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The cognitive treatment components and therapies of cognitive behavioral therapy for insomnia: A systematic review

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Abstract

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.

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... It is thus plausible that a new review encompassing all published studies on PI might yield different results. Further, two of the current study's authors recently performed a narrative review, which concluded that PI has empirical support for insomnia (Jansson-Fröjmark & Norell-Clarke, 2018). However, the review did not quantitatively assess the effectiveness of PI and did not specifically differentiate between outcomes (e.g. ...
... Although the effectiveness of PI has previously been reviewed quantitatively to some extent (Morin et al., ,1999(Morin et al., , , 2006 and narratively (Jansson-Fröjmark & Norell-Clarke, 2018), the present study aimed to conduct the first systematic review and meta-analysis of studies that explore the effectiveness of PI for insomnia. More specifically, the purpose was to investigate the effectiveness of PI on insomnia symptomatology (night-time and daytime symptoms) and theory-derived processes (e.g. ...
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Paradoxical intention (PI) has been considered an evidence‐based treatment for insomnia since the 1990s, but it has not been evaluated with modern review techniques such as meta‐analysis. The present study aimed to conduct the first systematic review and meta‐analysis of studies that explore the effectiveness of PI for insomnia on insomnia symptomatology and theory‐derived processes. A systematic review and meta‐analysis was conducted by searching for eligible articles or dissertations in six online bibliographic databases. Randomised controlled trials and experimental studies comparing PI for insomnia to active and passive comparators and assessing insomnia symptoms as outcomes were included. A random effects model was estimated to determine the standardised mean difference Hedge’s g at post‐treatment. Test for heterogeneity was performed, fail‐safe N was calculated, and study quality was assessed. The study was pre‐registered at International Prospective Register of Systematic Reviews (PROSPERO, CRD42019137357). A total of 10 trials were identified. Compared to passive comparators, PI led to large improvements in key insomnia symptoms. Relative to active comparators, the improvements were smaller, but still moderate for several central outcomes. Compared to passive comparators, PI resulted in great reductions in sleep‐related performance anxiety, one of several proposed mechanisms of change for PI. PI for insomnia resulted in marked clinical improvements, large relative to passive comparators and moderate compared to active comparators. However, methodologically stronger studies are needed before more firm conclusions can be drawn.
... Whilst the mechanisms by which sleep may affect evening technology use are not yet clear, here we propose that technology use may serve one understudied purposecognitive distraction. Cognitive distraction is a technique used in cognitive therapies for insomnia to manage negative thoughts and emotions (14). There is research spanning 16 years that provides clues that adolescents may use technology in the evening for such purposes. ...
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Study Objectives The aim of this study was to; 1) explore whether adolescents use technology as distraction from negative thoughts before sleep, 2) assess whether adolescents who perceive having a sleep problem use technology as distraction more compared to adolescents without sleep complaints, 3) collect qualitative information about which devices and apps adolescents use as a distraction. Methods This study used a mixed-methods cross-sectional design, where 684 adolescents (M = 15.1, SD = 1.2, 46% female) answered both quantitative and qualitative questions about their sleep (perceived sleep problem, sleep onset time, and sleep onset latency) and technology use as distraction from negative thoughts. Results The majority of adolescents answered ‘yes’ or ‘sometimes’ using technology as a distraction from negative thoughts (23.6% and 38.4%). Adolescents who answered ‘yes’ to using technology as distraction were more likely to report having a sleep problem, longer sleep onset latency and later sleep onset time, compared to adolescents who answered ‘no’. The most popular device to distract was the phone, because of its availability, and the most common apps used for distraction included YouTube, Snapchat, and music apps. Conclusions This study shows that many adolescents use technology to distract themselves from negative thoughts, which may help them manage the sleep-onset process. Thus, distraction may be one mechanism explaining how sleep affects technology use, rather than vice versa.
... As a standardized approach, CBT-I involves 6 modules: psychoeducation, sleep restriction, stimulus control, sleep hygiene, relaxation, and cognitive therapy. CBT-I effectiveness data have been summarized in several meta-analyses [23][24][25][26] and reviews [27][28][29][30], which conclude that CBT-I produces large improvements in sleep by substantially increasing patient-reported sleep efficiency and reducing dysfunctional beliefs about sleep. ...
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Background Prevention of major depressive disorder (MDD) is a public health priority. Strategies targeting individuals at elevated risk for MDD may guide effective preventive care. Insomnia is a reliable precursor to depression, preceding half of all incident and relapse cases. Thus, insomnia may serve as a useful entry point for preventing MDD. Cognitive-behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia, but widespread implementation is limited by a shortage of trained specialists. Innovative stepped-care approaches rooted in primary care can increase access to CBT-I and reduce rates of MDD. Methods/design We propose a large-scale stepped-care clinical trial in the primary care setting that utilizes a sequential, multiple assignment, randomized trial (SMART) design to determine the effectiveness of dCBT-I alone and in combination with clinician-led CBT-I for insomnia and the prevention of MDD incidence and relapse. Specifically, our care model uses digital CBT-I (dCBT-I) as a first-line intervention to increase care access and reduce the need for specialist resources. Our proposal also adds clinician-led CBT-I for patients who do not remit with first-line intervention and need a more personalized approach from specialty care. We will evaluate negative repetitive thinking as a potential treatment mechanism by which dCBT-I and CBT-I benefit insomnia and depression outcomes. Discussion This project will test a highly scalable model of sleep care in a large primary care system to determine the potential for wide dissemination and implementation to address the high volume of population need for safe and effective insomnia treatment and associated prevention of depression. Trial registration ClinicalTrials.gov NCT03322774. Registered on October 26, 2017
... 36,37 As a standardized approach, CBT-I involves 6 modules: psychoeducation; sleep restriction; stimulus control; sleep hygiene; relaxation; and cognitive therapy. CBT-I effectiveness data have been summarized in several meta-analyses 37-40 and reviews, [41][42][43][44] which conclude that CBT-I produces large improvements in sleep by substantially increasing patient-reported sleep e ciency and reducing dysfunctional beliefs about sleep. ...
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Background Prevention of major depressive disorder (MDD) is a public health priority. Strategies targeting individuals at elevated risk for MDD may guide effective preventive care. Insomnia is a reliable precursor to depression, preceding half of all incident and relapse cases. Thus, insomnia may serve as a useful entry point for preventing MDD. Cognitive-behavioral therapy for insomnia (CBT-I) is recommended as first-line treatment for insomnia, but widespread implementation is limited by a shortage of trained specialists. Innovative stepped-care approaches rooted in primary care can increase access to CBT-I and reduce rates of MDD. Methods/Design We propose a large-scale stepped-care clinical trial in the primary care setting that utilizes a sequential, multiple assignment, randomized trial (SMART) design to determine the effectiveness of dCBT-I alone and in combination with clinician-led CBT-I for insomnia and the prevention of MDD incidence and relapse. Specifically, our care model uses digital CBT-I (dCBT-I) as a first-line intervention to increase care access and reduce need for specialist resources. Our proposal also adds clinician-led CBT-I for patients who do not remit with first-line intervention and need a more personalized approach from specialty care. We will evaluate negative repetitive thinking as a potential treatment mechanism by which dCBT-I and CBT-I benefit insomnia and depression outcomes. Discussion This project will test a highly scalable model of sleep care in a large primary care system to determine the potential for wide dissemination and implementation to address the high volume of population-need for safe and effective insomnia treatment and associated prevention of depression. Trial Registration NCT03322774. Date of registration, October 26, 2017.
... [15][16][17] Cognitive behavioral therapy for insomnia (CBT-I) is a multimodal intervention that combines several cognitive and behavioral treatment elements, generally including cognitive restructuring (eg, addressing maladaptive thoughts and beliefs about sleep), sleep hygiene education, stimulus control strategies, sleep restriction, and relaxation training. [18][19][20] CBT-I has been demonstrated to be effective in improving insomnia when delivered by trained therapists and/or self-help automated programs or delivered in individual, group, telephone, or computerized formats. 2,[21][22][23] As the standard management for insomnia in the general population, 24,25 CBT-I also appears to have better effects on insomnia in cancer patients. ...
