This article appeared in a journal published by Elsevier. The attached
copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
Author's personal copy
Sleep and emotions: A focus on insomnia
Chiara Baglionia,*, Kai Spiegelhaldera,c, Caterina Lombardob,d, Dieter Riemanna,e
aDepartment of Psychiatry & Psychotherapy, University of Freiburg Medical Center, Hauptstraße 5, 79104 Freiburg, Germany
bDepartment of Psychology, ‘‘Sapienza’’ University of Rome, Via dei Marsi 78, 00185 Roma, Italy
a r t i c l e i n f o
Received 7 August 2009
Received in revised form
16 October 2009
Accepted 17 October 2009
Available online 3 February 2010
s u m m a r y
Insomnia disorder is defined as difficulties in initiating/maintaining sleep and/or non-restorative sleep
accompanied by decreased daytime functioning, persisting for at least four weeks. For many patients
suffering from depression and anxiety, insomnia is a pervasive problem. Many of the aetiological theories
of insomnia postulate that heightened emotional reactivity contributes to the maintenance of symptoms.
This review focuses on the role of emotional reactivity in insomnia, and how the relationship between
insomnia and depression and anxiety may be mediated by emotional reactivity. Furthermore, studies
investigating the valence of emotions in insomnia are reviewed. Overall, there is empirical evidence that
dysfunctional emotional reactivity might mediate the interaction between cognitive and autonomic
hyperarousal, thus contributing to the maintenance of insomnia. Moreover, dysfunctions in sleep–wake
regulating neural circuitries seem to be able to reinforce emotional disturbances. It seems plausible that
dysfunctional emotional reactivity modulates the relationship between insomnia and depression and
anxiety. Considering the interaction between sleep and emotional valence, poor sleep quality seems to
correlate with high negative and low positive emotions, both in clinical and subclinical samples. Good
sleep seems to be associated with high positive emotions, but not necessarily with low negative
emotions. This review underlines the need for future research on emotions in insomnia.
? 2009 Elsevier Ltd. All rights reserved.
The International Classification of Sleep Disorders-2nd edition
(ICSD-2)1defines insomnia as a difficulty in initiating/maintaining
sleep or non-restorative sleep accompanied by decreased daytime
functioning, such as fatigue/malaise, daytime sleepiness, mood
disturbance/irritability, motivation/energy/initiative reduction and
a period of at least four weeks. Insomnia is a pervasive problem for
many patients suffering from psychiatric conditions such as
depression, posttraumatic stress disorder, alcoholism, bipolar
disorder, eating disorder, generalized anxiety, and obsessive
compulsive disorder.2In this article, a systematic review will be
presented focussing on the role of emotional reactivity, and of
positive and negative emotions, in insomnia and in the relationship
between insomnia and depression and anxiety. First, a brief
introduction on the conceptualization of emotions from a psycho-
logical perspective will be provided. Moreover, in the introductory
section the role of emotional reactivity in insomnia, as described by
aetiological theories, will be briefly reviewed. Subsequently, the
research methodology will be described. This review will then
focus on two parts: the involvement of emotional reactivity in the
relationship between insomnia and depression and anxiety; and
the relationships between sleep and negative and positive
emotions (considering first sleep deprivation and then sleep
Emotions from a psychological perspective
Emotions are responses to internal and external stimulation
characterised byavalence connotation and a specific strength. They
include changes in multiple systems: subjective, physiological,
behavioural, and relational.3Emotions are processes evolved for
facilitating appropriate responses to environmental circumstances
to reach individual or social goals in quick and effective ways.3
Emotional reactivity indicates the individual’s threshold, peak
intensity, rise time, and recovery time in response to emotional
individuals and are linked to stable personality dimensions (e.g.,
neuroticism, anxiety, and extraversion). High or low emotional
* Corresponding author. Tel.: þ49 761 270 6589; fax: þ49 761 270 6619.
E-mail addresses: email@example.com (C. Baglioni), kai.
uniroma1.it (C. Lombardo), firstname.lastname@example.org (D. Riemann).
cTel.: þ49 761 270 6589; fax: þ49 761 270 6619.
dTel.: þ39 06 4991 7529; fax: þ39 06 4991 7711.
eTel.: þ49 761 270 6919; fax: þ49 761 270 6523.
Contents lists available at ScienceDirect
Sleep Medicine Reviews
journal homepage: www.elsevier.com/locate/smrv
1087-0792/$ – see front matter ? 2009 Elsevier Ltd. All rights reserved.
Sleep Medicine Reviews 14 (2010) 227–238
Author's personal copy
reactivity, which results from difficulties in regulating emotions, is
a central feature of most psychiatric conditions.4
Emotions have been conceptualized as discrete entities or as
defined by underlying motivational or personality dimensions. The
discrete approach considers a small number of basic emotions
reflecting specific neuronal, body/expressive and feeling/motiva-
tional pathways (e.g.,5). Izard,5for example, describes 10 basic
emotions: anger, disgust, fear, shyness, interest, joy, surprise,
distress, contempt, and guilt. The dimensional approach refers to
varying activation in centrally organized appetitive and defensive
motivational systems (e.g.,6,7). It has been shown that these moti-
vational systems are reciprocally inhibitory, which means that
when one system is activated the other one is inhibited.7These
systems direct behaviour toward appetitive stimuli or away from
aversivestimuli. Accordingly, the subjective experience of emotions
can be described on the basis of valence (positive vs negative) and
arousal level (from low to high). Watson and Tellegen,8based on
a personality perspective, proposed that the positive and negative
affect dimensions are independent and orthogonal dimensions.
According to this, the emotional experience is not always a marker
of pure positive or negative emotions: surprise, for example, could
be a marker of both high positive and negative emotions.
Self-reports are the most common methodology to assess the
subjectivecomponentof emotions.One of the most frequently used
instruments is the Positive and Negative Affective Schedule
(PANAS9), which is based on the Watson and Tellegen model.8The
PANAS is a list of 20 adjectives describing affective states, 10 posi-
tive (interested, excited, strong, enthusiastic, proud, alert, inspired,
determined, attentive, active) and 10 negative (distressed, upset,
guilty, scared, hostile, irritable, ashamed, nervous, jittery, afraid).
People are instructed to rate how intense they experience each
affective state on a five-point scale ranging from 1 (not at all) to 5
Studies on the psychophysiological component of emotions
have typically focussed on autonomic outputs, such as heart rate,
blood pressure, electrodermal activity or muscle tension changes.7
There is increasing evidence indicating that some autonomic
indices capture predominantly the arousal dimension (e.g., skin
conductance), while others measure the valence dimension of
emotions (e.g., facial EMG).7Finally, neuroimaging techniques may
lead to a better understanding of the neurobiological correlates of
emotions. Neuroimaging studies in major depression have identi-
fied structural and functional brain abnormalities in those struc-
tures that are involved in the regulation of emotions, for example in
the prefrontal cortex, and the amygdala.10
Emotional reactivity within the aetiological theories of insomnia
The first theoretical account concerning the role of emotion
dysregulation in insomnia was proposed by Kales et al.11The
authors evaluated personality patterns of 124 people with primary
insomnia using the Minnesota Multiphasic Personality Inventory
(MMPI). Clinical relevant scores in one or more MMPI scales were
reported by 85% of the sample. The scales with the highest scores
were: depression, psychasthenia, and conversion hysteria. These
results were replicated by the same authors in another study
including a control group.12Thus, the personality style of people
with primary insomnia was characterised more by internalising
problems (e.g., depression) than by externalising problems
(e.g., acting out oraggression). Based on these findings, Kales et al.11
proposed the ‘‘internalisation of conflicts model’’ of insomnia.
According to this model, the predisposition to internalise psycho-
logical conflicts leads to heightened levels of emotional arousal,
which in turn provokes physiological hyperarousal and renders the
individual unable to sleep.
The majorityof current aetiological theories considerheightened
levels of autonomic, cortical, cognitive, and emotional arousal to be
a stable feature of patients with insomnia (e.g.,13–16). Perlis et al.16
postulated a top-down approach: insomnia results from enhanced
cortical hyperarousal, measured objectively, for example, as
increased fast frequencies in the sleep EEG. This is experienced
subjectively as cognitive hyperarousal (e.g., intrusive thoughts
increased autonomic arousal. According to Espie,15affect dysregu-
lation mediates the effect of cognitive and autonomic hyperarousal
on sleep. Riemann et al.13proposed alternatively that a bottom-up
process may be involved in the aetiology of insomnia: a genetically
determined dysfunction in sleep–wake regulating neural circuitries
in conjunction with precipitating stressors may lead to sleep
disruption as well as to cognitive and emotional disturbances. Of
note, the top-down and the bottom-up processes are not in contra-
diction. Indeed, as transitory insomnia is a common experience for
many persons, it seems plausible that only those individuals genet-
prone to develop a disorder of chronic insomnia.
