1-yr follow-up, 136 participants had completed the entire study. At the 1-yr follow-up, the CBT group intervention was, compared with the control group, effective in producing reductions in dysfunctional beliefs and attitudes about sleep, negative daytime symptoms, as well as vital improvements in sleep (i.e. sleep onset latency, time awake after sleep onset, total sleep time, sleep quality, and sleep efficiency). In comparison with the control group, significantly more participants in the CBT group met criteria at the 1-yr follow-up for clinically meaningful improvements in sleep onset latency, time awake after sleep onset, and sleep efficiency. A CBT group intervention may well be a viable early intervention for patients with insomnia in a wide range of health services.

The purpose of this study was to examine whether arousal, distress, and sleep-related beliefs are related to the maintenance of insomnia. From a randomly selected sample from the general population (N = 3,600), 1,936 participants filled out a baseline and 1-year follow-up survey. Logistic regressions were used to investigate whether arousal, distress, and beliefs were related to sleep status (insomnia: n = 116; poor sleep: n = 222; normal sleep: n = 529; good sleep: n = 234) over one year. Cluster analysis was employed to assess whether it was possible to classify the participants based on their profiles of psychological functioning. The results showed that beliefs in the long-term negative consequences of insomnia, anxiety, depression, and arousal were significantly related to the maintenance of insomnia (18-72% of the variance). Of the individuals with persistent insomnia, 91% belonged to a cluster characterized by high scores on sleep-related beliefs, anxiety, depression, and arousal, and 9% to a cluster defined by low scores on the mechanisms. This study shows that sleep-related beliefs, anxiety, depression, and arousal are related to the maintenance of persistent insomnia, but also that these mechanisms often co-occur in individuals with insomnia.

OBJECTIVES: The aim of this investigation was to study the relationships between sleep-related worry and subjective sleep perception as a function of stage of chronicity.

DESIGN: A cross-sectional study consisting of 136 individuals with a short history of insomnia was used.

METHODS: The 136 participants were grouped to form two different levels of chronicity based on their duration of insomnia: short (3-7 months; n=69) and long (>7-12 months; n=67). Two domains of sleep-related worry (sleeplessness and health) were used as predictors of subjective sleep perception (sleep onset latency, time awake after sleep onset, and total sleep time).

RESULTS: The association between worry for sleeplessness and subjective sleep perception was significantly different across the stages of chronicity. In the group with a short duration of insomnia, worry for sleeplessness was not related to subjective sleep perception. Worry for sleeplessness was however a significant predictor of subjective sleep perception in the group with a long duration of insomnia (unique variance: 33% on sleep onset latency, 19% on time awake after sleep onset, and 13% on total sleep time). Even if marked differences were observed between the two groups, worry for health was not significantly different across stages of chronicity on subjective sleep perception.

CONCLUSIONS: This suggests that the role of sleep-related worry to subjective sleep perception may increase over time. Given that worry was a mechanism with an increasingly stronger impact over time, this supports the idea that worry is a potential mechanism related to the development of insomnia.

The purpose of this study was to examine the associations between anxiety, depression and insomnia, and to investigate whether anxiety and depression are related to future insomnia. This study employed a combination of a cross-sectional and a prospective design. From a randomly selected sample from the general population (N = 3600), 1936 participants filled out a baseline and 1-year follow-up survey on insomnia, anxiety and depression. Odds ratios (ORs) estimations were used to investigate the associations between anxiety, depression, and insomnia. In the cross-sectional study, anxiety (OR: 4.61) and depression (OR: 2.42) showed moderate to strong associations with insomnia. However, the prospective study showed that anxiety (OR: 3.35) was more strongly related than depression (OR: 1.96) to the development of insomnia 1 year later. While anxiety seems to play a key role in the development of insomnia, depression may be considered as a possible precipitating mechanism but even more likely as a consequence of insomnia.

Background: Dysfunction is an integral part of chronic insomnia. Despite this, very little effort has yet been made to design and psychometrically validate an insomnia-specific measure of dysfunction.

Aims: The purpose was to examine the psychometric properties of the Work and Social Adjustment Scale (WSAS) as a measure of dysfunction in chronic insomnia.

Method: Seventy-three patients with chronic insomnia from three subsamples participated. All the patients completed the WSAS, the Insomnia Severity Index (ISI), and sleep diaries over one week.