Article
Objective: The aim of this study was to examine the most effective delivery format of cognitive behavioral therapy for insomnia (CBT-I) on insomnia in cancer patients. Methods: We searched five databases up to February 2021 for randomized clinical trials that compared CBT-I with inactive or active controls for insomnia in cancer patients. Outcomes were insomnia severity, sleep efficiency, sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time (TST). Pairwise meta-analyses and frequentist network meta-analyses with the random-effects model were applied for data analyses. Results: Sixteen unique trials including 1523 participants met inclusion criteria. Compared with inactive control, CBT-I could significantly reduce insomnia severity (mean differences [MD] = -4.98 points, 95% confidence interval [CI]: -5.82 to -4.14), SOL (MD = -12.29 min, 95%CI: -16.48 to -8.09), and WASO (MD = -16.58 min, 95%CI: -22.00 to -11.15), while increasing sleep efficiency (MD = 7.62%, 95%CI: 5.82% to 9.41%) at postintervention. Compared with active control, CBT-I could significantly reduce insomnia severity (MD = -2.75 points, 95%CI: -4.28 to -1.21), SOL (MD = -13.56 min, 95%CI: -18.93 to -8.18), and WASO (MD = -6.99 min, 95%CI: -11.65 to -2.32) at postintervention. These effects diminished in short-term follow-up and almost disappeared in long-term follow-up. Most of the results were rated as "moderate" to "low" certainty of evidence. Network meta-analysis showed that group CBT-I had an increase in sleep efficiency of 10.61%, an increase in TST of 21.98 min, a reduction in SOL of 14.65 min, and a reduction in WASO of 24.30 min, compared with inactive control at postintervention, with effects sustained at short-term follow-up. Conclusions: CBT-I is effective for the management of insomnia in cancer patients postintervention, with diminished effects in short-term follow-up. Group CBT-I is the preferred choice based on postintervention and short-term effects. The low quality of evidence and limited sample size demonstrate the need for robust evidence from high-quality, large-scale trials providing long-term follow-up data.
... Open access co-occurring disorders like major depression, 16 with longlasting benefits. CBT-I is now recommended as first-line therapy for insomnia 15 17 and its primary components include a focus on sleep restriction and consolidation, stimulus control, sleep hygiene and cognitive restructuring. ...
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Introduction Cognitive behavioural therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multidimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a prescription digital therapeutic (PDT) (PEAR-003b, FDA-authorised as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilisation. Methods and analysis We are conducting a pragmatically designed, prospective, multicentre randomised controlled trial that leverages Hugo, a unique patient-centred health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centres will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity and then randomised 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score from baseline to 9-week postrandomisation. Secondary outcomes include healthcare utilisation, health utility scores and clinical outcomes; change in sleep outcomes as measured with sleep diaries and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT. Ethics and dissemination The Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes and healthcare utilisation. Findings will be disseminated to participants, presented at professional meetings and published in peer-reviewed journals. Trial registration number NCT04909229 .
... Persistent sleep difficulties (3 nights or more/week) and continued of them for over 3 months are necessary to diagnose this disorder. Insomnia trig-gers daytime functioning impairment and notably reduced the quality of life by its complications, such as fatigue, reduced energy, mood disturbances, and decreased cognitive functions [3,4]. Insomnia can arise primarily or be comorbid with psychiatric conditions like anxiety and depression in a duplex relationship manner [5,6]. ...
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Insomnia is one of the most prevalent sleep disorders worldwide which significantly affects the quality of life. Pharmacological and non-pharmacological approaches have been applied in managing insomnia. The risk of tolerance and dependence on conventional medications and their other side effects leads the surveys to complementary and alternative medicine. This overview aimed to compile the clinical trials on herbal remedies in managing insomnia for facilitating future studies on medicinal plant in this issue. The keywords “Medicinal plant”, “Herbal medicine” in combination with “Hypnotic and sedative”, “Insomnia” or “Sleep” were searched through PubMed, Google Scholar, and Scopus electronic databases from 1st January 2000 to 31st August 2020. Then, all clinical trials focusing on the efficacy of medicinal plants on insomnia were collected. Based on the inclusion and exclusion criteria, 36 articles were selected, included 16 medicinal plants (23 studies) as a single herb and 13 polyherbal formulations. The most prevalent route of administration among these trials was oral. Matricaria chamomilla L., Valeriana officinalis L., Viola odorata L., and Passiflora incarnata L. were among the most prevalent effective herbal medicines on insomnia. Also, the modulation of the GABAergic system was the most common target of these medicinal plants. Herbal remedies can be introduced as safe and effective alternatives for conventional medications in managing insomnia. The popular herbal medicines, such as M. chamomilla, V. officinalis, V. odorata, are suitable for further therapeutic development. Other cited medicinal plants in this review can be more investigated in improvement of sleep.
... This finding suggests that using evening technology might benefit adolescents. Specifically, using devices while waiting for sleep onset might be a form of cognitive distraction from negative pre-sleep cognitions 195 . Cross-sectional associations have been found between using social media to cope with negative feelings and sleep-onset difficulties in adolescents 196 . ...
Article
Two adolescent mental health fields — sleep and depression — have advanced largely in parallel until about four years ago. Although sleep problems have been thought to be a symptom of adolescent depression, emerging evidence suggests that sleep difficulties arise before depression does. In this Review, we describe how the combination of adolescent sleep biology and psychology uniquely predispose adolescents to develop depression. We describe multiple pathways and contributors, including a delayed circadian rhythm, restricted sleep duration and greater opportunity for repetitive negative thinking while waiting for sleep. We match each contributor with evidence-based sleep interventions, including bright light therapy, exogenous melatonin and cognitive-behaviour therapy techniques. Such treatments improve sleep and alleviate depression symptoms, highlighting the utility of sleep treatment for comorbid disorders experienced by adolescents. Sleep problems are both a symptom and precursor of adolescent depression. In this Review, Gradisar et al. describe how the combination of adolescent sleep biology and psychology predisposes adolescents to develop depression, and describe interventions that improve sleep and depression symptoms in this population.
... Cognitive restructuring techniques used in CBT for insomnia and fatigue are often beneficial in maintaining long-term gains from treatment. Frequently used cognitive restructuring strategies include cognitive therapy, cognitive refocusing, paradoxical intention, and addressing unhelpful and perpetuating thoughts surrounding symptoms [21,24,25]. Our CBT-SF intervention employed these strategies, in addition to relaxation techniques, thought records and time management skills. ...
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Background In psychological research, control conditions in the form of “treatment as usual” provide support for intervention efficacy, but do not allow the attribution of positive outcomes to the unique components of the treatment itself. Attentionally and structurally equivalent active control conditions, such as health education (HE), have been implemented in recent trials of cognitive behavioural therapy (CBT). However, descriptions and evaluations of these control conditions are limited. The aims of this paper were to (i) provide a detailed description and rationale for a novel HE active control condition and (ii) to evaluate the face validity, treatment integrity and feasibility of HE. Method We developed a HE active control similar in structure and duration to a CBT intervention for reducing sleep disturbance and fatigue (CBT-SF) in a pilot randomised controlled trial ( n = 51). Face validity was measured using post-treatment participant satisfaction and helpfulness ratings for fatigue and sleep symptoms, treatment fidelity was measured with integrity monitoring ratings from an independent expert and feasibility was measured with completion and attrition rates. HE and CBT-SF groups were compared using Wilcoxon rank-sum tests and chi-square tests of independence. Results There were no significant differences in participant ratings of overall satisfaction between HE ( n = 17) and CBT ( n = 34) or in how helpful each intervention was for fatigue symptoms. Participants rated helpfulness for sleep symptoms higher in the CBT-SF group compared to HE. Integrity monitoring ratings were not significantly different for overall treatment delivery and therapist competency, but HE had greater module adherence than CBT-SF. There were no significant differences in completion or attrition rates between groups. Conclusion Our findings suggest that the HE control had adequate face validity, was delivered with fidelity and was feasible and suitable for use as a comparator for CBT-SF. In providing a real-world example of practical and theoretical issues we considered when designing this control condition, we aim to provide a framework and guidance for future investigators. Trial registration ACTRN12617000879369 (registered 15/06/2017) and ACTRN12617000878370 (registered 15/06/2017).
... CBT-I is an effective treatment (Edinger et al., 2021;van der Zweerde et al., 2019;van Straten et al., 2018) with a cognitive part and a behavioral part as its main components. In cognitive therapy (CT), the focus is on selective attention, misperception of sleep, and dysfunctional beliefs about sleep (Jansson-Frojmark & Norell-Clarke, 2018). Behavior therapy (BT) focuses on sleep restriction and/or stimulus control to fix rising times and regulate the circadian system (Bootzin et al., 1991;Spielman et al., 1987). ...