Emotion dysregulation in insomnia has been described by two
patterns of subjective experience of emotions. The cognitive model
of insomnia14described the heightened cognitive activity as exces-
sively negative toned in this patient group. The psychobiological
strong positive and negative emotions.
DSM-IV Diagnostic and Statistical Manual for Mental
fMRIFunctional magnetic resonance imaging
IAPS International Affective Picture System
ICSD-2 International Classification of Sleep Disorders-2nd
MMPI Minnesota Multiphasic Personality Inventory
PANASPositive and Negative Affective Schedule
PFC Prefrontal cortex
American Academy of Sleep Medicine
American Psychiatric Association
Cognitive behavioural therapy for insomnia
Glossary of terms
Affect: a superordinate construct which includes at least four categories of states or
Emotion: process triggered by internal and external stimulation characterised by
a valence connotation and which include changes in multiple systems: subjec-
tive, physiological, behavioural, and relational
Emotion dysregulation: difficulties in regulating emotions (see emotion regulation).
Emotion regulation: process by which people influence the quality, intensity and
duration of emotions
Emotional instability: difficulties in tolerating frustration and frequent experience of
intense negative emotions.
Emotional reactivity: threshold, peak intensity, rise time, and recovery time of
a response to emotional stimulation
Emotional valence: positive or negative tone of an emotion
Emotionality: responsiveness to emotional stimulation
Impulses: responses characterized by a valence connotation, but independent of the
Mood: emotional tone that is unprovoked by a stimulus and which refers to a stable
Stress: state of negatively toned psycho-physiological activation
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238 228
Author's personal copy
A summary of the interplay between the different types of
arousal in insomnia, as described by the present aetiological
theories of insomnia, is schematized in Fig. 1.
Studies were identified via literature searches using PUBMED,
MEDLINE, PsycINFO, and PsycArticles. Key search terms included:
‘‘emotions’’ paired with ‘‘sleep’’ and ‘‘insomnia’’.
We grouped the identified articles in the following categories:
1) Insomnia or poor sleep and emotional reactivity: relations with
other psychological diseases and implications for treatment: a)
sleep length and vulnerability to stress; b) insomnia and
depression and anxiety; c) efficacy of strategies dealing with
emotional processes in CBT-I;
2) The developmental perspective;
3) Does sleep predict affective states?: a) sleep deprivation and
d) insomnia: the emotional valence of cognitive activity;
4) Do affective states predict sleep quality?: a) loneliness; b)
complicated grief and bereavement; c) hostility, impulsivity,
aggression and anger; d) romantic love.
As we focussed on the role of emotionality and its valence in
insomnia and poor sleep in humans, we excluded articles dealing
with issues not directly related to it, namely: 1) dreams; 2) sleep
disorders other than insomnia; 3) pharmacological treatment
effects; 4) sleep and emotional memory; 5) the effects of sleep
deprivation treatment on depressive mood; 6) insomnia and
burnout; and 7) insomnia and the emotional component of pain.
Additionally, non-English articles were excluded. Following these
criteria, we identified 72 publications which were estimated to be
of interest and warranted closer inspection.
Insomnia or poor sleep and emotional reactivity: relations
with other psychological diseases and implications for
Sleep length and vulnerability to stress
Short sleep duration (<6 h) has been linked to specific person-
ality traits that are known to predispose to psychiatric condi-
tions.17–19Kumar and Vayda19collected information about anxiety
levels in 25 long and 25 short sleepers, and found that short sleep
length was associated with high levels of anxiety. In another
study,18worry was found to be negatively correlated with habitual
sleep length in a sample of 222 undergraduate and graduate
students. Thus, people who slept less tended to worry more often.
In a very large sample of 5877 participants aged between 15 and
54 years, neuroticism, extraversion, openness to experiences,
self-criticism, and interpersonal dependency were assessed, as well
as information about sleep duration.17In this study, neuroticism
and self-criticismwerenegativelyrelated tosleep length, evenafter
controlling for depression and anxiety. Based on these results,
reduced quantity of sleep seems to be associated with difficulties in
coping with stressful life events. However, as all of these studies
were cross-sectional, no conclusions can be drawn about cause–
Insomnia and depression and anxiety: directionality studies and
a possible modulation role of emotionality
Historically, insomnia has been conceptualized as a symptom of
psychopathology, especially in relation to mood disorders.20More
recently, insomnia has been considered as a primary disorder if it is
present without the co-existence of clinically relevant psychiatric
diseases, and as a secondary symptom of psychopathology when
aclinical diagnosis foranother mental disorder ispresent. However,
at least with respect to the link to depression, chronic insomnia can
also exist years before the first onset of an episode of depression.
a more appropriate term than ‘‘secondary’’.21–23Riemann and
Voderholzer24summarised the findings on the link between
a period of more than two weeks predict an increased risk for
developing depression within the following three years. Indeed,
a number of longitudinal studies indicate that insomnia or poor
sleep are risk factors for major depression (Table 1). Of the 2125–45
studies that we identified, only two failed to find that symptoms of
insomnia predict an increased risk for future depression.31,45Two
studies found this result only in women.35,43Two investigations
reported that insomnia had a higher predictive value for future
anxiety27–29,31,33,39,44,45: five of them found insomnia to predict
turn, one study found anxiety to be predictive for subsequent
insomnia.27Of note, one study did not find any effect.45
Fig.1. The interaction between cortical, cognitive, emotional and autonomic hyperarousal in insomnia is maintained through two parallel routes: a top-down process (hyperarousal
determining and maintaining insomnia) and a bottom-up process (dysfunctions in sleep–wake circuitres determining and maintaining emotional and cognitive alterations).
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238229
Author's personal copy
Longitudinal and test–retest studies on the directionality between insomnia and depression and anxiety.
Number % Female Measures of InsomniaMeasures of Depression
or/ and Anxiety
Brief summary of the
Gregory et al.,
2 yrs 8 yrs and
2 months–8 yrs
and 11 months
57.0 Child Sleep Habits
sleep problems at BSL
predicted symptoms of
depression at 10 yrs, but not
the other way round. (OR not
Insomnia with a duration
>2 weeks predicted major
depression episodes (OR¼1.60)
Buysse et al.,
20 yrs19–20 yrs 59150.6 The Structured
Interview and Rating of
Social Consequences of
Psychic Disturbances for
Basic Nordic Sleep
& Lindblom 2008
12 months 20–60 yrs1.498 55.0
HADS to assess anxiety
Anxiety indicative of a greater
risk for insomnia (OR¼4.27).
Insomnia indicative of a
greater risk for depression
between anxiety and
depression on one side and
insomnia on the other side
(insomnia indicative of future
anxiety OR¼2.28 and of
future depression OR¼2.71)
Insomnia: risk factor for
depression (OR¼1.10) and
Morphy et al., 200712 months
?18 yrs2.363 55.9Jenkins Sleep Scale HADS to assess anxiety
Neckelmann et al.,
11 yrs20–69 yrs25.130 48.1Questions about the
presence of DIS
sleep) and/or DMS
Hamilton Rating Scale for
Depression (HAMD) sleep
HADS to assess anxiety
Perlis et al., 200612 months60–94 yrs147 56.5
SCIDþHAMD Persistent insomnia was
approximately 6 times more
likely to be associated with a
first episode of major
depression compared to no
46% of children with
persistent sleep problems
at age 5, 7 and 9 had anxiety
in adulthood (OR¼1.60).