Results: An exploratory factor analysis suggested a one-factor solution for the WSAS, determining dysfunction, accounting for 73.7% of the variance. The internal consistency of the WSAS was α = .91. The test-retest reliability for the WSAS items was high at .90-.99 and for the entire scale .99. A cut-off at 17 points was established, discriminating those with subclinical versus moderate or severe clinical insomnia (88% sensitivity and 78% specificity). Evidence of convergent and criterion validity was documented via (1) a significant, positive association between the WSAS and ISI and (2) a higher WSAS score among those with severe clinical insomnia, relative to those with moderate clinical and subthreshold insomnia, as well as a higher WSAS score among those with moderate clinical insomnia relative to those with subthreshold insomnia. The WSAS was also shown to be a treatment-sensitive measure for insomnia patients.

Conclusions: The WSAS appears as a reliable and valid measure of dysfunction in chronic insomnia. Additional advantages are its shortness, easiness, and treatment-sensitivity.

The purpose of this study was to examine whether individuals with primary insomnia (PI) have an attentional bias towards insomnia-specific stimuli, relative to normal sleepers (NS). Also, the aim was to determine if the attentional bias was characterized by vigilance or disengagement. A between-groups, matched design was employed. Forty-two individuals completed the study (PI = 21; NS = 21). Participants completed a dot-probe task with stimuli comprising insomnia-specific (fatigue/malaise) and neutral pictures. It was hypothesized that individuals with PI would show greater attentional bias to insomnia-specific stimuli compared with NS. An overall bias effect was noted. This effect was however not due to vigilance; taking into account the reaction times on neutral trials, the PI group and the NS group did not display significantly different results in reaction times to insomnia-specific pictures. On the contrary, the results suggest that the overall bias effect was due to disengagement; the PI group had significantly longer reaction times than the NS group when shifting away from the insomnia-specific pictures, relative to neutral-neutral picture presentations. The findings suggest that individuals with insomnia are not more vigilant than normal sleepers to insomnia-specific stimuli, but instead have greater difficulties in shifting away from such stimuli.

Objectives: The purpose of this study was to investigate whether there is a bidirectional relationship between pain and insomnia symptoms over the course of a year.

Design: A longitudinal design with a 1-year follow-up was used. Methods. From a randomly selected sample of the adult general population (N = 3,000), 1,746 individuals filled out a baseline and 1-year follow-up survey on pain, insomnia symptoms, anxiety symptoms, and depressive symptoms.

Results: Pain (OR = 1.64) and anxiety symptoms increased the risk for the incidence of insomnia symptoms (R-2 =.125) and pain (OR = 1.98), anxiety symptoms and depressive symptoms were related to the persistence of insomnia symptoms (R-2 =.212). Gender and anxiety symptoms increased the risk for the incidence of pain (R-2 =. 073); and age, insomnia symptoms (OR= 1.49), anxiety symptoms, and depressive symptoms were associated with the persistence of pain (R-2 =.187).

Conclusion: While pain was linked to future insomnia symptoms and insomnia symptoms to the persistence of pain over the course of a year, insomnia symptoms was not associated with the incidence of pain. The results, thus, partly argue against bidirectionality between pain and insomnia symptoms.

Objectives:  Few questionnaires have been developed and validated to specifically index insomnia-specific cognitive mechanisms. The purpose of this study was to investigate the psychometric properties of a newly developed instrument, the Insomnia Catastrophising Scale (ICS). We seek to examine the factorial validity and internal consistency, discriminative and convergent validity along with associations with anxiety, depression, sleep parameters, and daytime impairment.

Methods: Participants (n = 1803) from a randomly selected sample of the general population completed a survey that probed demographics, night-time symptoms, daytime impairment, anxiety and depression.  The ICS was also administered. Excluding those with a sleep disorder other than insomnia, the study sample consisted of 1558 participants.  

Results: Of the twenty original ICS items, three were removed due to low communality. Exploratory factor analysis of the eleven items indexing night-time catastrophising indicated a one-factor solution (59.1% variance), strong primary loadings, and high internal consistency (α = .92). Analysis of the six items indexing daytime catastrophising indicated a one-factor solution (70.1% variance), strong primary loadings, and high internal consistency (α = .91). The internal consistency for the total ICS was .95. At scale-, subscale-, and item-levels significant mean differences were noted between three groups which differed on insomnia symptomatology; the insomnia disorder group (n = 113) reported significantly higher scores than the poor sleep (n = 247) and normal sleep groups (n = 1157), and the poor sleep group exhibited significantly higher scores than the normal sleep group. Receiver operating characteristics analyses indicated that when using an optimal cut-off for the ICS, the sensitivity was 84.1% (detecting those with insomnia disorder) and specificity was 81.5% (detecting those with normal sleep). The ICS was significantly associated with anxiety and depression (ρ = .44-.54), total wake time (η = .38), total sleep time (η = .29), sleep quality (ρ = .49), and daytime impairment (ρ = .57).