Article
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Cognitive therapy (CT) and behavior therapy (BT) are both effective for insomnia. In this study we applied Network Intervention Analysis to investigate specific effects of CT and BT on outcomes and process measures. The analysis was based on a randomized controlled trial comparing CT (n = 65), BT (n = 63) and cognitive behavioral therapy for insomnia (n = 60; not included in this study). In the first networks, the separate items of the Insomnia Severity Index and sleep efficiency were included. In the second networks, the pre-specified process measures for BT and CT, sleep efficiency, and the sum-score of the Insomnia Severity Index were included. At the different time points, we found CT-effects on worry, impaired quality of life, dysfunctional beliefs, and monitoring sleep-related threats, and BT-effects on sleep efficiency, difficulty maintaining sleep, early morning awakening, time in bed, sleep incompatible behaviors and bed- and rise time variability. These observed effects of CT and BT were consistent with their respective theoretical underpinnings. This study provided new information on the mechanisms of change in CT and BT. In the future, this may guide us to the most effective treatment modules or even subsets of interventions.
... There is empirical evidence indicating that cognitive-behavioral therapy for insomnia (CBT-I) can effectively treat chronic insomnia, [9][10][11][12][13][14][15] including when present with co-occurring disorders like major depression, 16 with long-lasting benefits. CBT-I is now recommended as first-line therapy for insomnia 15,17 and its primary components include a focus on sleep restriction and consolidation, stimulus control, sleep hygiene, and cognitive restructuring. ...
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Introduction Cognitive behavioral therapy for insomnia (CBT-I) is effective at treating chronic insomnia, yet in-person CBT-I can often be challenging to access. Prior studies have used technology to bridge barriers but have been unable to extensively assess the impact of the digital therapeutic on real-world patient experience and multi-dimensional outcomes. Among patients with insomnia, our aim is to determine the impact of a Prescription Digital Therapeutic (PDT) (PEAR-003b, FDA-authorized as Somryst; herein called PDT) that provides mobile-delivered CBT-I on patient-reported outcomes (PROs) and healthcare utilization. Methods and Analysis We are conducting a pragmatically designed, prospective, multi-center randomized controlled trial that leverages Hugo, a unique patient-centered health data-aggregating platform for data collection and patient follow-up from Hugo Health. A total of 100 participants with insomnia from two health centers will be enrolled onto the Hugo Health platform, provided with a linked Fitbit (Inspire 2) to track activity, and then randomized 1:1 to receive (or not) the PDT for mobile-delivered CBT-I (Somryst). The primary outcome is a change in the insomnia severity index score (ISI) score from baseline to 9-weeks post-randomization. Secondary outcomes include healthcare utilization, health utility scores, and clinical outcomes; change in sleep outcomes as measured with sleep diaries; and a change in individual PROs including depressive symptoms, daytime sleepiness, health status, stress, and anxiety. For those allocated to the PDT, we will also assess engagement with the PDT. Ethics and Dissemination The Institutional Review Boards at Yale University and the Mayo Clinic have approved the trial protocol. This trial will provide important data to patients, clinicians, and policymakers about the impact of the PDT device delivering CBT-I on PROs, clinical outcomes, and healthcare utilization. Findings will be disseminated to participants, presented at professional meetings, and published in peer-reviewed journals. Trial Registration Number NCT04909229 Strengths and limitations of this study This is the first controlled study to examine the impact of a mobile-delivered, prescription digital therapeutic (PDT) delivering Cognitive Behavioral Therapy for Chronic Insomnia (i.e., PEAR-003b, FDA-authorized as Somryst) on real-world patients outcomes of care that includes a multi-dimensional analysis of patient benefit across guideline-recommended health domains (e.g., insomnia severity index) and healthcare utilization (e.g., emergency department visits). This randomized clinical trial will use Hugo, a novel patient-centered health data-aggregating platform for data collection and patient follow-up, which gathers and collates patient-reported outcomes, clinical outcomes, and healthcare utilization metrics for real-world patients with chronic insomnia. The participant has ownership over their data and contributes it to research. Future studies should focus on patients with chronic insomnia as well as co-morbid conditions such as major depression and whether sleep improvements can be sustained, particularly in the long-term.
... It has reported CBT is beneficial to insomnia in patients with or without PD (64). This may be because insomnia has been associated more with persistent psychological factors than specific disease characteristics in the general population (65), while the goal of CBT in treating insomnia is to alter erroneous perceptions, cognitive arousal, and maladaptive behaviors toward sleep hygiene (66). Another result revealed that sleep quality did not ameliorate, which demonstrates that CBT can influence sleep duration rather than sleep architecture. ...
Article
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Objective: The aim of this study was to perform a quantitative analysis to evaluate the efficacy of cognitive behavioral therapy (CBT) on mood disorders, sleep, fatigue, and its impact on quality of life (QOL) in Parkinson's Disease (PD). Methods: We searched for randomized controlled trials in three electronic databases. Fourteen studies, including 507 patients with PD, met the inclusion criteria. We determined the pooled efficacy by standard mean differences and 95% confidence intervals, using I ² to reveal heterogeneity. Results: The result showed CBT had a significant effect on depression [−0.93 (95%CI, −1.19 to −0.67, P < 0.001)] and anxiety [−0.76 (95%CI, −0.97 to −0.55, P < 0.001)]. Moderate effect sizes were noted with sleep disorders [−0.45 (95% CI, −0.70 to −0.20, P = 0.0004)]. There was no evident impact of CBT on fatigue or QOL. We found an intervention period >8 weeks was advantageous compared with <8 weeks, and CBT implemented in non-group was more effective than in group. Between the delivery methods, no significant difference was found. Conclusion: We found that CBT in patients with PD was an efficacious therapy for some non-motor symptoms in PD, but not efficacious for fatigue and QOL. These results suggest that CBT results in significant improvement in PD and should be used as a conventional clinical intervention.
... Theoretical considerations and data from previous trials suggest that reducing pre-sleep arousal, as measured by HRV, might be beneficial in people with insomnia symptoms. Guidelines recommend cognitive behavioral therapy for insomnia as a first-line therapy [144], to, amongst other effects, reduce pre-sleep arousal [145]. There is some evidence that biofeedback interventions that reduce pre-sleep arousal positively affect cardiac autonomic control during the night [146,147] and objectively measured sleep quality [147,148]. ...
Article
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Unipolar depression is associated with insomnia and autonomic arousal. The aim of this study was to quantify the effect of a single bout of aerobic exercise on nocturnal heart rate variability and pre-sleep arousal in patients with depression. This study was designed as a two-arm, parallel-group, randomized, outcome assessor-blinded, controlled, superiority trial. Patients with a primary diagnosis of unipolar depression aged 18–65 years were included. The intervention consisted of a single 30 min moderate-intensity aerobic exercise bout. The control group sat and read for 30 min. The primary outcome of interest was RMSSD during the sleep period assessed with polysomnography. Secondary outcomes were additional heart rate variability outcomes during the sleep and pre-sleep period as well as subjective pre-sleep arousal. A total of 92 patients were randomized to either the exercise (N = 46) or the control (N = 46) group. Intent-to-treat analysis ANCOVA of follow-up sleep period RMSSD, adjusted for baseline levels and minimization factors, did not detect a significant effect of the allocation (β = 0.12, p = 0.94). There was no evidence for significant differences between both groups in any other heart rate variability measure nor in measures of cognitive or somatic pre-sleep arousal. As this is the first trial of its kind in this population, the findings need to be confirmed in further studies. Patients with depression should be encouraged to exercise regularly in order to profit from the known benefits on sleep and depressive symptoms, which are supported by extensive literature.
... There have been a proliferation of randomized controlled trials (RCTs) to evaluate the efficacy of CBT-I in treating chronic insomnia in adults. Collective evidence emanated from multiple systematic and meta-analyses supported that CBT-I is an efficacious treatment in a wide range of populations with medium to large effect sizes [41][42][43][44][45][46][47]. Its effect on improving sleep is comparable to medication in a short-term but is more sustainable in a long run [48][49][50]. ...
Article
Insomnia is a prevalent sleep problem associated with a constellation of negative health-related outcomes and significant socioeconomic burden. It commonly co-occurs with psychiatric and medical conditions, which may further exacerbate these comorbid conditions and hinder treatment response. There is much empirical evidence to support the clinical efficacy of non-pharmacological treatment for insomnia, especially cognitive behavioral therapy for insomnia (CBT-I), in managing insomnia in a wide range of populations. This article reviews the research on the efficacy of CBT-I for primary insomnia and insomnia comorbid with other psychiatric and medical conditions, the empirical evidence regarding different CBT-I treatment modalities, the implementation of CBT-I across different age groups, and some initial evidence on the sequential combination of insomnia treatments. A brief overview of other non-pharmacological treatment with regard to complementary alternative medicine is also provided.