No significant effect with
respect to depression
Difficulty falling asleep
indicative of a greater risk
of future depression
Sleep problems at 4 years
(OR not computable)
High insomnia at BSL
increased the subsequent
risk of depression (OR ¼1.92)
Gregory et al., 20052–7–16–21 yrs 5 yrs 94348.0 Parent reports on children
sleep: responses to questions
scored on a binary scale
(0¼no sign of a problem,
1¼sign of a problem)
Schedule to assess
anxiety and depression
at 21 and 26 yrs
Hein et al., 20035 yrs
?55 yrs 664 59.3 Composite International
Diagnostic Interview (CIDI)
Gregory & O’ Connor
9–10–11 yrs 4 yrs 49046.0 Children Behaviour
Roberts et al., 200212 months 11–17 yrs4.17549.0 Questions on sleep in the
past 4 weeks based on
Module on major
from the Diagnostic
Interview Schedule for
‘‘Do you feel depressed’’
dicotomic question at
baseline and HADS at
*DSM-12D (12 items
for the diagnosis of
depression based on
Mallon et al., 200012 yrs45–65 yrs1.244 53.0 Uppsala Sleep Inventory
Insomnia is indicative of a
greater risk of future
depression only in women
2.6% of people with
no sleep complaints at BSL
was classified as depressed
at FU, whereas 71.9% of
people with sleep complaints
at BSL was classified as
depressed at FU (OR¼4.85)
Roberts et al., 200012 months50–95 yrs2.370 56.41 item from the DSM-12 D*:
trouble falling asleep or
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238230
Author's personal copy
These studies clearly show that insomnia predicts the onset
of depression, especially in women. That being said, whether the
relationship is unidirectional or not, awaits further assessment,
as the majority of the studies aforementioned focussed specifi-
cally on the effect of insomnia on depression. Additionally,
insomnia and anxiety seem to be linked through a bidirectional
relationship. Koffel and Watson46conducted an interesting study
investigating the association between nighttime and daytime
symptoms were defined as poor sleep quality, long sleep latency,
and minutes awake at night; daytime symptoms were con-
ceptualised as fatigue and sleepiness. This association was tested
in three different samples: 349 college students, 213 older
adults, and 266 patients. Both nighttime and daytime symptoms
of insomnia were found to be significantly related to depression
and anxiety (panic attacks, post-traumatic stress disorder, social
Table 1 (continued)
Number% Female Measures of Insomnia Measures of Depression
or/ and Anxiety
Brief summary of the
Foley et al.,
?65 yrs6.89963.3 Insomnia questionnaire
falling asleep or early
Center for Epidemiologic
Studies Depression Scale
People with insomnia were
more likely to report
depression at FU
compared to people without
Insomnia is indicative of a
greater risk for subsequent
Chang et al.,
34 yrs Mean of 26 yrs1.024 All males Habit Survey Questionnaire Checklists þmedical
reviewed by 5 physicians
basing on DSM-IV
Schedule (DIS) based
on the DSM-III diagnoses
et al., 1997
?18 yrs7.113 60.4‘‘Have you ever had a period
of 2 weeks or more when
you had trouble falling
asleep, staying asleep or
waking up too early’’ þfurther
information about physical
illness, medication, or drug
or alcohol use for exclusion
National Institute of Mental
Health (NIMH) Diagnostic
Interview Schedule sleep
items: insomnia is defined
as a period of at least 2 weeks
of trouble falling asleep,
staying asleep or waking up
too early nearly every day
Geriatric Mental State (GMS)
(‘‘Have you had any problems
information about symptoms
and causes in the previous
The Sleep Disturbance
Scale for assessing the
presence of the insomnia
Insomnia is associated with
increased risk of subsequent
first onset of major depression
and panic disorder (OR¼5.40)
Breslau et al.,
3 yrs21–30 yrs 1.00761.7
*The NIHM Diagnostic
revised to cover the
Complaints of 2 weeks or
more of insomnia nearly
every night as a marker of
subsequent onset of major
Brabbins et al.,
?65 yrs1.070 60.8
Geriatric Mental State
Insomnia enhanced the risk
for depression (OR¼1.39).
Livingston et al.,
?65 yrs705 63.4Semi-structured
People with chronic
insomnia were significantly
more likely to present
depression at FU than
those without insomnia
Sleep disturbance among
women and fatigue among
males were significantly
associated with experiencing
an onset of major depression
People with chronic insomnia
were nearly 40 times more
likely to have major
and over 6 times more likely
to have an anxiety disorder
(OR¼6.3) compared to those
Insomnia at baseline did not
predict subsequent onsets
of depressive disorders
(OR¼2.16) or anxiety
Dryman & Eaton
?18 yrs133 71.4Diagnostic Interview
of DSM-III criteria for
of DSM-III criteria for
Ford & Kamerow
?18 yrs7.95459.8Questions about sleep
disturbances on the
DIS þfurther information
about symptom duration
(and about physical illness,
medication, or drug or
alcohol use for exclusion
Three groups of insomnia
were identified: continuous
repeated brief insomnia
Schedule (DIS) based
on the DSM-III diagnoses
Vollarath et al.,
?21 yrs 591 51.2
based on the DSM-III
SCID¼Structural clinical interview; HADS¼Hospital Anxiety and Depression Scale; BSL¼baseline; FU¼follow up; OR ¼odd ratios.
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238 231
Author's personal copy
phobia, and generalized anxiety disorder). However, daytime
symptoms were more strongly related to depression and anxiety,
when compared with nighttime symptoms. Moreover, daytime
impairments showed a stronger relationship to depression than
to anxiety in all three samples. Additionally, daytime symptoms
were associated with a higher negative emotionality and a lower
positive emotionality, as measured by the PANAS, in all three
samples. Thus, heightened negative emotionality and diminished
positive emotionality might be the psychological mechanism
through which insomnia, and especially the daytime component
of insomnia, acts as a risk factor for depression. It appears of
utmost importance to investigate whether specific daytime
impairments have a stronger relation to psychopathology than
others (e.g., fatigue or daytime sleepiness or mood disturbances/
irritability) or whether the link is explained by the combination
of different forms of impairment.
Cognitive–behavioural treatment for insomnia (CBT-I): could the
inclusion of strategies dealing with emotional processes enhance the
CBT-I is a multi-component treatment that features behavioural,
cognitive and educational components.47The efficacy of CBT-I for
primary insomnia has been clearly demonstrated.48–50Moreover,
CBT-I is also efficacious in patients with insomnia in the context of
other psychiatric disorders.51,52This treatment does not only seem
patients. Thus, treating insomnia could be important for preventing
the development of subsequent disorders. Concerning heightened
emotionality in those with insomnia, two studies have used the
Pennebaker writing intervention as a method to specifically target
emotional processes.53,54This intervention consists of the instruc-
tion to write down thoughts, worries and emotions. It is proposed
that writing about emotional experiences is a method to facilitate
emotional processes. Harvey and Farrel54found in 44 poor sleepers
that those who underwent a 3-nights Pennebaker writing
intervention reported shorter sleep-onset latencies compared to
a no-writing group. Mooney, Espie and Broomfield53found that
a Pennebaker writing group reported significantly reduced pre-
sleep arousal compared to a control group. However, they did not
find an effect of the intervention on sleep-onset latencies. The
standard CBT-I protocol already includes some strategies which
armchairandwritedownalistofworries andalistof whattodothe
next day. The rationale of this strategy is to prevent emotionally-
loaded intrusive thoughts during the sleep-onset period, as all
worries have been ‘‘already’’ processed before going to bed.
A deeper understanding of the mechanisms through which
insomnia leads to an increased risk for psychopathology is of great
relevance; perhaps leading to the enhancementof existing effective
treatments, as well as a more complete understanding of the role of
intervention in the prevention of psychopathology development.
If heightened negative emotionality characterises insomnia and
modulates its relationship with psychiatric conditions, additional
strategies dealing with emotional processes could enhance the
efficacy of the treatment.