Conclusion: The ICS can be considered as a reliable and valid questionnaire for indexing insomnia-specific catastrophising. The use of the ICS is recommended in research and clinical settings for assessing insomnia-related catastrophising.  

The aim of this study was to examine the psychometric properties of the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), with a focus on factorial validity and internal consistency as well as discriminative, convergent, and association with sleep parameters and daytime impairment. Among a randomly selected sample from the general population (N = 5,000), 2,333 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1800 participants who did not fulfill criteria for another sleep disorder than insomnia. A two-factor solution, accounting for 70.7% of the variance, was extracted from the 10 APSQ items. One six-item factor determined worries about the consequences of poor sleep (a = .91); the second factor, with four items, assessed worries about the uncontrollability of sleep (a = .86). The two factors were significantly intercorrelated (ρ = .65) and significantly associated with the total APSQ (ρs = .97 and .76, respectively). The APSQ and the two subscales showed discriminant validity between three sleep status groups (normal sleep, poor sleep, and insomnia disorder; R² = .33-.41). The APSQ and the subscales demonstrated convergent validity with measures on cognitive arousal, sleep-related beliefs, anxiety, and depression. They also were significantly correlated with sleep parameters and daytime impairment. The findings suggest that the APSQ is a psychometrically sound instrument for assessing worry in insomnia.

Objectives: Cognitive models of insomnia underscore cognitive mechanisms as important in the maintenance of insomnia. The aim of this study was to examine psychological factors in insomnia and the association between psychological mechanisms with night-time and daytime symptoms.

Methods: In a cross-sectional examination, participants (n = 2327) from a randomly selected sample of the general population completed a survey on demographic parameters, night-time symptoms, daytime impairment, health outcomes, and psychological factors intended to index five cognitive processes (Harvey, 2002). Excluding those with a sleep disorder other than insomnia, the study sample consisted of 1890 participants.  

Results: Relative to poor and normal sleepers, the insomnia group scored higher on worry, beliefs, physiologic arousal, monitoring/attentional bias, and safety behaviours relative to the other two groups, and the poor sleepers exhibited a similar pattern relative to the normal sleepers. High total wake time was associated with more worry, physiologic arousal, and safety behaviours (26.3% variance), low sleep restoration with more worry, unhelpful beliefs, and monitoring/attentional bias (28.2% variance), and low sleep quality with higher scores on all the psychological mechanisms (35.8% variance). Elevated daytime symptoms were related to more unhelpful beliefs and monitoring/attentional bias (44.3% variance).

Conclusion: The findings show that psychological factors discriminate those with insomnia from those with poor or normal sleep. The results also indicate that psychological factors are linked to insomnia-specific night-time and daytime symptomatology.

Purpose: The aim of this study was to examine psychological factors in insomnia and the association between psychological mechanisms and nighttime and daytime symptoms.

Methods: A cross-sectional examination in the general population was used. The study sample consisted of 1890 participants from the general population. The participants completed a survey on nighttime and daytime symptoms, health outcomes, and psychological factors.

Results: Relative to poor and normal sleepers, the insomnia group had higher scores on worry, beliefs, physiologic arousal, monitoring/attentional bias, and safety behaviors than the other two groups, and the poor sleepers exhibited a similar pattern relative to the normal sleepers. High total wake time was associated with more worry, physiologic arousal, and safety behaviors (26.3% variance), low sleep restoration with more worry, unhelpful beliefs, and monitoring/attentional bias (28.2% variance), and low sleep quality with higher scores on all the psychological mechanisms (35.8% variance). Elevated daytime symptoms were related to more unhelpful beliefs and monitoring/attentional bias (44.3% variance).

Conclusion: The findings indicate that psychological factors are linked to nighttime and daytime symptomatology in insomnia.

Objectives: Based on the lack of research on interventions targeting intrusive and worrisome thinking for insomnia, the aim was to examine whether a constructive worry (CW) intervention adds to the effects of behaviour therapy (BT).