... It has reported CBT is beneficial to insomnia in patients with or without PD [31]. This may be because insomnia has been associated more with persistent psychological factors than specific disease characteristics in the general population [32], while the goal of CBT in treating insomnia is to alter erroneous perceptions, cognitive arousal and maladaptive behaviors toward sleep hygiene [33]. Another result revealed that sleep quality did not ameliorate, which demonstrates that CBT can influence sleep duration rather than sleep architecture. ...
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Objective The aim of this study was to perform a quantitative analysis to evaluate the efficacy of cognitive behavioral therapy (CBT) on non-motor symptoms and its impact on quality of life (QOL) in Parkinson’s disease (PD). Methods We searched for randomized controlled trials in three electronic databases. Twelve studies, including 358 patients with PD, met the inclusion criteria. We determined the pooled efficacy by standard mean differences and 95% confidence intervals, using I 2 to reveal heterogeneity. Results The result showed CBT had a significant effect on depression [-0.94 (95% CI, -1.25 to -0.64, P < 0.001)] and anxiety [-0.78 (95% CI, -1.05 to -0.50, P < 0.001)]. Moderate effect sizes were noted with stress [-0.60 (95% CI, -1.06 to -0.14, P = 0.01)] and sleep disorders [-0.44 (95% CI, -0.74 to -0.15, P = 0.003)]. There was no evident impact of CBT on fatigue or QOL. We found an intervention period > 8 weeks was advantageous compared with < 8 weeks, and CBT intervention was more effective than CBT developmental therapy. Conclusion We found that CBT in patients with PD was an efficacious therapy for some non-motor symptoms in PD, but not efficacious for fatigue and QOL. These results suggest that CBT results in significant improvement in PD and should be used as a conventional clinical intervention.
... A Cochrane review 142 shows that antidepressants, acupuncture, music and physical exercise all offer some benefit for patients with insomnia. Cognitive and behavioural therapies are also effective for sleep problems 143,144 . However, the quality of the evidence for all these treatments ranges from very low to moderate, with further studies needed. ...
Article
Gut–brain dysregulation has been recognized by the scientific community as being crucial to the understanding of chronic gastrointestinal conditions, and this has translated into the practice of a newly established discipline, psychogastroenterology. Along with psychotherapy, antidepressants (a subtype of central neuromodulators) have been proposed as treatments for gut–brain disorders that might benefit both psychological and gastrointestinal health. Antidepressants have been found to be effective for the treatment of comorbid anxiety and depression, pain and impaired sleep. Although the efficacy of antidepressants is well established in disorders of gut–brain interaction (DGBI), evidence is only now emerging in IBD. This Perspective discusses the use of antidepressants in DGBI and IBD, focusing on how what we have learnt about the role of antidepressants in DGBI could be applied to help optimize the management of IBD. This Perspective discusses the use of antidepressants in disorders of gut–brain interaction (DGBI) and IBD, focusing on how what we have learnt about the role of antidepressants in DGBI could help optimize the management of IBD.
... 41 Recent meta-analysis evaluating eligible studies of Cognitive Behavioral Treatment for Insomnia (CBT-I) with children and adolescents consistently found that CBT-I significantly improved sleep onset latency and sleep efficiency in children and adolescents with chronic insomnia. [42][43][44][45][46][47][48][49][50][51] Meltzer provided a detailed summary of how to apply evidence-based behavioral strategies for insomnia in young children 52 (2010). She described the importance of a consistent sleep schedule and consistent bedtime routine for all children. ...
Article
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Throughout their childhood, pediatric insomnia impacts approximately 25% of all children in the general population. Although it can occur as an isolated condition, it commonly associates with other comorbidities, such as autism, developmental delay, and psychiatric disorders. Careful and detailed history is essential, and sleep logs and actigraphy are useful tools in the assessment and diagnosis of pediatric insomnia. However, polysomnography is usually not warranted in the assessment of pediatric insomnia unless underlying medically-based sleep symptoms are concurrently identified and justify such test. In the majority of cases, behavioral interventions are the recommended approach for treatment. Despite the fact that many pharmacological approaches are used for child insomnia off-label, there are currently no FDA (Food and Drug Administration) approved medications for the management of pediatric insomnia. The high prevalence of pediatric insomnia, coupled with the low number of providers, who are formally trained in behavioral treatment for this prevalent condition, highlights the urgent need for improving primary care practitioner awareness, while expanding alternative routes to access to care, such as interactive virtual technology-based treatments, parent education and manuals, along with ongoing efforts to increase professional training opportunities.
Chapter
This chapter provides an overview of contemporary evidence (as of 2021) for the efficacy of CBT‐I and its components. The scientific support for the clinical use of CBT‐I has emerged over the last 40 years and now comprises over 100 randomised controlled trials (RCTs). These trials have informed numerous meta‐analyses that have, as a consequence, shaped the treatment guidelines we use today. The evidence considered in this chapter focuses on the most recent meta‐analyses that report on the effects of CBT‐I and its components on insomnia symptoms and measures of sleep continuity. The overarching conclusion from meta‐analyses is that CBT‐I is effective in improving night‐time insomnia symptoms in both the short term and the long term. In addition, CBT‐I improves day‐time functioning and its efficacy seems to be independent of co‐morbid conditions, age and use of medication. The efficacy of CBT‐I components as standalone therapies has been examined to a lesser extent but shows promising results, especially for behavioural components.
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This review compared the efficacy and acceptability of different delivery formats for cognitive behavioral therapy for insomnia (CBT-I) in insomnia. We searched five databases for randomized clinical trials that compared one CBT-I delivery format against another format or control conditions for insomnia in adults. We used pairwise meta-analyses and frequentist network meta-analyses with the random-effects model to synthesize data. A total of 61 unique trials including 11571 participants compared six CBT-I delivery formats with four control conditions. At post-intervention, with low to high certainty evidence, individual, group, guided self-help, digital assisted, and unguided self-help CBT-I could significantly increase sleep efficiency and total sleep time (TST) and reduce sleep onset latency (SOL), wake after sleep onset (WASO), and insomnia severity compared with treatment as usual (MD range for sleep efficiency: 7.81% to 12.45%; MD range for TST: 16.14 to 33.96 minutes; MD range for SOL: -22.42 to -13.81 minutes; MD range for WASO: -40.84 to -19.48 minutes; MD range for insomnia severity: -6.40 to -3.93) and waitlist (MD range for sleep efficiency: 7.68% to 12.32%; MD range for TST: 12.67 to 30.49 minutes; MD range for SOL: -19.0 to -10.46 minutes; MD range for WASO: -47.10 to -19.15 minutes; MD range for insomnia severity: -7.59 to -5.07). The effects of different CBT-I formats persisted at short-term follow-up (4 weeks to 6 months). Individual, group, and digital assisted CBT-I delivery formats would be the more appropriate choices for insomnia in adults, based on post-intervention and short-term effects. Further trials are needed to investigate the long-term effects of different CBT-I formats.
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The view that perfectionists are prone to experiencing sleep disturbance is widely held. Yet, almost three decades of empirical research have yielded conflicting results. Whereas some researchers viewed perfectionism as a risk factor for sleep disturbance, others spoke of “adaptive” or “positive” forms of perfectionism in the context of sleep. The multidimensional conceptualisation of perfectionism may resolve this disagreement. Thus, this systematic review aimed to clarify the perfectionism‒sleep disturbance link using the widely accepted two-dimensional perfectionism model, differentiating perfectionistic concerns (defined by worries over imperfections) and perfectionistic strivings (defined by excessively high personal standards). A systematic literature search returned 24 relevant empirical studies. Perfectionistic concerns were robustly linked to sleep disturbance. Perfectionistic strivings displayed comparatively small and inconsistent relations with sleep disturbance. Finally, cross-sectional mediation studies suggested that psychological distress and dysfunctional cognitive processes might underlie the perfectionistic concerns‒sleep disturbance link. These findings show that considering perfectionistic concerns in explaining, predicting, and treating sleep disturbance may be a promising approach. In contrast, perfectionistic strivings appeared neither universally adaptive nor maladaptive. We identified several critical gaps in the empirical literature and point towards future research directions, highlighting the need for more longitudinal studies.