Sleep quality, insomnia and emotions: a developmental
The investigation of the relationship between insomnia and
other psychological diseases is of particular interest in children
because improvements in the efficacy of treatments might stop the
progression to serious and enduring problems in adulthood. Sleep
problems in childhood are bidirectionally related to emotional and
behavioural problems (e.g.,55,56). Reid et al.55investigated how
child, parent, and family factors contribute to sleep problems and
internalising (emotional) and externalising (behavioural) prob-
lems. Sleep problems were more strongly related to internalising
problems than to externalising problems.55As illustrated inTable 1,
four studies evaluated the relationship between insomnia and
depression/anxiety in children or adolescents and found similar
results as those studies that were conducted in adults.25,31,33,34Like
in adults, dysfunctional emotionality might modulate the rela-
tionship between insomnia and emotional disorders. Consistent
with this hypothesis, short sleep duration in children was found to
be associated with heightened emotional instability.57Moreover,
high negative affect was linked to resistance to having a nap in the
afternoon in a sample of 38 childrenwith a mean age of 3.8 years.58
El-Sheikh and Buckhalt59investigated physiological and subjective
measures of emotion regulation in 23 boys and 18 girls aged
between 6 and 12 years. Decreased levels of vagal suppression,
which were considered indices of poorer emotion regulation, were
found to be associated with sleep problems. Moreover, higherlevels
of emotional intensity, defined as the frequencyand the intensity of
the child’s expression of emotions, were linked to reduced amounts
of sleep and increased nocturnal activity. The same group showed
that disrupted sleep in childrenwas a moderating variable between
emotional insecurity in the familyand schoolperformance.60In this
study, emotional insecurity was evaluated by a scale measuring
emotional arousal (e.g., feeling sad, scared and angry), behavioural
dysregulation (e.g., throwing things), and destructive family
representations (e.g., worrying about what the parents will do
Does sleep predict affective states?
Sleep deprivation and positive and negative affective states
Recent literature on sleep deprivation supports an exciting role
for sleep in regulating emotional experience.61Dahl56indicated
that the interaction between sleep and affect regulatory systems is
modulated and integrated in regions of the prefrontal cortex (PFC).
Sleep deprivation induces alterations in goal-directed behaviours
by weakening the PFC influence over other brain regions. This
results in a reduced modulation of emotions, drives, and
impulses.56Consistent with this, the cognitive-energy model
proposed byZoharet al.62indicates that sleep loss affects cognitive-
energy resources required for coping with goal-obstructing events
or for capitalizing on new opportunities offered by goal-enhancing
events. The availability of cognitive energy resources influences the
perception of the progression toward a valued goal. When enough
cognitive resources to reach a goal are anticipated, positive
emotions are promoted; when a lack of resources is perceived,
negative emotions are enhanced. According to this model, sleep
deprivation affects cognitive-energy resources resulting in the
perception that the goal is obstructed. Two studies have evaluated
subjective emotional responses in sleep deprivation.63,64Wagner
et al.63investigated the effect of selective first-half and second-half
nocturnal sleep deprivation on subjective ratings of a set of pictures
taken from the International Affective Picture System (IAPS65). The
IAPS is a large database of pictures validated for the dimensions of
valence and arousal, based on the dimensional approach to
emotions. Twenty-four participants (all males, age range 18–30)
were investigated. Second-half nocturnal sleep deprivation resul-
ted in increased emotional responses to negative pictures. As REM
sleep is prevalent in the second-half of the night, and as increased
REM density and REM time is frequently found in patients with
depression, the authors interpreted this finding in terms of
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238232
Author's personal copy
enhancement of emotional reactivity after periods rich in REM
sleep. Leotta et al.64showed 10 positive,10 negative and 10 neutral
pictures to 15 healthy adolescents (60% girls, age range 10–15) after
a night of ‘‘optimized’’ sleep (in which participants were allowed to
sleep up to 10 h) and after a night of restricted sleep (in which
participants were woken up after 4 h). After viewing the pictures,
participants had to rate the dimensions of valence and arousal and
the intensity of self-experienced anger, sadness, fear, disgust,
happiness, and interest. After sleep restriction, they reported
higher rates of anger, sadness and fear, but no difference was found
between conditions with respect to valence and arousal.
Physiological responses to visual emotional stimulation have
been investigated in three sleep deprivation studies.66–68All these
studies used visual stimuli selected from the IAPS. In the two
studies conducted by Franzen et al.66,67pupillary responses were
obtained to measure the magnitude and the time-course of
emotional information processing. The pupil dilates in response to
emotional stimulation. High arousing negative and positive, and
low-arousing neutral pictures were presented. In the first study,67
29 participants were investigated (52% women); and, in the second
study,6630 participants (50% women). In both studies the age range
was between 21 and 30 years. In the sleep deprivation group,
pupillary responses to negative emotional pictures were larger
than in the control group,66and positively correlated with
self-reported sleepiness.67Moreover, the sleep-deprived partici-
pants showed an anticipatory pupillary reactivity during blocks of
negative pictures.66No group difference was found with respect to
positive stimuli. However, in the PANAS, the sleep deprived group
reported lower positive emotions, but no group difference was
found with respect to negative emotions.67Yoo et al.68investigated
the neural correlates of emotions in a sleep deprivation group
through functional magnetic resonance imaging (fMRI). Twenty-six
participants (50% women, age range 18–30) were asked to watch
100 pictures ordered from emotionally neutral (neutral valence,
low arousal) to increasingly aversive (negative valence, high
arousal). The sleep deprivation group (n¼14) displayed enhanced
activity in the amygdala and reduced functional connectivity
between the amygdala and the medial PFC. These results were
interpreted as an increased neurobiological response to emotional
stimuli and a reduced inhibitory influence of the PFC on emotional
reactivity after sleep deprivation.
Naps and positive and negative affective states
Short naps have been reported to have a positive effect on
mood. In a study by Kaida et al.69the mood of 16 healthy female
participants (age range 33–43) was assessed by self-rating scales
before and after a short nap or a natural bright light condition of
30 min. Both the conditions were efficacious in improving positive
mood, defined as pleasantness, satisfaction, and relaxation.
However, while the light condition improved only pleasantness,
the short nap had a significant effect on all three dimensions. Pre-
and post-nap emotional levels were also examined in a study by
Luo and Inoue ´.70Eight participants (50% women, age range 27–30)
were requested to take a nap in the laboratory between 13:00 and
14:00 for three consecutive days. Results showed an increase in joy
and relaxation from the pre- to the post-nap period. However,
perhaps less expected, anger levels were also enhanced after the
Quality of sleep and positive and negative affective states
It is a common belief that a night of good quality sleep enhances
positive emotions and well-being during the dayand that a night of
bad quality sleep increases irritability and negative emotions.
However, only few studies have investigated the relationship
between poor sleep and positive and negative emotions. Berry and
Webb71,72used PSG recordings and showed that increased sleep
efficiency and total sleep time were associated with positive
affective states as measured by mood scales, at least in elderly
women. Additionally, increased wake time after sleep-onset was
related to negative affective states.
To the best of our knowledge, three studies used the PANAS to
investigate these effects (Table 2).73–75The results of these studies
are consistent with the assumption that poor sleep quality is linked
to increased negative emotions and decreased positive emotions.
However, many questions remain unanswered. Only one study73
used an objective measure of sleep, actigraphy, and found no
Sleep quality/insomnia and negative (NE) and positive (PE) emotions evaluated through the PANAS.
Study Number % Female (% F)
Measures of Sleep
Other measures ProcedureResults
McCrae et al.
103 participants with
no severe psychiatric
condition or other
sleep disorder than
insomnia, and no
% F: not reported 14-days sleep
Age range: >60
- Completion of sleep
diaries and PANAS
every morning þ
actigraph for 2 weeks
Higher self-report sleep quality
and less wake time: higher PE.
Lower self-report sleep quality and
higher wake time: higher NE and
No effect was found with respect to
the data taken with the actigraph
Insomnia the previous night had a
contributory effect on negative
emotions at work (hostility and
fatigue), as well as a dampening
effect on positive emotions (joviality
and attentiveness), especially in
High PE and low NE associated with
the best sleep quality.
Low PE and high NE associated with
worst sleep quality.
High PE and high NE associated with
high levels of anxiety, stress, as well
as of optimism, energy, and good
Scott & Judge
45 employees% F: w71.0
Mean age ?sd:
the surveys every
working day for a
period of 3 weeks
Norlander et al.