Design: A randomized, controlled design was used. The design included a 2-week baseline, a 4-week intervention phase (sleep restriction and stimulus control [BT] or sleep restriction and stimulus control plus constructive worry [BT + CW]), and a 2-week follow-up.

Methods: Twenty-two patients with primary insomnia participated. The primary outcome was the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), and secondary endpoints were subjective sleep estimates, the Insomnia Severity Index (ISI), and the Work and Social Adjustment Scale (WSAS).

Results: Although both conditions produced significant improvements in subjective sleep estimates, no significant group differences over time were shown for total wake time (TWT) and total sleep time (TST). Both interventions resulted in reductions over time in insomnia severity, worry, and dysfunction. Compared to BT, BT + CW led to a larger decrease in insomnia severity at all three time points (controlled d= 1.101.68). In comparison with BT, BT + CW resulted in a larger reduction in worry at two of the time points (controlled d= 0.761.64). No significant differences between the two conditions were demonstrated for dysfunction. While more participants responded positively to treatment in the BT + CW (80100%) than in the BT condition (1827%), none of the participants remitted.

Conclusions: The findings suggest that, compared to BT alone, CW might result in additional improvements in insomnia severity and worry. Given the small sample size and short follow-up, future studies are warranted.

Objective: The purpose of this study was to examine whether there is a bidirectional relationship between on the one hand anxiety and depression and on the other hand insomnia over the course of a year.Methods: A randomly selected sample of 3,000 participants from the general population filled out a baseline (N = 1,812) and 1-year follow-up survey (N = 1,498) on anxiety, depression, and insomnia.Results: In cross-sectional analyses, bivariate correlations showed that anxiety, depression, and insomnia were significantly inter-correlated (φ = .31-.54). In prospective analyses, logistic regression analyses demonstrated that baseline anxiety (OR = 4.27, 8% of the variance) and baseline depression (OR = 2.28, 2% of the variance) were related to new cases of insomnia at follow-up. Further, baseline insomnia was related to new episodes of high anxiety and high depression at follow-up (OR = 2.30, 2% of the variance; OR = 3.51; 4% of the variance).Conclusion: Evidence suggested that there is a bidirectional relationship between on the one hand anxiety and depression and on the other hand insomnia. This suggests that anxiety, depression, and insomnia are intertwined over time, which has implications for theoretical conceptualizations and interventions.

Background: Insomnia and burnout has been suggested to form a bidirectional association.

Purpose: The aim of this study was to investigate whether there is a bidirectional relationship between insomnia and burnout over the course of a year among individuals in the workforce.

Method: This study employed a prospective design, where a randomly selected sample from the general population (20-60 year; N = 1,812) filled out a survey on insomnia and burnout. In employed participants (n = 1,258), the associations between insomnia and three dimensions of burnout (Maslach Burnout Inventory - General Survey) were examined, while controlling for age, gender, anxiety, and depression.

Results: The bivariate correlations between insomnia and the three burnout dimensions were significant at a low level (η: .12-.29). The longitudinal analyses demonstrated that insomnia was not associated with the incidence of burnout and vice versa. However, insomnia was demonstrated to increase the risk for the persistence of emotional exhaustion (OR = 3.02). Further, insomnia was not associated with the persistence of professional efficacy and cynicism, and burnout was not related to the persistence of insomnia.

Conclusion: In summary, this investigation demonstrated that insomnia and burnout are not bidirectionally related in the working population. While insomnia was linked to the maintenance of the central part of burnout, burnout was not related to future insomnia.

OBJECTIVE: The purpose of this study was to examine the role of perfectionism to pre-existing and future insomnia. METHODS: Based on a random sample from the general population (N=3600), 1936 participants filled out a baseline and 1-year follow-up survey on perfectionism (concern over mistakes and personal standards), emotional distress and insomnia. RESULTS: The results from sequential logistic regression analyses showed that concern over mistakes was significantly related to pre-existing and future insomnia. When emotional distress was accounted for, none of the perfectionism subscales contributed significantly in explaining pre-existing and future insomnia. CONCLUSIONS: The results indicate that though perfectionism seems to be related to both pre-existing and future insomnia, its role seems relatively weak

Study Objectives: The purpose of this study was to examine the course of insomnia in the general population over one year with an emphasis on prevalence, consequences, persistence, remission, and incidence of insomnia.

