To Örebro University

BACKGROUND: Insomnia is a common and distressing disorder. Evidence suggests that metacognitive beliefs and maladaptive strategies, such as worry and rumination, may maintain insomnia.

OBJECTIVES: This study is the first trial of metacognitive therapy (MCT) for insomnia. It aimed to evaluate the effects of MCT on insomnia severity and examine how cognitive-attentional syndrome (CAS) components predict these changes.

METHODS: An uncontrolled open cohort trial was conducted with 31 participants in a clinic setting. Participants received up to ten MCT sessions and completed weekly measures of insomnia severity, anxiety, depressive symptoms, and metacognitive beliefs, including maladaptive strategies. The primary outcome was remission status from pre-to post-treatment. Associations between components of the cognitive-attentional syndrome (CAS) and insomnia severity were examined using a mixed model. Follow-up data were collected at 3, 6, and 12 months.

RESULTS: At post-treatment, 57 % of participants met remission criteria and 67 % scored below the clinical cut-off. Within-group effect sizes were large for the Insomnia Severity Index (Hedges' g = 1.64) and moderate for anxiety (HADS-A, g = 0.67) and depression (HADS-D, g = 0.72). Among those providing follow-up data, 87.5 % remained at or further improved their insomnia symptoms by their last assessment. Moreover, both between-person averages and within-person changes in maladaptive CAS strategies significantly predicted ISI scores, whereas only within-person changes in CAS-negative metacognitions reached significance.

CONCLUSIONS: These preliminary findings indicate that metacognitive therapy (MCT) shows promise as an intervention for insomnia. However, large-scale, controlled trials are necessary to further evaluate its clinical utility for this condition.

BACKGROUND: Although there is substantial evidence of the negative impact of caffeine use on sleep quality, few studies focus specifically on adolescents' patterns of use. This study aimed to identify patterns of caffeine use among adolescents and analyze their association with sleep quality.

METHOD: A cross-sectional study was conducted in southern Sweden including 1,404 adolescents aged 15-17 (56.3% girls). The frequency of use for coffee, tea, and energy drinks was evaluated, as well as the quality of sleep and its dimensions. Latent class analysis and multivariate analyses were conducted.

RESULTS: The weekly prevalence of caffeine use in adolescents reached 85% (n = 1189), with 40% (n = 559) drinking almost every day. Three caffeine-using patterns were identified: low probability caffeine use (28.1%; n = 393) characterized by sporadic use of coffee/tea, caffeinated soda use (55.2%; n = 784) related to high soda weekly consumption, and mixed caffeine use (16.7%; n = 227) that includes drinking diverse caffeine products almost every day including soda and energy drinks. Mixed caffeine pattern was associated to worse sleep followed by the soda pattern (p < .05), with significant differences observed in difficulties falling asleep (OR = 1.4; 95% CI = 1.1-1.7) or waking up (OR = 1.8; 95% CI = 1.4-2.4), greater daytime dysfunction (OR = 1.3; 95% CI = 1.1-1.7), and shorter sleep duration on schooldays (OR = 1.9; 95% CI = 1.5-2.4).

CONCLUSION: Distinct severity levels were found for caffeine use patterns among adolescents based on their association with sleep quality. Findings emphasize the need for addressing caffeine misuse among adolescents to promote health and adequate sleep habits in the transition to adulthood.

Background: Previous reports have highlighted the abundance of cognitive constructs in insomnia research as a growing issue. Several questionnaires that measure sleep-related cognitions have been developed and there are indications of conceptual overlap between different cognitive constructs and the questions used to operationalize them.

Objectives: This study examines the convergent validity of three established questionnaires measuring cognitive processes in insomnia: the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-10), and the Pre-Sleep Arousal Scale (PSAS-C). Another objective was to explore how a briefer scale can be structured as well as to investigate this scale's ability to predict incident and persistent insomnia compared to the established scales.

Methods: 2333 participants from the general population completed surveys on insomnia symptoms and cognitive processes at baseline and 18 months later. Confirmatory factor analysis was used to investigate the scales' conceptual overlap as well as distinctive factors. An exploratory factor analysis was conducted to investigate the underlying factor structure of the items from the APSQ, the DBAS-10 and the PSAS-C. This analysis formed the basis of the creation of a new short scale: Sleep Worry 7. Binary logistic regressions were used to assess all scales' abilities to predict incident and persistent insomnia.

Results and conclusions: The overlap between the three scales was neither large enough to conclude that they are measuring the same construct, nor could it be confirmed that they measure three distinct questionnaire-specific cognitive processes within insomnia. The brief scale created within this study was able to predict persistent insomnia at similar levels to the three established scales combined, indicating that it captures important cognitions involved in the maintenance of insomnia. Measuring sleep-related cognitions with fewer items might be beneficial in both clinical contexts and research.