50 healthy subjects
and 41patients with
% F: 81.0
11 Sleep Quality
(e.g., How often
do you feel you
did not get enough
Scale; 2) Hospital
Scale; 3) Life
(a measure of
4) Diurnal Type
Scale (a measure
of circadian preference)
Battery of questionnaire
to fill in
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238 233
Author's personal copy
associations between objectively determined sleep and self-
reported emotionality. Additionally, Scott and Judge74found that
the relationship between emotional dysregulation and poor sleep
quality was stronger in women as compared to men, while no
gender differences were reported by McCrae et al.73However, with
respect to the latter point, Scott and Judge74did not control for
psychiatric disorders, which might be related to gender, and
McCrae et al.73did not report the gender distribution. Finally, the
finding by Norlander et al.75that reporting both strong negative
and positive emotions in the PANAS is linked to high stress and
anxiety as well as to high self-reported sleep quality should be
Three studies investigated positive and negative emotions in
insomnia for severaltimes per dayusing self-report measures other
than the PANAS.76–78Steptoe et al.76found in 736 participants aged
58–72 years that positive emotions were associated with good
sleep quality independently of age, gender, household income,
employment status, and self-rated health. Levitt et al.78reported
from a study of 7 insomnia patients and 8 healthy controls (87%
women, age range 20–30) that people with insomnia exhibited
a higher variability in mood compared to good sleepers. In another
study, it was found that negative and positive mood had different
time courses in 47 people with primary insomnia compared to 18
good sleepers (62% women, age range 20–50).77Specifically, with
respect to negative mood, those with insomnia showed higher
overall values than good sleepers. The groups presented similar
values in the morning, however, in the evening, people with
insomnia showed an increase of negative mood, while good
sleepers showed a decrease. With respect to positive mood, good
sleepers presented higher overall values. Concerning the daily time
course, good sleepers presented an increase of positive emotions
both in the morning and in the evening. Those with insomnia
presented, instead, a roughly stable pattern.
Only few studies have reported physiological indices of
emotional reactivity in insomnia; with the majority using electro-
dermal activity as the dependent measure. Waters et al.79investi-
gated orienting response and emotional stress elicitation in 27
people with insomnia and 13 healthy controls (73% women,
undergraduates) using measures of skin conductance, vasomotor
response and heart rate. In this study, an increased electrodermal
activity has been found to be associated with poor sleep.
Additionally, the results support the assumption of an increased
emotional reactivity during encoding of new stimuli in insomnia
patients as measured by physiological indices. Similar results were
reported by Broman and Hetta80who also measured electrodermal
activity in an orienting and habituation task. In this study,
40 insomnia patients were compared with 20 healthy controls (80%
women, age range 31–69). Results showed that electrodermal
activity was again higher in the patient group. Within the insomnia
patients, a reduced total sleep time was associated with a slower
habituation to new stimuli which was interpreted as an indicator of
increased daytime arousal. This is, however, one of the major
limitations of the aforementioned work: skin conductance and
electrodermical activity have been described as sensitive predom-
inantly to the arousal dimension of emotional responses.7More-
over, autonomic activity is not only related to emotional reactivity,
but also to cognitive processes. So far no study has been published
investigating specific physiological indices of the valence dimen-
sion of emotional response in poor sleep or clinical insomnia.
Insomnia: the emotional valence of cognitive activity
thoughts in the sleep-onset period which interfere with their
ability to fall asleep. They describe this cognitive activity as
with insomniafrequently experienceintrusive
worrisome and negatively toned.81Indeed, affect-laden cognitions
are more likely to interfere with sleep.15Negative thoughts at
bedtime were found to be positively associated with longer sleep-
onset periods.82A qualitative analysis revealed three types of
typical cognitions in insomnia: problem solving, analysis of the
context of the sleep-onset period, and thoughts about sleep and the
consequences of sleep loss.83According to Carney et al.,84intrusive
thoughts have two components: rumination and worry. While
rumination is associated with dysphoric mood and is often
focussed on the causes of this mood state, worry is linked to
anxious mood and involves catastrophizing about future stressful
events.84Considering rumination, it was found that people with
insomnia are more prone to ruminate than good sleepers and that
the rumination is predominantly symptom-focused.84Concerning
worry, Watts et al.85found that people with insomnia and low
worry report predominantly thoughts about sleep and the conse-
quences of sleep loss, while people with insomnia and high worry
report more heterogeneous thoughts both about sleep and other
issues like work and social relations.
Do affective states predict sleep quality?
The construct of loneliness refers to the discrepancy between an
individual’s desired and actual relationships. Cacioppo et al.86
investigated the relationship between loneliness and sleep quality
in 54 undergraduates (39% women) who reported non-clinical
scores of depression. Participants were classified in three groups
with respect tothe measure of loneliness: ‘‘lonely’’, ‘‘middling’’, and
‘‘non-lonely’’. Total sleep time, sleep efficiency, sleep duration,
number of awakenings, and wake time after sleep-onset were
evaluated through polysomnographic recordings. Lonely individ-
uals had a lower sleep efficiency and higher wake time after sleep-
onset, compared to the other two groups. A study by Mahon87
investigated self-reported sleep disturbances in 106 early adoles-
cents (age range 12–14),111 middle adolescents (age range 15–17),
and 113 late adolescents (age range 18–21). Sleep disturbances
were positively associated with higher scores of loneliness only in
the early and middle adolescents, but not in the late adolescents.
Complicated grief and bereavement
Grief refers to feelings, thoughts, and behaviours following the
loss of a loved one. Complicated grief (CG) is characterized by the
following: intrusive emotional feelings of pain due to the associated
loss; persistent yearning and longing for the deceased; intrusive
thoughts of death; and avoidance of reminders of the lost indi-
vidual (e.g.,88). The Pittsburgh sleep group conducted a number of
studies on the impact of CG on sleep. Considering these studies, it
has to be noted that CG, although being an independent construct,
is closely connected to depression. In one study, polysomono-
graphically determined sleep impairments were only found in
those participants with both CG and depression, but not in those
without depression.89In other studies, only mild impairments in
subjective or objective sleep parameters were reported in CG
without depression.88,90,91,92The relationship between CG and
sleep was also investigated in 508 bereaved and 307 non-bereaved
college students using questionnaires.93Bereavement was found to
be positively associated with the number of awakenings during the
night. However, no measure of depression was taken in this study.
Furthermore, sleep disturbances were found to modulate the
relationship between CG and bipolar disorder.94
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238 234
Author's personal copy
Hostility, impulsivity, aggression and anger
Brissette and Cohen95found that hostility is linked to height-
ened negative emotionality and subsequently with increased sleep
disruption. In a 2-year longitudinal study by Grano ¨ et al.,965433
hospital employees (89% women, age range 19–62) filled in
questionnaire surveys about hostility, insomnia and sleep duration.
Participants with trait hostility were compared on the sleep
measures to participants with transient hostility. Transient
hostility, but not trait hostility, was associated with shorter sleep
duration, even after statistical adjustment for psychiatric disorders.
In another study, impulsivity, aggression and anger, and their
relationship with total sleep time, number of awakenings, and
sleep-onset latency were investigated in a sample of 184 incarcer-
ated male offenders (age range 14–20).97Only the hostility
sub-scale of the aggression questionnaire predicted both sleep
quality and sleep quantity. However, comorbid psychiatric condi-
tions were not controlled in this study. Another investigation
evaluated the relationship between impulsivity and insomnia in
223 participants (75% women, age range 18–49).98The urgency
dimension of impulsivity, defined as engaging in impulsive/rapid
behaviours in order to alleviate negative emotions, without
considering harmful long-term consequences, was associated with
increased insomnia severity and daytime impairments.
ArecentstudybyBrandet al.99evaluatedtheeffectof earlystage
intense romantic love on sleep quality in 113 adolescents (64% girls,
mean age?sd: 17.8?1.3). Three groups were evaluated: adoles-
cents that reported recently falling in love; adolescents reporting
being in a long-term relationship; and adolescents reporting being
single and not in love. Love-related depressive states and psycho-
pathologies were ruled out by interview. Self-reported daily sleep-
iness, relaxation, daily concentration, and mood were assessed in
the evening. Self-reported sleep quality, sleep-onset latency, total
sleep time, relaxation, and mood were acquired in the morning.
With respect to the evening ratings, adolescents in love reported
significantly less daily sleepiness, higher daily concentration, more
physical activity, and better mood, compared to the other 2 groups.
With respect to the morning ratings, they reported significantly
shorter sleep duration, better sleep quality and mood, and a greater
feeling of being relaxed. Thus, intense love in adolescents is
comparable with a hypo-maniac state, which involves for example
increased energy and arousal, loss of appetite and decreased need
for sleep, mood swings, irritability, and accelerated thinking.99
According to this, intense positive emotions could disturb sleep
quantity through the presence of heightened psychophysiological
arousal, while improving perceived sleep quality and daytime
activity. However, the reduction of sleep duration could be linked
with increased slow wave sleep, which would indicate a beneficial
understand the effects of intense positive emotions on sleep.