Design: This study employed a longitudinal design with a 1-year follow-up. Insomnia was defined as reporting problems sleeping for three nights or more per week during the past three months, problems with daytime symptoms or daytime functioning, and difficulties with sleep onset, sleep maintenance, or early morning awakening.

Participants: From a randomly selected sample of the adult general population (N = 3,000; 20-60 year), 1,746 individuals filled out a baseline and 1-year follow-up survey.

Results: The prevalence rates of insomnia were 6.8-9.7% at the two assessment points. The longitudinal analyses suggested that for 44.4% of the individuals with insomnia at baseline, insomnia was characterized by persistence (4.3% of the general population). For 56.6% of the individuals with insomnia at baseline, the condition remitted over one year (5.4% of the general population). The cumulative incidence of insomnia was 2.8% over the course of a year.

Conclusions: In summary, the results showed that insomnia is a prevalent condition in the general population associated with negative consequences and is characterized not only by persistence but also by relatively high remission and incidence.

The aim of this study was to investigate whether arousal, distress, and sleep-related beliefs are related to the development of insomnia. From a randomly selected sample of 3,600 individuals from the general population (50-60 year), 2,239 participants filled out a baseline and 1-year follow-up questionnaire. Logistic regression and cluster analysis were used to investigate whether the psychological mechanisms were related to the development of new cases of insomnia over one year and whether it was possible to classify the participants based on their profiles of psychological mechanisms. The results showed that arousal, sleep-related beliefs, and depression were significantly related to the development of new cases of insomnia (13% of the variance). High scores on all three mechanisms were characteristic of one cluster (18% new cases of insomnia) and low scores on the mechanisms of another cluster (5% new cases of insomnia). This study shows that arousal, sleep-related beliefs, and depression are associated with the development of insomnia, and that psychological mechanisms often co-occur in individuals who develop insomnia.

The aim with this investigation was to examine whether sleep-related beliefs, and reductions in such beliefs and attitudes, were related to clinical improvements in sleep and daytime symptoms following cognitive-behavioral therapy (CBT). In total, 64 patients with a short history of insomnia (3-12 months) who had participated in a randomized controlled trial with a one-year follow-up and received CBT were included. With stepwise multiple regression analyses, sleep-related beliefs were linked to clinical improvements in sleep (five outcomes) and daytime symptoms (seven outcomes). Results indicated that sleep-related beliefs played a small predictive role for clinical improvements in sleep and daytime symptoms following CBT group treatment. Sleep-related beliefs were only predictive of treatment response on sleep efficiency and sleepiness. Reductions in sleep-related beliefs were however differently related to improvements in sleep and daytime symptoms. Reductions in such beliefs were consistently linked to improvements in daytime symptoms (7-14% of the variance), but not to sleep improvements (except for sleep quality). In all, this might suggest that sleep-related beliefs play a slightly different role in insomnia than previously envisioned.

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.

Objectives: The purpose of this study was to examine whether arousal, distress, and sleep-related beliefs are related to the maintenance of insomnia in old adults.Design: From a randomly selected sample from the general population (N = 3,600; 50-60 year old), 2,239 participants filled out a baseline and 1-year follow-up survey.Methods: Logistic regressions were used to investigate whether psychological mechanisms were related to sleep status (insomnia: n = 230; poor sleep: n = 210; normal sleep: n = 658; good sleep: n = 253) over one year. Cluster analysis was employed to assess whether it was possible to classify the participants based on their profiles of psychological functioning.Results: The results showed that arousal, sleep-related beliefs about future consequences, and anxiety were significantly related to the maintenance of insomnia (14-66% of the variance). Of the individuals with persistent insomnia, 67% belonged to a cluster characterized by high scores on arousal, sleep-related beliefs, and anxiety, 24% to a cluster defined by medium scores on the three mechanisms, and 9% to a cluster characterized by low scores on the three mechanisms.Conclusions: This investigation shows that arousal, sleep-related beliefs, and anxiety are associated with the maintenance of persistent insomnia, but also that these mechanisms often co-occur in individuals with persistent insomnia.

This prospective study aimed to examine whether psychosocial work stressors were related to the development and maintenance of insomnia. From a randomly selected sample from the general population (N = 3,600), 1,873 participants aged 50-60 years old in the workforce filled out a baseline and 1-year follow-up questionnaire. Stepwise logistic regressions were used to investigate whether work stressors were related to the development and maintenance of insomnia over one year. The results showed that, among individuals with no insomnia at baseline, high work demands increased the risk of developing insomnia 1 year later (4% of the variance). Among participants with insomnia at baseline, work stressors did not influence the course of insomnia over one year. Finally, low influence over decisions, high professional compromise, and high work demands were related to the maintenance of insomnia (9% of the variance). The findings indicate that perceived work stressors are, although rather weakly, associated with the development and maintenance of insomnia. This might have implications for how insomnia is conceptualized as it places work stressors in the model and for how interventions at different stages of insomnia is implemented.