OBJECTIVES: Insomnia is the most common sleep disorder in adults. About 10% of adults meet the diagnostic criteria, and about 30% suffer from subclinical symptoms. Seeking advice online is common when having health issues. There are no previous studies on Swedish Internet forums regarding types of advice and the logic behind the recommendations given for how to handle troubled sleep. The purpose of the study was to examine which treatment methods for insomnia symptoms were recommended by forum users on the Swedish Internet forum Flashback.

METHODS: A thematic analysis was conducted on 1174 posts.

RESULTS: The analysis resulted in four themes: (1) Advice on healthcare, (2) Bedtime and sleep environment strategies, (3) Implement long-term lifestyle changes, and (4) Advice on nonprescribed, legal, or illegal drugs. Notably, a large portion of the recommendations provided emphasized the utilization of pharmacological interventions, including prescription drugs, over-the-counter medications, supplements, illegal substances, or combinations of these. This despite the fact that many advice givers attributed insomnia to psychological causes such as stress.

CONCLUSIONS: Insight into recommendations given on Internet forums is important for healthcare personnel; advice might shape patients' sleep habits as well as expectations on insomnia treatments.

Introduction: Teenagers who identify as other genders than their biological sex (transgender and gender diverse: TGD) are at a higher risk of health problems compared to gender conforming peers (cisgender youth). One aim of the current study was to investigate the prevalence of TGD youth in a general population sample. A second aim was to investigate differences in insomnia and stress between TGD youth ,cisgender girls, and cisgender boys as well as the influence of stressors and demographic factors on insomnia for the different groups.

Method: Cross-sectional survey data from a Swedish school-based study collected in 2018 were used. Those who had reported their gender identity as “other” were compared to cisgendered girls and boys. ANOVAs were used to compare group means. Regression models (hierarchical linear regressions) were tested in the whole group to explore if demographics and stressors as measured by the Adoles-cent Stress Questionnaire (ASQ) statistically predicted outcomes on the Insomnia Severity Index (ISI).

Results: The sample consisted of 3067 students (M = 17.8 years) who were categorized as cisgendered girls (n = 1544), cisgendered boys (n = 1482) or TGD youth (n = 41, 1.3% of the whole sample). ANOVAs demonstrated that TGD youth (ISI = 9.28) and cisgender girls (8.84) reported more insomnia symptoms in comparison to boys (6.78). Also, TGD youth (ASQ = 65.66) and cisgender girls (60.32) reported higher degrees of stress compared to cisgender boys (45.37). Further, the regressions demonstrated that cisgender girls were more likely to report insomnia symptoms than cisgender boys, when only demographic variables were entered into regression models. (TGD youth showed a similar result, albeit not significant). Models with stressors magnified the odds of reporting insomnia for the whole group, and erased gender differences.

Conclusion: Stress increased the odds of reporting insomnia. The higher degrees of insomnia symptoms in cisgender girls and TGD youth might be explained by more exposure to stressors. Thus, this study highlights health disadvantages of not belonging to the gender norm. As both stress and insomnia are possible to affect through prevention and promotion, targeted interventions for vulnerable groups might decrease the gender differences.

INTRODUCTION: Transgender and gender-diverse (TGD) youth experience more stressors and are therefore at a higher risk of health problems compared with their cisgender peers. The aim of this study was to investigate the prevalence of TGD youth in a general population sample and to explore a wide variety of health-related factors. We investigate differences in stressors and health outcomes between TGD youth and cisgender girls and boys and the influence of stressors and demographic factors on health outcome in the whole group.

METHODS: Cross-sectional survey data from a Swedish school-based study were used (N = 3,067, M = 17.8 years). Those who had reported their gender identity as "other" or other than their assigned gender (N = 41) were compared with cisgendered girls (n = 1,544) and boys (n = 1,482). Regression models in the whole group explored if demographics and stressors statistically predicted health outcomes.

RESULTS: In comparison with cisgender girls and boys, TGD youth (1.3% of the whole sample) reported a higher prevalence of self-harm and pain problems. Both TGD youth and cisgender girls more frequently reported insomnia, social anxiety, depressive symptoms, pain, and stressors compared with cisgender boys. When only demographic variables were entered, but not when stressors were added to the model, being TGD magnified the odds of depressive symptoms, sub-diagnostic social anxiety, and pain problems. Stressors magnified the odds of reporting health problems for the whole group.

CONCLUSION: TGD youth generally reported more stressors, which negatively influence health outcomes. Results are important for professionals who meet TGD youth.