Heightened emotional reactivity is considered as a maintaining
factorfor insomnia, however, todate, the exact mechanism through
which it intervenes in perpetuating insomnia has received little
attention. Kales et al.11proposed that emotional hyperarousal,
provoked by a predisposition to internalise psychological conflicts,
increases autonomic activity and leads to sleep difficulties.
Noteworthy, studies in children and adolescents, as well as studies
on the effect of negative affective states (such as hostility) on sleep,
highlight relations between insomnia and externalising problems.
Importantly, however, it appears that, insomnia seems to be more
strongly related to internalising problems (depression, anxiety)
than toexternalising ones (actingout, aggression), as shownalso by
the study of Reid et al.55Recent aetiological theories of insomnia
suggest that it is more generally linked to a dysregulation of
emotional reactivity. Considering the psychobiological model of
insomnia by Espie,15insomnia is maintained by the interaction
between cognitive and autonomic processes. This interaction is
mediated by heightened emotionality.15Moreover, dysfunction in
sleep–wake regulating neural circuitries leads to alteration in
emotional reactivity.13From a neurobiological point of view,
emotional stimuli interact with the basic homeostatic and circadian
drives for sleep through the interaction between affect-related
regions, such as the infralimbic cortex or the central nucleus of the
amygdala, and regions that control sleep and wake, inparticular the
ventrolateral preoptic nucleus (VLPO).100Additionally, neuro-
imaging studies have shown significant elevations in activity in
affect-related regions (e.g., amygdala, hippocampus, anterior
cingulate cortex) during REM sleep. Specifically, during REM sleep,
due to the increased limbic activation, the emotional event would
be first reactivated and then associated to previous events and
processed.101Indeed, it is known that insomnia and alterations of
REM sleep are present in most psychological diseases. In order to
further our understanding of the interaction between sleep and
emotions, studies integrating the three domains of clinical
psychology of emotions (low and high emotional reactivity),
insomnia, and neurobiology of emotions and insomnia (including
imaging approaches) are necessary. From a psychological point of
view, the association between insomnia and psychiatric disorders
could be modulated by a difficulty in regulating emotions which
results in high negative and low positive emotionality. This
hypothesis has been supported bythe studyof Koffel and Watson,46
who found that a trait of high negative and low positive emotions
modulated the link between daytime symptoms of insomnia and
anxiety or depression. Furthermore, with respect to a develop-
mental perspective, poor sleep has been found to be linked with
emotional dysregulation as measured by physiological indices, and
reports of expression variables and intensity of emotions.59
Considering the impact of sleep on emotions, studies on sleep
deprivation showed enhanced emotional physiological responses
to negative stimuli both by measuring pupillary responses66,67and
brain activity68following experimental sleep loss. Overall, the
findings of these studies suggest that sleep is relevant for main-
taining adaptive emotional regulation and reactivity, but more
research is needed to more profoundly understand this relation-
ship. For example, referring to the dimensional approach to
emotions, as in the study by Yoo et al.68pleasant stimuli were not
used; it could be possible that the increase of brain activity found
could not reflect specifically the negative experience related to the
view of the stimulus, but also the arousal dimension of the
emotional response. Additionally, pupillary responses measured in
the studies conducted by Franzen et al.66,67are not specific indices
of the valence dimension of emotional responses. We think that it
would be of interest to further investigate the dimensions of
valence and arousal and the relationships of each dimension with
sleep deprivation studies. As sleep deprivation seems to increase
negative emotionality, it could be expected that good sleep would
promote the reduction of the experience of negative emotions.
However, Luo and Inoue ´70showed that taking a nap enhances
anger, as well as positive emotions such as joy. This suggests that
good sleep does not simply decrease negative emotions and
enhance positive emotions. Sleep could be important to promote
those emotional states which are necessary to reach valued goals.
Negative affective states, such as loneliness, grief or hostility, are
related with increased mild or relevant sleep impairments. Little is
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238235
Author's personal copy
known, though, about the effect of specific strong positive affective
states on sleep. Intense love was found to be associated with
decreased sleep duration, and enhanced subjective sleep quality.99
However, so far, we have no information about the effects of love or
other intense positive affective states on objective sleep quality.
Emotionality has been found to be negatively toned in insomnia
and poor sleep. Good sleep quality, instead, seems to be linked with
positive emotionality. However, the link between sleep and valence
of emotions seems to be neither clear nor simple. While both high
negative emotions and low positive emotions seem related to a bad
good sleep.Norlanderet al.75foundgoodsleep qualityeveninthose
with both high negative and positive emotionality. This could mean
that positive emotions have a protecting value for sleep, specifically
It appears important and relevant to investigate the time course of
positive and negative emotions during the day in people with
insomnia and in good sleepers, as recent studies have done.77,78
and being moreenhanced during times of the dayclose tosleep (for
example,thesleep onsetperiod). Moreoverhighvariabilityof mood
in people with insomnia78could be linked with the high variability
in night sleep quality characteristic of this group.
Finally, of note, there is a lack of studies using physiological
measures of emotions and emotional valence in insomnia.
The reviewed literature on the relationship between sleep and
emotions includes a number of limitations, which should be taken
into account in further research. Many studies aforementioned used
small samples. In order to obtain a clear picture of the topic, it is
important to conduct further studies which include a large number
of participants. Additionally, some of these studies have been con-
from these samples may, therefore not generalize to other pop-
constructs of mood, emotions, and affects are often confused in the
or emotions). This important caveat, concerning the specificity of
measurement, should be addressed in future investigations in order
to further elucidate the relationship between sleep and emotions.
Dr. Baglioni and Prof. Dr. Riemann have received funding from
the European Community’s Seventh Framework Programme
(People, Marie Curie Actions, Intra-European Fellowship, FP7-
PEOPLE-IEF-2008) under grant agreement n?235321 and from
OPTIMI (FP7-JCT-2009-4; 248544).
1. AASM (American Academy of Sleep Medicine). International classification of
Sleep disorders. 2nd ed. Westchester, Il: AASM; 2005.
2. Smith MT, Huang MI, Manber R. Cognitive behavior therapy for chronic
insomnia occurring within the context of medical and psychiatric disorders.
Clin Psychol Rev 2005;25(5):559–92.
Handbook of emotions. 3rd ed. New York, NY: Guilford; 2008. pp. 497–512.
4. Derryberry D, Reed MA. Information processing approaches to individual differ-
ences in emotional reactivity. In: Davidson RJ, Scherer K, Goldsmith HH, editors.
Handbook of affective sciences. Oxford University Press; 2003. pp. 681–97.
5. Izard CE. The face of emotion. New York: Appleton-Century-Crofts; 1971.
6. Russell JA. A circumplex model of affect. J Pers Soc Psychol 1980;39(6):1161–78.
7. Bradley MM. Emotion and Motivation. In: Cacioppo JT, Tassinary LG,
Bernston GG, editors. Handbook of Psychophysiology. 2nd ed. New York: Cam-
bridge University Press; 2000. pp. 602–42.
8. Watson D, Tellegen A. Toward a consensual structure of mood. Psychol Bull
9. Watson D, Clark LA, Tellegen A. Development and validation of brief
measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol
10. Drevets WC. Functional anatomical abnormalities in limbic and prefrontal
cortical structures in major depression. Prog Brain Res 2000;126:413–31.
11. Kales A, Caldwell AB, Preston TA, Healey S, Kales JD. Personality patterns in
insomnia. Theoretical implications. Arch Gen Psychiat 1976;33(9):1128–34.
12. Kales A, Caldwell AB, Soldatos CR, Bixler EO, Kales JD. Biopsychobehavioral
correlates of insomnia. II. Pattern specificity and consistency with the Min-
nesota Multiphasic Personality Inventory. Psychosom Med 1983;45(4):341–56.
*13. Riemann D, Spiegelhalder K, Feige B, Voderholzer U, Berger M, Perlis M, et al.
The hyperarousal of insomnia: A Review of the concept and its evidence. Sleep
Med Rev 2010;14(1):19–31.
14. Harvey A. A cognitive model of insomnia. Behav Res Ther 2002;40(8):869–93.
*15. Espie CA. Insomnia: conceptual issues in the development, persistence and
treatment of sleep disorders in adults. Annu Rev Psychol 2002;53:215–43.
16. Perlis ML, Giles D, Mendelson WB, Bootzin RR, Wyatt JK. Psychophysiological
insomnia: the behavioural model of a neurocognitive perspective. J Sleep Res
17. Vincent N, Cox B, Clara I. ArePersonalitydimensionsassociatedwithsleeplength
in a large nationally representative sample? Compr Psychiat 2009;50(2):158–63.