Objectives: The purpose of this study was to examine the factorial solution of the Modified Somatic Perception Questionnaire (MSPQ) among individuals with insomnia symptoms in the general population.

Design: A cross-sectional study with a randomly selected sample from the general population (N = 3,600; 20-60 year old) was used. In total, 251 of the 2,179 respondents fulfilled the criteria for insomnia symptoms and filled out a survey on demographic parameters, the MSPQ, the Hospital Anxiety and Depression Scale, sleep medication use, and health care consumption.

Methods: Exploratory factor analysis and correlations were used.

Results: The results showed that a two-factor solution, accounting for 47.31% of the variance, was extracted from the 13 items of the MSPQ. While one factor consisting of 10 items determined general symptoms of somatic arousal (a = .83), the other factor with 3 items assessed stomach symptoms and nausea (a = .78). The two factors were significantly inter-correlated (r = .54) and significantly associated with the total MSPQ (r = .96, r = .74). The two factors also showed discriminant validity with anxiety and depression and predictive validity with retrospective reports of sleep medication use and health care consumption. A few significant interactions emerged the two MSPQ factors and degree of sleep complaints.

Conclusions: Although it is often assumed that the MSPQ taps a single factor of somatic arousal, this study on individuals with insomnia symptoms suggests that a two-factor solution has the best fit. Further research on the factorial solution of the MSPQ is warranted.

Insomnia means difficulties in initiating or maintaining sleep and is commonly comorbid with psychiatric disorders. From being considered secondary to primary psychiatric disorders, comorbid insomnia is now considered an independent health issue that warrants treatment in its own right. Cognitive behavioural therapy for insomnia (CBT-I) is an evidence-based treatment for insomnia. The effects from CBT-I on comorbid psychiatric conditions have received increasing interest as insomnia comorbid with psychiatric disorders has been associated with more severe psychiatric symptomologies, and there are studies that indicate effects from CBT-I on both insomnia and psychiatric symptomology. During recent years, the literature on CBT-I for comorbid psychiatric groups has expanded and has advanced methodologically. This article reviews recent studies on the effects from CBT-I on sleep, daytime symptoms and function and psychiatric comorbidities for people with anxiety, depression, bipolar disorder, psychotic disorders and post-traumatic stress disorder. Future strategies for research are suggested. 

Objective: The purpose was to examine the psychometric properties of the Pre-Sleep Arousal Scale.

Methods: From a randomly selected sample of the general population (N = 5000), 2327 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1890 participants who did not fulfill criteria for a sleep disorder other than insomnia.

Results: Findings indicated that the PSAS did not produce an adequate factorial solution. When three problematic items were removed, the solution, accounting for 48.5% of the variance, improved (PSAS-13). One subscale, cognitive arousal (alpha = .88), consisted of five items (37.1%), and one subscale, somatic arousal (alpha = .72), of eight items (11.4%). The two factors were significantly inter-correlated (rho = .51) and associated with the PSAS-13 (rho = .91, rho = .80). Among those with insomnia, a shortened PSAS (PSAS-14) was established, which consisted of a cognitive and a somatic subscale (48.6% of the variance). The PSAS-13 and the two subscales showed discriminant validity between three sleep groups (normal sleep, poor sleep, and insomnia disorder) (R-2 = .24-.34). The PSAS-13 and the subscales demonstrated convergent validity with measures on sleep-related worry, sleep-related beliefs, anxiety, and depression. The PSAS-13 and the two subscales were significantly correlated with sleep parameters and daytime impairment.

Conclusion: Though acceptable psychometric properties were established for the PSAS, the cognitive sub-scale's focus upon general pre-sleep arousal and the relatively low variance accounted for calls for further work on and a possible re-conceptualization of the PSAS.