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Study objectives: Insomnia is highly prevalent and associated with anxiety and depression in coronary heart disease (CHD) patients. The development of effective psychological interventions is needed. Worry and rumination are potential risk factors for the maintenance of insomnia, anxiety and depression that may be modified by psychological treatment grounded in the Self-Regulatory Executive Function model. However, the relationships between worry, rumination, anxiety and depression and insomnia are not known. Therefore, we investigated these relationships both cross-sectionally and longitudinally among CHD patients. Methods: A cross-sectional study consecutively included 1082 patients in 2014-15, and 686 were followed up after mean of 4.7 years. Data were gathered from hospital records and self-report questionnaires comprising assessment of worry (Penn State Worry Questionnaire), rumination (Ruminative Responses Scale), anxiety and depression (Hospital Anxiety and Depression Scale) and insomnia (Bergen Insomnia Scale). Results: Insomnia correlated moderately with all other psychological variables (R 0.18-0.50, all p-values <0.001). After adjustments for anxiety and depression, Odds Ratios for insomnia at baseline were 1.27 (95% CI 1.08-1-50) and 1.60 (95% CI 1.31-1.94) per 10 points increase of worry and rumination, respectively. Corresponding Odds Ratios for insomnia at follow-up were 1.28 (95% CI 1.05-1.55) and 1.38 (95% CI 1.09-1.75). Depression was no longer significantly associated with insomnia after adjustments for worry and rumination, but anxiety remained significant. Conclusions: Worry and rumination predicted insomnia both cross-sectionally and prospectively, even after controlling for anxiety and depression, although anxiety remained significant. Future studies may test psychological interventions targeting these factors in CHD patients with insomnia.
Chapter
Sleep disturbance is a major public health problem. Highly prevalent, sleep disturbance is bidirectionally associated with psychiatric and physical illness. This article provides an overview of sleep, sleep disturbance, and evidence-based assessment methods. Then, for each of the most common sleep disorders—namely, insomnia, obstructive sleep apnea, restless leg syndrome, and nightmare disorder—the diagnostic criteria, clinical features, prevalence, and evidence-based assessment and treatment methods are reviewed. Finally, future research directions are highlighted, with an emphasis on comorbidity and transdiagnostic approaches to treatment.
Article
Purpose We aimed to evaluate the effectiveness of CBT-i in patients with fibromyalgia in comparison with other non-pharmacological treatments. Methods Randomized controlled trials assessing the effects of CBT-i in adults with fibromyalgia, published in English or Spanish, were eligible. Electronic searches were performed using PubMed, Scopus, The Cochrane Library, WebOfKnowledge and Psicodoc databases in March 2021. The main outcome measures were sleep efficiency and sleep quality. Secondary outcomes included pain, depression, and anxiety. Results Of 226 studies reviewed, five were included in the meta-analysis. CBT-i compared with non-pharmacological treatments showed no significant improvements in sleep efficiency (p = 0.05; standardized mean difference (SMD) [95% CI] 0.31 [−0.00 to 0.61]). CBT-i showed significant improvements in sleep quality (p = 0.009; SMD [95% CI] − 0.53 [−0.93 to −0.13]), pain (p = 0.002; SMD [95% CI] − 0.41 [−0.67 to −0.16]), anxiety (p = 0.001; SMD [95% CI] − 0.46 [−0.74 to 0.18]) and depression (p = 0.02; SMD [95% CI] − 0.33 [−0.61 to −0.05]), compared to non-pharmacological treatments. Effect sizes ranged from small to moderate. Conclusions CBT-i was associated with a significant improvement in sleep quality, pain, anxiety, and depression, although these results are retrieved from very few studies with only very low to low quality evidence. Trial registration: The review protocol was registered with PROSPERO (Record ID = CRD42016030161). • IMPLICATIONS FOR REHABILITATION • CBT-i has been proven to improve sleep quality, pain, anxiety and depression, although with small effect sizes. • Implementing hybrid CBT for pain and sleep or combining CBT and mindfulness may improve symptoms in people diagnosed with FM. • This meta-analysis results highlight the need to enhance sleep management skills among people suffering from this health condition.
Chapter
While the field of sleep is developing, the impact of sleep on a child’s development and well-being is starting to garner attention. Pediatric insomnia affects approximately one-third of all children in the general population. It is commonly associated with other comorbidities such as autism, developmental delay, and psychiatric disorders and can also occur as an isolated condition. In order to assess and diagnose, a thorough and detailed history is essential. Sleep logs and actigraphy have shown to be useful tools in the assessment and diagnosis of pediatric insomnia. Under current clinical practice, polysomnography is not indicated in the assessment of pediatric insomnia unless underlying medically based sleep symptoms are concurrently present and justify a diagnostic test. Behavioral interventions continue to be the recommended treatment approach for pediatric insomnia. While pharmacological agents are utilized off-label for pediatric insomnia, there are currently no FDA-approved medications for the management of pediatric insomnia. The high prevalence of pediatric insomnia in the setting of a low number of providers who are formally trained in assessment and behavioral treatment for this condition prompts the need for increasing primary care provider awareness. Advocating for increased education and intervention through various methods including caregiver education, manuals, and increasing health professional training opportunities at all educational levels will continue to expand this developing field.
Article
Objective: Cognitive therapy (CT) and behavior therapy (BT) are both effective for insomnia but are expected to work via different pathways. Empirically, little is known about their symptom-specific effects. Method: This was a secondary analysis of a randomized controlled trial of online treatment for insomnia disorder (N = 219, 72.9% female, mean age = 52.5 years, SD = 13.9). Participants were randomized to CT (n = 72), BT (n = 73), or wait-list (n = 74). Network Intervention Analysis was used to investigate the symptom-specific treatment effects of CT and BT throughout treatment (wait-list was excluded from the current study). The networks included the Insomnia Severity Index items and the sleep diary-based sleep efficiency and were estimated biweekly from Week 0 until Week 10. Results: Participants in the BT condition showed symptom-specific effects compared to CT on "sleep efficiency" (Week 4-8, post-test), "difficulty maintaining sleep" (Week 4), and "dissatisfaction with sleep" (post-test). Participants in the CT showed symptom-specific effects compared to BT on "interference with daily functioning" (Week 8, post-test), "difficulty initiating sleep", "early morning awakenings," and "worry about sleep" (all post-test). Conclusions: This is the first study that observed specific differential treatment effects for BT and CT throughout the course of their treatment. These effects were more pronounced for BT than for CT and were in line with the theoretical background of these treatments. We think the embedment of the theoretical background of CT and BT in empirical data is of major importance to guide further treatment development. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Article
Repetitive negative thinking (RNT), i.e., worry, rumination, and transdiagnostic repetitive thinking, is thought to exacerbate and perpetuate insomnia in cognitive models. Moreover, RNT is a longitudinal precursor of depression and anxiety, which are often co-present alongside insomnia. Whilst accumulating evidence supports the efficacy of cognitive behavioural therapy for insomnia (CBT-I) in reducing depression and anxiety symptoms, the literature on the effects of CBT-I on RNT has never been systematically appraised. Importantly, preliminary evidence suggests that reduction of RNT following CBT-I may be associated with reduction of depression and anxiety. Therefore, we aimed to conduct a systematic review and meta-analysis on the effects of CBT-I on RNT. Seven databases were searched, and 15 randomised controlled trials were included. Results showed robust effects of CBT-I on worry (Hedge’s g range: -.41 to g = -.71) but small and non-reliable effects on rumination (g = -.13). No clear evidence was found for an association between post-treatment reduction in RNT and post-treatment reduction in depression and anxiety. Although the literature is small and still developing, CBT-I seems to have a stronger impact on sleep-related versus general measures of RNT. We discuss a research agenda aimed at advancing the study of RNT in CBT-I trials.
Thesis
Les données épidémiologiques concernant l’initiation d’hypnosédatifs (HS) chez le sujet âgé hospitalisé, les facteurs de risque associés et l’efficacité des actions de promotion du bon usage sont peu nombreuses. Les objectifs étaient (1) d’évaluer l’incidence des initiations d’HS en hospitalisation aiguë, la proportion de reconduction à la sortie, les facteurs de risque associés (SÉDATIF) et (2) d’identifier/évaluer les interventions de promotion du bon usage des HS décrites dans la littérature (HYPNOREV). Dans l’étude rétrospective multicentrique SÉDATIF, la proportion d’initiations d’HS était de 21,5% à 20 jours. L’HS était reconduit chez 56,0% des patients sortant en Soins de Suite et de Réadaptation (SSR) et 38,7% des sortants à domicile. Aucun facteur de risque d’initiation n’a été mis en évidence. Chez les patients sortant en SSR, l’initiation après 6 jours était protectrice de la reconduction à la sortie (OR = 0,19 ; p = 0,02). La revue systématique HYPNOREV (1980-2015) a permis d’identifier 31 études portant sur des interventions réglementaires ou éducatives de promotion du bon usage des HS. Les interventions éducatives multifacettes impliquant professionnels de santé, patients et utilisant les médias étaient les plus efficaces. De nouvelles études plus robustes étudiant la mise en la place de telles interventions en milieu hospitalier sont nécessaires.