18. Kelly WE. Worry and sleep length revisited: worry, sleep length, and sleep
disturbance ascribed to worry. J Genet Psychol 2002;16(3):296–304.
1) Heightened levels of emotional arousal act as a main-
taining factor in insomnia by mediating the interaction
between cognitive and physiological hyperarousal.
Moreover, dysfunction in sleep–wake regulating neural
circuitries leads to emotional disturbances.
2) The relationship between insomnia and anxiety and
depression seems to be explained by referring to two
pathways: 1) insomnia and anxiety are related through
a bidirectional relationship; 2) insomnia, and especially
daytime symptoms of insomnia, predicts the onset of
depression. These directional relationships might be
modulated by heightened negative emotionality and
diminished positive emotionality.
3) Negative emotionality is enhanced by sleep deprivation.
4) Poor sleep quality seems to be linked with high negative
and low positive emotions. This link could be enhanced
in times of day close to sleep. Good sleep seems to be
associated with high positive emotions, regardless of
the intensity of negative emotions.
1) The modulatory role of heightened negative and low-
ered positive emotionality in the relationship between
insomnia and depression and anxiety should be evalu-
ated. Longitudinal studies, both observational and
interventional, to describe the sequences are necessary.
2) Studies investigating physiological indices of emotions
and specifically of the valence dimension of emotions in
insomnia shouldbe conducted
methods, such as neuroimaging techniques or facial
3) The role of positive and negative emotions in insomnia
as well as good sleep requires more thorough investi-
gation. Increased emphasis in distinguishing the rela-
tionships of different affective states (e.g., moods vs
emotions) in insomnia should be considered a research
4) In terms of insomnia treatment, the efficacy of strategies
dealing with emotional processes should be evaluated.
* The most important references are denoted by an asterisk.
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238 236
Author's personal copy
19. Kumar A, Vayda AK. Anxiety as a personality dimension of short and long
sleepers. J Clin Psychol 1984;40(1):197–8.
20. Riemann D, Berger M, Voderholzer U. Sleep in depression results from
psychobiological studies. Biol Psychol 2001;57(1–3):67–103.
21. (NIH) National Institutes of health state of the science conference statement.
Manifestations and management of chronic insomnia in adults. Sleep
22. Lichstein KL. Secondary insomnia: a myth dismissed. Sleep Med Rev
23. McCrae CS, Lichstein KL. Secondary insomnia: diagnostic challenges and
intervention opportunities. Sleep Med Rev 2001;5(1):47–61.
*24. Riemann D, Voderholzer U. Primary insomnia: a risk factor to develop
depression? J Affect Disorders 2003;76(1–3):255–9.
25. Gregory AM, Rijsdijk FV, Lau JYF, Dahl RE, Eley TC. The direction of longitu-
dinal associations between sleep problems and depression symptoms:
a study of twins aged 8 and 10 years. Sleep 2009;32(2):189–99.
26. Buysse DJ, Angst J, Gamma A, Ajdacic V, Eich D, Ro ¨ssler W. Prevalence, course,
and comorbidity of insomnia and depression in young adults. Sleep
27. Jansson-Fro ¨jmark M, Lindblom K. A bidirectional relationship between
anxiety and depression, and insomnia? A prospective study in the general
population. J Psychosom Res 2008;64(4):443–9.
28. Morphy H, Dunn KM, Lewis M, Boardman HF, Croft PR. Epidemiology of
insomnia: a longitudinal study in a UK population. Sleep 2007;30(3):274–80.
29. Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for
developing anxiety and depression. Sleep 2007;30(7):873–80.
30. Perlis ML, Smith LJ, Lyness JM, Matteson SR, Pigeon WR, Jungquist CR, et al.
Insomnia as a risk factor for onset of depression in elderly. Behav Sleep Med
31. Gregory AM, Caspi A, Eley TC, Moffitt TE, Oconnor TG, Poulton R. Prospective
longitudinal associations between persistent sleep problems in childhood and
anxietiy and depression disorders in adulthood. J Abnorm Child Psychol
32. Hein S, Bonsignore M, Barkow S, Jessen F, Ptok U, Heun R. Lifetime depressive
and somatic symptoms as preclinical markers of late-onset depression. Eur
Arch Psych Clin N 2003;253(1):16–21.
33. Gregory AM, O´Connor TG. Sleep problems in childhood: A longitudinal study
of developmental change and association with behavioral problems. J Am
Acad Child Adolesc Psychiatry 2002;41(8):964–71.
34. Roberts RE, Robert CR, Chen IG. Impact of insomnia on future functioning of
adolescents. J Psychosom Res 2002;53(1):561–9.
35. Mallon L, Broman JE, Hetta J. Relationship between insomnia, depression, and
mortality: a 12-year follow-up of older adults in the community. Int Psycho-
36. Roberts RE, Shema SJ, Kaplan GA, Strawbridge WJ. Sleep complaints and
depression in an aging cohort: a prospective perspective. Am J Psychiat
37. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep
complaints among elderly persons: an epidemiological study of three
communities. Sleep 1999;18(6):425–32.
38. Chang PP, Ford DE, Mead LA, Cooper-Patrick L, Klag MJ. Insomnia in young
men and subsequent depression. Am J Epidemiol 1997;146(2):105–14.
39. Weissman MM, Greenwald S, Nin ˜o-Murcia G, Dement WC. The morbidity of
insomnia uncomplicated by psychiatric
40. Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric
disorders: a longitudinal epidemiological study of young adults. Biol Psychiat
41. Brabbins CJ, Dewey ME, Copeland JRM, Davidson IA, McWilliam C, Saunders P,
et al. Insomnia in the elderly: prevalence, gender differences and relationships
with morbidity and mortality. Int J Geriatr Psych 1993;8(6):473–80.
42. Livingston G, Blizard B, Mann A. Does sleep disturbance predict depression in
elderly people? A study in inner London. Brit J Gen Pract 1993;43(376):445–8.
43. Dryman A, Eaton WW. Affective symptoms associated with the onset of major
depression in the community: findings from the US National Institute of
Mental Health Epidemiologic Catchment Area Program. Acta Psychiat Scand
44. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychi-
atric disorders. An opportunity for prevention? JAMA 1989;262(11):1479–84.
45. Vollrath M, Wicki W, Angst J. The Zurich study. VIII. Insomnia: association
with depression, anxiety, somatic syndromes, and course of insomnia. Eur
Arch Psychiatry Neurol Sci 1989;239(2):113–24.
*46. Koffel E, Watson D. The two-factor structure of sleep complaints and its
relation to depression and anxiety. J Abnorm Psychol 2009;118(1):183–94.
47. Morin CM, Vallie `res A, Guay B, Ivers H, Savard J, Me ´rette C, et al. Cognitive
behavioral therapy, singly and combined with medication, for persistent
insomnia: a randomized controlled trial. JAMA 2009;301(19):2005–15.
48. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of
benzodiazepine receptor agonists and psychological and behavioural thera-
pies. Sleep Med Rev 2009;13(3):205–14.
49. Murtagh DR, Greenwood KM. Identifying effective psychological treatments
for insomnia: a meta-analysis. J Consult Clin Psych 1995;63(1):79–89.
50. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions
for insomnia: a meta-analysis of treatment efficacy. Am J Psychiat
disorders.Gen Hosp Psychiat
51. Edinger JD, Olsen MK, Stechuchak KM, Means MK, Linebeger MD, Kirby A,
et al. Cognitive behavioral therapy for patients with primary insomnia or
insomnia associated predominantly with mixed psychiatric disorders:
a randomized clinical trial. Sleep 2009;32(4):499–510.
52. Manber R, Edinger J, Gress JL, Pedro-Salcedo S, Kuo TF, Kalista T. Coginitive
behavioural therapy for insomnia enhances depression outcome in
patients with comorbid major depressive disorder and insomnia. Sleep
53. Mooney P, Espie CA, Broomfield NM. An experimental assessment of a Pen-
nebaker writing intervention in primary insomnia. Behav Sleep Med
54. Harvey AG, Farrell C. The efficacy of a Pennebaker-like writing intervention
for poor sleepers. Behav Sleep Med 2003;1(2):115–24.
55. Reid GJ, Hong RY, Wade TJ. The relation between common sleep problems and
emotional and behavioral problems among 2- and 3-year-olds in the context
of known risk factors for psychopathology. J Sleep Res 2009;18(1):49–59.