Since the beginning of the twenty-first century, there has been an increased focus on developing and testing cognitive components and therapies for insomnia disorder. The aim of the current review was thus to describe and review the efficacy of cognitive components and therapies for insomnia. A systematic review was conducted on 32 studies (N = 1455 subjects) identified through database searches. Criteria for inclusion required that each study constituted a report of outcome from a cognitive component or therapy, that the study had a group protocol, adult participants with diagnosed insomnia or undiagnosed insomnia symptoms or reported poor sleep, and that the study was published until and including 2016 in English. Each study was systematically reviewed with a standard coding sheet. Several cognitive components, a multi-component cognitive program, and cognitive therapy were identified. It is concluded that there is support for paradoxical intention and cognitive therapy. There are also other cognitive interventions that appears promising, such as cognitive refocusing and behavioral experiments. For most interventions, the study quality was rated as low to moderate. We conclude that several cognitive treatment components and therapies can be viewed as efficacious or promising interventions for patients with insomnia disorder. Methodologically stronger studies are, however, warranted. 

OBJECTIVES: The purpose of this longitudinal investigation was to examine the association between emotion regulation and future insomnia (incidence and persistence).

DESIGN: A longitudinal study in the general population.

METHODS: A survey was sent out to 5,000 individuals in the community. To those who returned the baseline questionnaire (n = 2,333), two follow-up surveys, 6 and 18 months later, were sent out and then completed by 1,887 and 1,795 individuals, respectively. The survey contained information about demographic factors, insomnia symptomatology, the Difficulties in Emotion Regulation Scale, anxiety, and depression.

RESULTS: The findings suggested that emotion regulation at baseline was not associated with the incidence or persistence of insomnia. Overall, the effect sizes were very small to medium. When examining changes in emotion regulation over time, a different pattern emerged. Partial support was established for the notion that decreases in emotion regulation were related to incident and persistent insomnia, as a decrease in emotion regulation was associated with a higher likelihood of future insomnia. Yet, the effect sizes were very small to small.

CONCLUSION: This study does partly point towards a longitudinal association between emotion dysregulation and insomnia. This might have implications for the conceptualization and management of insomnia as well as for future research.

Statement of contribution:

What is already known on this subject?

• Previous research has indicated that emotion dysregulation might be enhanced in patients with insomnia.
• A number of limitations have however hindered progress in understanding how emotion dysregulation is related to insomnia, such as limited research on the topic and relying solely on cross-sectional data.

What does this study add?

• The current investigation showed that emotion dysregulation is a risk factor for the development of incident and persistent insomnia.
• This study also shows that increased emotion dysregulation over time heightens the risk of incident and persistent insomnia.

Objectives: The aim of the studywas to compare the effects of a brief body scan with relaxation as an active control group to better understand their respective contributions to the reduction of sleep problems and anxiety symptoms among adolescent athletes.

Method: Two hundred and six adolescent athletes were recruited during the school year 2016/2017 and randomized into four arms: 4 weeks body scan, 8 weeks body scan, 4 weeks relaxation, and 8 weeks relaxation. Sleep problems and anxiety were measured at baseline and 4, 8, and 16 weeks after baseline. Time trends in sleep problems and anxiety were estimated using linear repeated measures models and compared between the four groups.

Results: Overall, there were beneficial time changes for sleep problems and anxiety symptoms in all four intervention groups, but significantly so only for anxiety symptoms. Specifically, the reduction of anxiety symptoms varied between - 11% per month for 8 weeks body scan, - 12% per month for 8 weeks relaxation, - 13% per month for 4 weeks relaxation, and - 16% per month for 4 weeks body scan. However, the time trends did not differ by intervention type or duration.

Conclusions: Both types of interventions had beneficial effects on anxiety independent of length of intervention, suggesting that a brief body scan as well as a brief relaxation could be part of a daily recovery practice for adolescent athletes.

Preregistration: This study was not preregistered.

BACKGROUND: Pain-related fear is related to disability in persistent pain conditions. Exposure treatment has been reported to be of great benefit in replicated single case experiments.

AIM: To evaluate the effects of exposure in vivo on fear and function in patients with persistent pain and work disability.

METHOD: We recruited 46 patients suffering from long-term back pain and reduced function, who also were deemed fearful according to standardized measures. Participants were randomized into either an exposure plus usual treatment or waiting list control plus usual treatment group. After the waiting period the control group crossed over and received the exposure treatment.

RESULTS: Between group comparisons showed a significantly better result for the exposure group on function, but not for fear or pain and effect sizes were modest (function=.6; fear=.4; pain=.1). When the control group crossed over to treatment significant treatment effects were noted for fear and function. For all patients treated, the pre to post-treatment effect sizes were large (function=.7; fear=1.1; pain=.9). There were 12 dropouts (8 in exposure and 4 in the control) during the first treatment phase and an additional 4 when the control group crossed over to exposure.