Article
Waine, Broomfield, Banham, & Espie (2009) developed and validated the Metacognitions Questionnaire-Insomnia (MCQ-I) to assess metacognition about sleep, which was hypothesized to have a two-factor structure consisting of metacognitive belief about sleep, and metacognitive plans about sleep. However, it is unclear if the MCQ-I reflects metacognition about sleep as hypothesized because no item analysis or factor analysis was conducted. The present study was designed to develop a short version of MCQ-I using selected items and investigate its reliability and validity. A cross-sectional survey using the MCQ-I was conducted with undergraduates (N=330) and 27 patients with chronic insomnia disorder. Results of factor analysis and item analysis of their responses indicated that MCQ-I has a two-factor structure as hypothesized, and 25 items had high internal consistency. Moreover, the MCQ-I-25 was correlated with metacognition about worry, comprehensive dimensions of cognitive arousal, and sleep disturbances. Furthermore, the MCQ-I-25 score was higher in insomnia patients than healthy students. These results suggest that MCQ-I-25 reflects metacognition about sleep and could predict cognitive arousal and insomnia.
Article
Objectives To investigate how the different components of sleep dysfunction described in SLE patients combine together in sleep clusters. Methods We conducted a cross-sectional study on a perspective cohort of 79 SLE patients (mean age 8.2 ± 14.3 years). Sleep was evaluated using Pittsburgh Sleep Quality Index (PSQI). Clusters were defined using the single components of PSQI in a hierarchical clustering model. We used Beck Depression Inventory, Hamilton Anxiety Rating Scale, and Medical Outcomes Study Short Form 36 (SF36) to measure depressive symptoms, anxiety, and quality of life, respectively. Results Three sleep clusters were identified. The cluster 1 (N = 47) is characterized by the lowest values of PSQI total score. The cluster 2 (N = 21) presents higher values of sleep latency, but sleep duration similar to cluster 1. In cluster 3 (N = 11), we found sleep latency increased as in cluster 2, but the highest values of PSQI total score and reduced sleep duration. Scores of anxiety and sedentary time were higher in clusters 2 and 3 than in cluster 1. Cluster 3 presented the highest scores of depression and reduced mental and physical components of SF36. Conclusions The combination of different sleep components in SLE patients allowed us to identify three patterns of dysfunction: a first cluster with better sleep latency and duration, a second with increased sleep latency but conserved duration, and a third with impairment of both latency and duration. The stratification of sleep disorders in clusters might be useful for the personalization of therapy in relation to sleep cluster membership.
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This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).
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Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedges's g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.
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Insomnia disorder affects a large proportion of the population on a situational, recurrent or chronic basis and is among the most common complaints in medical practice. The disorder is predominantly characterized by dissatisfaction with sleep duration or quality and difficulties initiating or maintaining sleep, along with substantial distress and impairments of daytime functioning. It can present as the chief complaint or, more often, co-occurs with other medical or psychiatric disorders, such as pain and depression. Persistent insomnia has been linked with adverse long-term health outcomes, including diminished quality of life and physical and psychological morbidity. Despite its high prevalence and burden, the aetiology and pathophysiology of insomnia is poorly understood. In the past decade, important changes in classification and diagnostic paradigms have instigated a move from a purely symptom-based conceptualization to the recognition of insomnia as a disorder in its own right. These changes have been paralleled by key advances in therapy, with generic pharmacological and psychological interventions being increasingly replaced by approaches that have sleep-specific and insomnia-specific therapeutic targets. Psychological and pharmacological therapies effectively reduce the time it takes to fall asleep and the time spent awake after sleep onset, and produce a modest increase in total sleep time; these are outcomes that correlate with improvements in daytime functioning. Despite this progress, several challenges remain, including the need to improve our knowledge of the mechanisms that underlie insomnia and to develop more cost-effective, efficient and accessible therapies.
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Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia. To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia. Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening. Randomized, controlled trials assessing the efficacy of face-to-face, multimodal CBT-i compared with inactive comparators on overnight sleep in adults with chronic insomnia, with studies of insomnia comorbid with medical, sleep, or psychiatric disorders excluded. Study characteristics, quality, and data were assessed independently by 2 reviewers. Main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE%). Among 292 citations and 91 full-text articles reviewed, 20 studies (1162 participants [64% female; mean age, 56 years]) were included. Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, -0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%), and changes seemed to be sustained at later time points. No adverse outcomes were reported. Our narrow inclusion criteria limited applicability to patients with comorbid insomnia and other sleep problems, and the accuracy of estimates at later time points was less clear. CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes. None. (PROSPERO: CRD42012002863).
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Background: Sleep disturbance, including insomnia, is a major health issue among both adults and adolescents. Mindfulness-based interventions (MBIs) have recently received increased attention as a non-pharmacological treatment option for patients with insomnia. Objectives: This meta-analysis assesses the effects of MBIs on sleep disturbance in the general population. Methods: A literature search was conducted using PubMed, Medline, PsychInfo, Google Scholar, and Cochrane library. The search terms were “mindfulness therapy”, “mindfulness based cognitive therapy”, “mindfulness based stress reduction”, “acceptance and commitment therapy”, and “yoga” crossed by “insomnia”, “adults”, “adolescents”, or “children”. All studies in English-language were examined through October 2013. Sixteen studies from different age groups were included in this meta-analysis. Sleep measurements were evaluated before and after MBIs, using both subjective as well as objective methods. Long-term effects were also examined. Results: The meta-analysis included 575 individuals across 16 studies. Ages ranged from 8-87 years and 82.09% of participants were female (472/575). MBIs were associated with increased sleep efficiency (SE; ES = 0.88; p < 0.0001) and total sleep time (TST; ES = 0.47; p = 0.003) as assessed by sleep log. Additionally, wake after sleep onset and sleep onset latency decreased (WASO; ES = -0.84; p < 0.0001; SOL; ES = -0.55; p < 0.00001). Changes in sleep when measured by polysomnography and actigraphy, however, were not statistically significant. Sleep improvements as assessed by sleep log continued 2-6 months following treatment initiation. Interpretation is limited by the small number of studies on MBIs for insomnia, especially in adolescent populations. Conclusion: This meta-analysis suggests efficacy of mindfulness-based interventions for improving sleep, as assessed by subjective sleep logs but not by objective measures, and this continued several months after treatment initiation. More research is needed to explore this promising treatment option for adults and adolescents with insomnia.
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Objective: To examine the unique contribution of behavior therapy (BT) and cognitive therapy (CT) relative to the full cognitive behavior therapy (CBT) for persistent insomnia. Method: Participants were 188 adults (117 women; M age = 47.4 years, SD = 12.6) with persistent insomnia (average of 14.5 years duration). They were randomized to 8 weekly, individual sessions consisting of BT (n = 63), CT (n = 65), or CBT (n = 60). Results: Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%). Remission rates followed a similar trajectory, with higher remission rates at post treatment in CBT (57.3%) relative to CT (30.8%), with BT falling in between (39.4%); CT made further gains from post treatment to follow up (30.9% to 51.6%). All 3 therapies produced improvements of daytime functioning at both post treatment and follow up, with few differential changes across groups. Conclusions: Full CBT is the treatment of choice. Both BT and CT are effective, with a more rapid effect for BT and a delayed action for CT. These different trajectories of changes provide unique insights into the process of behavior change via behavioral versus cognitive routes.
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To compare the efficacy of problem-solving therapy (PST) combined with behavioral sleep strategies to standard cognitive therapy (CT) combined with behavioral sleep strategies in the treatment of insomnia. A six-week randomized controlled trial with one month follow-up. The Australian National University Psychology Clinic, Canberra, Australia. Forty-seven adults aged 18-60 years recruited from the community meeting the Research Diagnostic Criteria for insomnia. Participants received 6 weeks of treatment including one group session (sleep education and hygiene, stimulus control instructions and progressive muscle relaxation) followed by 5 weeks of individual treatment of PST or CT. Primary outcomes included sleep efficiency (SE) from sleep diaries, the Insomnia Severity Index (ISI), and the Pittsburgh Sleep Quality Index (PSQI). Secondary measures assessed dysfunctional sleep beliefs, problem-solving skills and orientations, and worry. Both treatments produced significant post therapy improvements in sleep which were maintained at 1 month follow-up (on SE Cohen d = 1.42, 95% CI 1.02-1.87 for PST; d = 1.26, 95% CI 0.81-1.65 for CT; on ISI d = 1.46, 95% CI 1.03-1.88 for PST; d = 1.95, 95% CI 0.52-2.38 for CT; for PSQI d = 0.97, 95% CI 0.55-1.40 for PST and d = 1.34, 95% CI 0.90-1.79 for the CT). There were no differences in PST and CT in the size or rate of improvement in sleep although CT produced a significant faster rate of decline in negative beliefs about sleep than PST and there was a trend (P = 0.08) for PST to produce a faster rate of improvement in negative problem orientation than CT. The results provide preliminary support for problem solving treatment as an equally efficacious alternative component to cognitive therapy in psychological interventions for insomnia. CITATION: Pech M; O'Kearney R. A randomized controlled trial of problem-solving therapy compared to cognitive therapy for the treatment of insomnia in adults. SLEEP 2013;36(5):739-749.