Introduction: The Cognitive Model of Insomnia by Harvey has gained widespread recognition since 2002 and stimulated treatment development. In short, the model describes how excessive mental focus on sleep creates vicious cycles which maintain insomnia. Little is known about how the model might fit other sleep diagnoses, although the processes are applicable to other somatic disorders such as chronic pain and IBS. The aim of this study was to investigate the degree of insomnia-related processes in other sleep disorders.

Method: Participants (n = 2370) from a randomly selected sample of the general population completed a survey that included five psychological processes as outlined by Harvey (2002): unhelpful beliefs about sleep, monitoring for sleep-related threats, sleep-related safety behaviours, pre-sleep somatic arousal, and sleep-related worry. The following sleep disorders were classified based on the SLEEP-50 questionnaire: apnoea (n = 176), delayed sleep phase (n = 93), insomnia (n = 367), narcolepsei (n = 12) nightmares (n = 84), and PLMS/RLS (n = 184).

Results: The scores on the five processes were significantly elevated for all sleep disorders compared to people without sleep problems.There was a significant positive correlation between presence of sleep disorder and several of the insomnia cognitive processes even after accounting for levels of insomnia. Comorbidity was high in the sample.

Conclusion: This study expands upon Harvey's Cognitive Model of Insomnia by demonstrating its possible applicability beyond insomnia to a range of other sleep disorders. The results indicate that sleep-disturbing processes of insomnia might be applicable in other sleep disorders. The high comorbidity observed in this sample points to the complexity of sleep disorders. Future research should further investigate the mechanisms through which these processes contribute to different sleep disorders.

OBJECTIVES: The use of social media during bedtime has increased in the past years among adolescents, contributing to disturbed sleep quality, which could potentially be related to emotional problems. This study aimed to analyze the mediation effects of sleep parameters on the relationship between NightTime Texting (NTT) on social media and adolescent sadness.

METHODS: We used a cross-sectional study and evaluated a total of 1464 Swedish students aged 15-17 (55.7% girls) to examine their frequency of NTT on social media, sleep parameters, and adolescent sadness. Bivariate and mediation analyses were performed.

RESULTS: Approximately 60% (n = 882) of adolescents engaged in nighttime instant messaging, with 37% (n = 330) reporting texting every night. Higher frequency of NTT was significantly associated with later bedtimes (η2 > 0.12), extended weekend wake-up times (η2 = 0.07), increased social jetlag (η2 = 0.07), and reduced sleep duration on schooldays (η2 = 0.10). Multicategorical parallel mediation analyses revealed that sleep duration on schooldays had an indirect effect on the relationship between both Occasional NTT (a11b1 = 0.05, p < .05) and Daily NTT (a21b1 = 0.12, p < .05) with sadness. Mediation effects were not moderated by gender (p > .05), however, the association between Occasional NTT and higher sadness was significantly linked to boys (t = 2.72; p = .007).

CONCLUSIONS: Findings showed a large percentage of adolescents engaging in nighttime social media use with worse quality of sleep, and underlined sleep duration on schooldays as a mediator associated with emotional problems in adolescents. These insights can aid in developing strategies for healthier habits to address the misuse of social media and prevent related health problems.

INTRODUCTION: Paradoxical intention (PI) is an insomnia treatment developed in the 1970s, which instructs patients to gently attempt to remain awake while in bed at night with the lights off. Previous research indicates PI's potential in improving insomnia, although no study has been conducted in the last few decades during which the insomnia diagnostic criteria have changed. Additionally, there are knowledge gaps regarding outcomes related to wake after sleep onset, the treatment mechanisms as well as the acceptability and feasibility of the treatment. This study therefore aims to address these gaps by assessing the potential mechanisms, preliminary efficacy, and patient experience and acceptability of PI.

METHODS AND ANALYSIS: We aim to include 40 adult participants with insomnia, aged 18 and above, from the Swedish general population. In this uncontrolled pilot study using a mixed-methods approach, both qualitative and quantitative data will be collected. The trial will be conducted on a self-help online platform, accessible from participants' homes, with weekly phone call support by therapists. Process and outcome measures will be assessed weekly across a 4-week intervention period and at a 3-month follow-up. A subset of participants will be asked to participate in qualitative semistructured interviews regarding the treatment.

ETHICS AND DISSEMINATION: Ethical approval for this project has been granted by the Swedish Ethical Review Authority (Dnr: 2023-06594-01). All participants will sign informed consent forms on a web service application prior to enrolment. From this mixed-methods study, we anticipate insights into the preliminary efficacy and mechanisms of paradoxical intention for treating insomnia, enriched by patient experience data. Results will be disseminated through peer-reviewed publications. The findings will inform adaptations to the treatment protocol and serve as groundwork for a possible larger scale randomised controlled trial.

TRIAL REGISTRATION NUMBER: NCT06259682.