CONCLUSIONS: Compared to a group receiving usual treatment and waiting for exposure, the exposure in vivo group demonstrated a significantly larger improvement on function. Overall exposure had moderate effects on function, fear and pain intensity. We conclude that exposure may be important in treatment, but is not recommended as a "stand alone" adjunct to usual treatment.

Objective: Recent recommendations suggest that reassuring patients with an acute bout of low back pain and encouraging a return to normal activities may be helpful in preventing the development of chronic disability. There is also a question as to whether psychologic or physical therapy interventions actually add anything to such reassurance and advice in terms of preventing chronicity. This study aimed to ascertain the preventive effects on future sick leave and health-care utilization of adding on a cognitive-behavioral group intervention or a cognitive-behavioral group intervention and preventive physical therapy (focused on activity and exercise) relative to a minimal treatment group (examination, reassurance, and activity advice).

Subjects: A total of 185 patients seeking care for nonspecific back or neck pain who were employed and at risk for developing long-term disability volunteered to participate in the study. Of these 185, 158 (85%) completed the pre- and 1-year follow-up assessments.

Results: Significant differences were observed on the key outcome variables of future health-care utilization and work absenteeism. For health-care utilization, the cognitive-behavioral intervention group and preventive physical therapy group had significantly fewer healthcare visits than did the Minimal Treatment Group. For work absenteeism, the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group had fewer days during the 12-month follow-up than did the Minimal Treatment Group. The risk for developing long-term sick disability leave was more than five-fold higher in the Minimal Group as compared with the other 2 groups. However, there was no difference between the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group on sick leave.

Conclusion: Taken as a whole, this study shows that adding cognitive-behavioral intervention and cognitive-behavioral intervention and preventive physical therapy can enhance the prevention of long-term disability. There was no substantial difference in the results between the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group.

Background: Research and theory suggest that the symptom pair of chronic pain and insomnia may be maintained by shared cognitive-behavioral processes and consequences. Purpose: This investigation describes the psychometric properties of an instrument designed to assess the way people think about symptoms of pain and poor sleep. Method: A pool of 12 items was generated from existing and validated measures. Exploratory factor analysis (EFA) was conducted on item responses from a community sample of respondents who reported having had a problem with pain or sleep (n = 1702) during the three months previous to the survey. Multinomial regression analyses (MRA) were used to describe derived subscale responses for distinct groups reporting different degrees of perceived symptom severity and overlap. Results: EFA suggested the existence of three distinct dimensions: safety behaviors of behavioral orientation, safety behaviors of cognitive orientation, and catastrophizing. MRA analyses indicated that catastrophizing appears to be a shared psychological process and that both types of safety behaviors may be enhanced in co-morbid problems with persistent pain and insomnia. Conclusion: Cognitions pertaining to avoidant safety behaviors and catastrophizing are associated with symptom severity and overlap in co-morbid pain and sleep disorders. More research is needed to explore the importance of shared psychological processes and consequences when studying and treating ill health.

Objectives: The present study uses a cognitive behavioural framework to explore the idea that people with pain and sleep disturbances share a common cognitive vulnerability. 

Design: A longitudinal classification of people (N=592) in a community sample reporting on symptoms of pain and sleep at baseline, 3 and 12 months after the initial survey. 

Method: Cluster analysis was used to classify people reporting different degrees of symptoms, and their endorsement of cognitive behavioural processes, and consequences at each time point. Groups in similar clusters were linked at adjacent time points to document patterns of stability and change. The clusters are described at baseline on a range of indices not used to form them (problem duration, problem frequency, anxiety, and depression). Reliable change in reports of symptom-related interference was cross tabulated with reliable change in cognitive behavioural processes and consequences.

Results: Cluster analyses resulted in six homogenous and distinct profiles at each time point. Linking the clusters over time showed partial individual stability in cluster membership at adjacent time points. Reliable change in symptom-related interference was associated with reliable change in endorsement of cognitive behavioural processes and consequences on the short term.

Conclusion: The character and partial individual stability of symptom cluster membership suggests that problems with pain and sleep may share mutually maintaining cognitive behavioural processes and consequences. Future research should examine the utility of identifying mutually maintaining factors in the treatment of concomitant pain and sleep disturbances.