56. Dahl RE. The impact of inadequate sleep on children’s daytime cognitive
function. Semin Pediatr Neurol 1996;3(1):44–50.
57. Nixon GM, Thompson JMD, Han DY, Becroft DM, Clark PM, Robinson E, et al.
Short sleep duration in middle childhood: risk factors and consequences.
58. Ward TM, Gay C, Alkon A, Anders TF, Lee KA. Nocturnal sleep and daytime nap
behaviors in relation to salivary cortisol levels and temperament in preschool-
age children attending child care. Biol Res Nurs 2008;9(3):244–53.
*59. El-Sheikh M, Buckhalt JA. Vagal regulation and emotional intensity predict sleep
problems children’s sleep problems. Dev Psychobiol 2005;46(4):307–17.
60. El-Sheikh M, Buckhalt JA, Mark Cummings E, Keller P. Sleep disruptions and
emotional insecurity are pathways of risk for children. J Child Psychol Psyc
61. Walker MP. The role of sleep in cognition and emotion. Ann N Y Acad Sci
62. Zohar D, Tzischinsky O, Epstein R, Lavie P. The effects of sleep loss on medical
residents’ emotional reactions to work events: a cognitive-energy model.
63. Wagner U, Frischer S, Born J. Changes in emotional responses to aversive
pictures across periods rich in slow-wave sleep versus rapid eye movement
sleep. Pysochosom Med 2002;64(4):627–34.
64. Leotta C, Carskadon MA, Acebo C, Seifer R, Quinn B. Effects of acute sleep
restriction on affective response in adolescents: preliminary results. Sleep Res
65. Lang PJ, Bradley MM, Cuthbert BN. International affective picture system
(IAPS): affective ratings of pictures and instruction manual. Technical report
A-6. University of Florida, Gainesville, FL, 2005.
66. Franzen PL, Buysse DJ, Dahl RE, Thompson W, Siegle GJ. Sleep deprivation
alters pupillary reactivity to emotional stimuli in healthy young adults. Biol
67. Franzen PL, Siegle GJ, Buysse DJ. Relationships between affect, vigilance, and
sleepiness following sleep deprivation. J Sleep Res 2008;17(1):34–41.
68. Yoo SS, Gujar N, Hu P, Jolesz FA, Walker MP. The human emotional brain
69. Kaida K, Takahashi M, Otsuka Y. A short nap and natural bright light exposure
improve positive mood status. Ind Health 2007;45(2):301–8.
70. Luo Z, Inoue ´ S. A short daytime nap modulates levels of emotions objectively
evaluated by the emotion spectrum analysis method. Psychiatry Clin Neurosci
71. Berry DTR, Webb WB. Mood and sleep in aging women. J Pers Soc Psychol
72. Berry DTR, Webb WB. State measures and sleep stages. Psychol Rep
*73. McCrae CS, McNamara JP, Rowe MA, Dzierzewski JM, Dirk J, Marsiske M, et al.
Sleep and affect in older adults: using multilevel modeling to examine daily
associations. J Sleep Res 2008;17(1):42–53.
*74. Scott BA, Judge TA. Insomnia, emotions, and job satisfaction: a multilevel
study. J Manage 2006;32(5):622–45.
*75. Norlander T, Johansson Å, Bood SÅ. The affective personality: its relation to
quality of sleep, well-being and stress. Soc Behav Personal 2005;33(7):709–22.
*76. Steptoe A, O’Donnell K, Marmot M, Wardle J. Positive affect, psychological
well-being, and good sleep. J Psychosom Res 2008;64(4):409–15.
*77. Buysse DJ, Thompson W, Scott J, Franzen PL, Germain A, Hall M, et al. Daytime
symptoms in primary insomnia: a prospective analysis using ecological
momentary assessment. Sleep Med 2007;8(3):198–208.
78. Levitt H, Wood A, Moul DE, Hall M, Germain A, Kupfer DJ, et al. A pilot
study of subjective daytime alertness and mood in primary insomnia
participants using ecological momentary assessment. Behav Sleep Med
79. Waters WF, Adams Jr SG, Binks P, Varnado P. Attention, stress and negative
emotion in persistent sleep-onset and sleep-maintanance insomnia. Sleep
80. Broman JE, Hetta J. Electrodermal activity in patients with persistent
insomnia. J Sleep Res 1994;3(3):165–70.
81. Be ´langer L, Morin CM, Gendron L, Blais FC. Presleep cognitive activity and
thought control strategies in insomnia. J Cogn Psychother 2005;19:19–28.
82. Van Egeren L, Hayness SN, Franzen M, Hamilton J. Presleep cognitions and
attributions in sleep onset insomnia. J Behav Med 1983;6(2):217–32.
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238 237
Author's personal copy Download full-text
83. Wicklow A, Espie CA. Intrusive thoughts and their relationship to actigraphic
measurements of sleep: towards a cognitive model of insomnia. Behav Res
84. Carney CE, Edinger JD, Bjo ¨rn M, Lindman L, Istre T. Symptom-focused rumi-
nation and sleep disturbance. Behav Sleep Med 2006;4(4):228–41.
85. Watts FN, Coyle K, East MP. The contribution of worry to insomnia. Brit J Clin
86. Cacioppo JT, Hawkley LC, Berntson GG, Ernst JM, Gibbs AC, Stickgold R, et al.
Do lonely days invade the nights? Potential social modulation of sleep effi-
ciency. Psychol Sci 2002;13(4):384–7.
87. Mahon NE. Loneliness and sleep during adolescence. Percept Mot Skill
88. Germain A, Caroff K, Buysse DJ, Shear MK. Sleep quality in complicated grief. J
Trauma Stress 2005;18(4):343–6.
89. Reynolds CF, Hoch CC, Buysse DJ, Houck PR, Schlernitzauer M, Frank E, et al.
Electroencephalographic sleep in spousal bereavement and bereavement-
related depression of late life. Biol Psychiat 1992;31(1):69–82.
90. Monk TH, Begley AE, Billy BD, Fletcher ME, Germain A, Mazumdar S, et al.
Sleep and circadian rhythms in spousally bereaved seniors. Chronobiol Int
91. McDermott OD, Prigerson HG, Reynolds CF, Houck PR, Dew MA, Hall M, et al.
Sleep in the wake of complicated grief symptoms: an exploratory study. Biol
92. Reynolds CF, Hoch CC, Buysse DJ, Houck PR, Schlernitzauer M, Pasternak RE,
et al. Sleep after spousal bereavement: a study of recovery from stress. Biol
93. Hardison HG, Neimeyer RA, Lichstein KL. Insomnia and complicated grief
symptoms in bereaved college students. Behav Sleep Med 2005;3(2):
94. Maytal G, Zalta AK, Thompson E, Chow CW, Perlman C, Ostacher MJ, et al.
Complicated grief and impaired sleep in patients with bipolar disorder.
Bipolar Disord 2007;9(8):913–7.
95. Brissette I, Cohen S. The contribution of individual differences in hostility to
the associations between daily interpersonal conflict, affect, and sleep. Pers
Soc Psychol B 2002;28(9):1265–74.
96. Grano ¨ N, Vahtera J, Virtanen M, Keltikangas-Ja ¨rvinen L, Kivima ¨ki M. Associ-
ation of hostility with sleep duration and sleep disturbances in an employee
population. Int J Behav Med 2008;15(2):73–80.
97. Ireland JL, Culpin V. The relationship between sleeping problems and
aggression, anger, and impulsivity in a population of juvenile and young
offenders. J Adolesc Health 2006;38(6):649–55.
98. Schmidt RE, Gay P, Van der Linden M. Facets of impulsivity are differentially
linked to insomnia: evidence from an exploratory study. Behav Sleep Med
99. Brand S, Luethi M, Von Planta A, Hatzinger M, Holsboer-Trachsler E. Romantic
love, hypomania, and sleep pattern
100. Saper CB, Cano G, Scammell TE. Homeostatic, circadian, and emotional
regulation of sleep. J Comp Neurol 2005;493(1):92–8.
101. Walker MP, Van der Helm E. Overnight theraphy? The role of sleep in
emotional brain processing. Psychol Bull 2009;135(5):731–48.
inadolescents.J Adolesc Health
C. Baglioni et al. / Sleep Medicine Reviews 14 (2010) 227–238238