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This investigation assessed the efficacy of a technique specifically designed to change the style and content of presleep thoughts in order to reduce nighttime cognitive arousal and decrease insomnia severity. This investigation, termed "cognitive refocusing treatment for insomnia" (CRT-I), previously improved sleep in a small sample of veterans with primary insomnia. In this investigation, university students with poor sleep were randomly assigned to attend either one session of CRT-I and sleep hygiene education (SH: n=27) or one session of only SH (n=24). Insomnia severity (assessed by the Insomnia Severity Index) and nighttime arousal (assessed by the Pre-Sleep Arousal Scale) were measured at baseline and 1month posttreatment. A significant Group×Time interaction for insomnia severity suggested more improved sleep over time for those receiving CRT-I+SH. A trend for a Group×Time interaction showed decreased cognitive arousal over time among those receiving CRT-I. These findings provide preliminary support for the efficacy of CRT-I for insomnia treatment among college students. Continued study of CRT-I in a community-based sample appears warranted.
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Geriatric insomnia is a prevalent problem that has not received adequate controlled evaluation of psychological treatments. The present study evaluated behavioral and cognitive methods, relative to a wait-list control condition, for treating 27 elderly subjects (mean age = 67 years) with sleep-maintenance insomnia. Both treatment methods, stimulus control and imagery training, produced significant improvement on the main outcome measure of awakening duration. Stimulus control yielded higher improvement rates than either imagery training or the control condition on awakening duration and total sleep-time measures. Sleep improvements were maintained by the two treatment methods at 3- and 12-month follow-ups. The results were corroborated by collateral ratings obtained from significant others. Subjective estimates of awakening duration and sleep latency correlated highly with objective measures recorded on an electromechanical timer. The findings suggest that geriatric insomnia can be effectively treated with psychological interventions and that behavioral procedures are more beneficial than cognitive procedures for sleep maintenance problems.
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This study compared the relative efficacy of stimulus control and imagery training with a wait-list control condition for treating 21 sleep-maintenance insomniacs. Stimulus control was more effective than either imagery training or no treatment in reducing both the frequency and duration of nighttime awakenings. Further reductions were made by the stimulus control group on both measures at 3-month follow-up, but these were only partially maintained at the 12-month follow-up. Although imagery training had minimal effects on both sleep measures during treatment, substantial reductions over baseline levels of awakening duration were obtained at follow-up. These findings suggest that behavioral and cognitive procedures, previously found effective in treating sleep-onset insomnia, are also beneficial in alleviating maintenance insomnia.
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It has been suggested that the quality of clinical trials should be assessed by blinded raters to limit the risk of introducing bias into meta-analyses and systematic reviews, and into the peer-review process. There is very little evidence in the literature to substantiate this. This study describes the development of an instrument to assess the quality of reports of randomized clinical trials (RCTs) in pain research and its use to determine the effect of rater blinding on the assessments of quality. A multidisciplinary panel of six judges produced an initial version of the instrument. Fourteen raters from three different backgrounds assessed the quality of 36 research reports in pain research, selected from three different samples. Seven were allocated randomly to perform the assessments under blind conditions. The final version of the instrument included three items. These items were scored consistently by all the raters regardless of background and could discriminate between reports from the different samples. Blind assessments produced significantly lower and more consistent scores than open assessments. The implications of this finding for systematic reviews, meta-analytic research and the peer-review process are discussed.
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This treatment program uses evidence-based cognitive-behavioral therapy (CBT) methods to correct poor sleep habits. CBT has been proven in multiple studies to improve sleep by reducing time spent in bed before sleep onset, reducing time spent awake after first sleep onset, and increasing the quality and efficiency of sleep. Thoroughly updated according to the DSM-5, which has eliminated the differentiation between primary and secondary insomnias, this program provides an expanded discussion of daytime related issues as well as delivery issues specific to those with comorbid mental and medical problems. Patients are first given information about healthy sleep and the reasons for improving sleep habits, then a behavioral program is developed to address that patient's specific sleep problems. Use of a sleep diary, assessment forms, and other homework (all provided in the corresponding patient Workbook) allow clients and therapists to work together to develop an effective sleep regimen tailored specifically for each client, and several sessions are dedicated to increasing compliance and problem-solving.
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Background: Insomnia is a widespread and debilitating condition that affects sleep quality and daily productivity. Although mindfulness meditation (MM) has been suggested as a potentially effective supplement to medical treatment for insomnia, no comprehensively quantitative research has been conducted in this field. Therefore, we performed a meta-analysis on the findings of related randomized controlled trials (RCTs) to evaluate the effects of MM on insomnia. Methods: Related publications in PubMed, EMBASE, the Cochrane Library and PsycINFO were searched up to July 2015. To calculate the standardized mean differences (SMDs) and 95% confidence intervals (CIs), we used a fixed effect model when heterogeneity was negligible and a random effect model when heterogeneity was significant. Results: A total of 330 participants in 6 RCTs that met the selection criteria were included in this meta-analysis. Analysis of overall effect revealed that MM significantly improved total wake time and sleep quality, but had no significant effects on sleep onset latency, total sleep time, wake after sleep onset, sleep efficiency, total wake time, ISI, PSQI and DBAS. Subgroup analyses showed that although there were no significant differences between MM and control groups in terms of total sleep time, significant effects were found in total wake time, sleep onset latency, sleep quality, sleep efficiency, and PSQI global score (absolute value of SMD range: 0.44-1.09, all p<0.05). Conclusions: The results suggest that MM may mildly improve some sleep parameters in patients with insomnia. MM can serve as an auxiliary treatment to medication for sleep complaints.
Article
Although cognitive behavioural therapy (CBT) for insomnia has resulted in significant reductions in symptoms, most patients are not classified as good sleepers after treatment. The present study investigated whether additional sessions of cognitive therapy (CT) or mindfulness-based therapy (MBT) could enhance CBT in 64 participants with primary insomnia. All participants were given four sessions of standard CBT as previous research had identified this number of sessions as an optimal balance between therapist guidance and patient independence. Participants were then allocated to further active treatment (four sessions of CT or MBT) or a no further treatment control. The additional treatments resulted in significant improvements beyond CBT on self-report and objective measures of sleep and were well tolerated as evidenced by no dropouts from either treatment. The effect sizes for each of these additional treatments were large and clinically significant. The mean scores on the primary outcome measure, the Insomnia Severity Index, were 5.74 for CT and 6.69 for MBT, which are within the good-sleeper range. Treatment effects were maintained at follow-up. There were no significant differences between CT and MBT on any outcome measure. These results provide encouraging data on how to enhance CBT for treatment of insomnia. Copyright © 2015 John Wiley & Sons, Ltd. Key practitioner message: CBT treatments for insomnia can be enhanced using recent developments in cognitive therapy. CBT treatments for insomnia can be enhanced using mindfulness-based treatments. Both cognitive therapy and mindfulness produce additional clinically significant change.
Article
Cognitive processes play an important role in the maintenance, and treatment of sleep difficulties, including insomnia. In 2002, a comprehensive model was proposed by Harvey. Since its inception the model has received >300 citations, and provided researchers and clinicians with a framework for understanding and treating insomnia. The aim of this review is two-fold. First, we review the current literature investigating each factor proposed in Harvey’s cognitive model of insomnia. Second, we summarise the psychometric properties of key measures used to assess the model’s factors and mechanisms. From these aims, we demonstrate both strengths and limitations of the current knowledge of appropriate measurements associated with the model. This review aims to stimulate and guide future research in this area; and provide an understanding of the resources available to measure, target, and resolve cognitive factors that may maintain chronic insomnia.
Article
Insomnia is the most common sleep disorder among the general population. Although cognitive behavioral therapy for insomnia (CBT-I) is the psychological treatment of choice, the availability of individual therapy is often not sufficient to meet the demand for treatment. Group treatment can increase the efficiency of delivery, but its efficacy has not been well-established. Randomized controlled trials (RCTs) comparing group CBT-I to a control group in patients with insomnia were identified. A review of 670 unique citations resulted in eight studies that met criteria for analysis. Outcome variables included both qualitative (e.g., sleep quality) and quantitative (e.g., sleep diary) outcomes, as well as depression and pain severity, at both pre- to post-treatment and follow-up (3-12 months post-treatment). Overall, we found medium to large effect sizes for sleep onset latency, sleep efficiency, and wake after sleep onset and small effect sizes for pain outcomes. Effect sizes remained significant at follow-up, suggesting that treatment gains persist over time. Other variables, including total sleep time, sleep quality, and depression, showed significant improvements, but these findings were limited to the within treatment group analyses. It is clear that group CBT-I is an efficacious treatment. Implications for stepped care models for insomnia are discussed.
Article
Insomnia is a prevalent health complaint that is associated with significant morbidity and health care costs. Progress has been made in developing and validating therapeutic approaches for the management of chronic insomnia, and CBT now is recognized as an effective treatment option. Despite these advances, insomnia remains undertreated in clinical practice, and CBT is underused by health care practitioners. An important future challenge will be to disseminate validated therapies and practice guidelines more efficiently and to increase their use in clinical practice. Additional research also is needed to optimize therapeutic outcomes in reducing insomnia symptoms and in increasing the impact of treatment on other indicators of morbidity and cost effectiveness.
Article
Background. The usefulness of any diagnostic scheme is directly related to its ability to provide clinically useful information on need for care. In this study, the clinical usefulness of dimensional and categorical representations of psychotic psychopathology were compared. Method. A total of 706 patients aged 16–65 years with chronic psychosis were recruited. Psychopathology was measured with the Comprehensive Psychopathological Rating Scale (CPRS). Lifetime RDC, DSM-III-R, and ICD-10 diagnoses and ratings of lifetime psychopathology were made using OPCRIT. Other clinical measures included: ( i ) need for care; ( ii ) quality of life; ( iii ) social disability; ( iv ) satisfaction with services; ( v ) abnormal movements; ( vi ) brief neuropsychological screen; and ( vii ) over the last 2 years – illness course, symptom severity, employment, medication use, self-harm, time in hospital and living independently. Results. Principal component factor analysis of the 65 CPRS items on cross-sectional psychopathology yielded four dimensions of positive, negative, depressive and manic symptoms. Regression models comparing the relative contributions of dimensional and categorical representations of psychopathology with clinical measures consistently indicated strong and significant effects of psychopathological dimensions over and above any effect of their categorical counterparts, whereas the reverse did not hold. The effect of psychopathological dimensions was mostly cumulative: high ratings on more than one dimension increased the contribution to the clinical measures in a dose-response fashion. Similar results were obtained with psychopathological dimensions derived from lifetime psychopathology ratings using the OCCPI. Conclusions. A dimensional approach towards classification of psychotic illness offers important clinical advantages.
Article
The efficacy of cognitive-behavioral therapy for insomnia (CBT-I) to improve both short- and long-term outcomes in both uncomplicated and comorbid insomnia patients has been repeatedly and conclusively demonstrated. Further demonstrations of efficacy, per se, in additional comorbid insomnia populations are likely not the best use of limited energy and resources. Rather, we propose that future CBT-I research would be better focused on three key areas: (a) increasing treatment efficacy, particularly for more clinically relevant outcomes; (b) increasing treatment effectiveness and potential for translation into the community, with a particular focus on variants of CBT-I and alternative delivery modalities within primary healthcare systems; and (c) increasing CBT-I practitioner training and dissemina-tion.
Article
Paradoxical intention has been shown to improve sleep performance in chronic insomniacs, presumably by interrupting their overly anxious sleep efforts. It was hypothesized that instructions to simply give up such sleep intentions—without trying to stay awake—could have a similar effect. Giving-up instructions framed as a paradoxical sleep-improvement method ("try giving up") were compared with giving up presented as a way to improve nighttime comfort and morning restedness without any sleep improvement ("give up trying"), along with a placebo-attention (self-monitoring) treatment. The 3 treatments were embodied in a printed booklet delivered by mail and evenly distributed among 33 20–56 yr old chronic insomniacs recruited from the general community. All 3 treatment groups improved in daily sleep estimates ("sleep efficiency") after treatment, but only the giving-up groups improved on a self-report measure of sleep performance anxiety. It is suggested that such a reduction in performance anxiety may be an important therapeutic outcome, with or without sleep improvement. (43 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
In a previous study, Ascher and Turner (1980) accounted for differential results of two types of paradoxical intention administrations by suggesting that in one case subjects were encouraged to follow the explicit demands of the instructions which adversely effected performance. It was the purpose of the present study to determine the effect of employing a procedural component to emphasize the explicit demands of paradoxical intention instructions. Two groups received identical paradoxical intention instructions. One was required to present “objective” data along with their subjective sleep report—the other had only to present the subjective data. Two control groups were included in the design which employed sleep onset latency as a dependent variable. As hypothesized, results indicated that the paradoxical intention group submitting “objective” data reported latencies which were significantly longer than those of the no-treatment control, while the paradoxical intention group that was not required to submit “objective” data reported sleep onset latencies which were significantly shorter than those of the no-treatment control group.(Received December 1981)
Article
The examination of treatment mechanisms in randomized controlled trials (RCTs) has considerable implications for research and clinical practice. Insomnia is a highly prevalent and distressing disorder, associated with many adverse outcomes. Although extensive work has focused on the cognitive-behavioral treatment of insomnia (CBT-I), few studies have directly examined the mechanisms of this intervention. CBT-I is a short-term, multi-component treatment that has demonstrated strong efficacy in treating insomnia. The purpose of the present study is: (a) to investigate if CBT-I works in accordance with its proposed mechanisms, and (b) to evaluate how the field is progressing in its understanding of these processes. This study comprehensively reviewed CBT-I RCTs for their inclusion of mediator variables. Secondary analysis studies were also surveyed for relevant mediator variables. Results demonstrated that 21 RCTs (39% of the total RCTs) and 11 secondary analysis studies examined at least one of the proposed mediators. Results of this review highlight that, although CBT-I appears to be targeting the hypothesized sleep processes, more research is needed to better understand whether CBT-I works in accordance with its theorized mechanisms. Inclusion of mediational analyses in future RCTs and secondary analysis studies would allow for further refinement of CBT-I and improved treatment outcomes.
Article
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). 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. 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). 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= 1.10-1.68). In comparison with BT, BT + CW resulted in a larger reduction in worry at two of the time points (controlled d= 0.76-1.64). No significant differences between the two conditions were demonstrated for dysfunction. While more participants responded positively to treatment in the BT + CW (80-100%) than in the BT condition (18-27%), none of the participants remitted. 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.
Article
A sample of physician-referred chronic insomniacs was randomly allocated to either progressive relaxation, stimulus control, paradoxical intention, placebo or no treatment conditions. Treatment process and outcome were investigated in terms of mean and standard deviation (night to night variability) measures of sleep pattern and sleep quality. Only active treatments were associated with significant improvement, but the nature of treatment gains varied. In particular, stimulus control improved sleep pattern, whereas relaxation affected perception of sleep quality. All improvements were maintained at 17 month follow-up. Results are discussed with reference to previous research and guidelines are given for clinical practice.
Article
It seems sensible to tailor treatments of insomnia in relation to the presenting characteristics of the sleeper and of the complaint. This report describes the first study formally to examine the comparative effectiveness of tailored and untailored (randomly allocated) treatments. We developed a questionnaire to facilitate the designing of individualized programmers. Results indicated that statistical analysis may underestimate the benefits of tailoring. Measures of clinically significant change, however, suggested that tailored treatment though it may be highly effective, is no more so than stimulus control therapy.
Article
Recent research in the treatment of insomnia by paradoxical intention has utilized two different methods of instruction. Studies utilizing the random assignment of subjects to treatment groups employ a procedure in which clients are provided with a straight-forward explanation based on the present authors' understanding of the use of paradoxical intention with insomnia (type A administration). In contrast, controlled case studies have employed reframing, a procedure which explains the need for the paradoxical intention in a manner which best suits the specific understanding of the individual client (type B administration). The present study employed the type B method in a design employing the random assignment of clients to groups. Three additional groups (type A administration, placebo control, no-treatment control) completed the design. The results indicated that the type A method was superior to the type B procedure when the same method for administering paradoxical intention was applied to a randomized group of individuals.
Article
Developing techniques designed to minimize arousing cognitions during the evening may be important to help improve the treatment of insomnia. This investigation assessed an intervention that focused exclusively on enhancing cognitive refocusing at sleep onset to change the content and style of presleep cognitions in order to improve sleep. Individuals with primary insomnia (N=10; 90% male, mean age=49.2, SD=12.6) attended four weekly individual meetings. Sleep quality (the Pittsburgh Sleep Quality Index), insomnia severity (the Insomnia Severity Index), sleep parameters based on one week of sleep diaries, and arousing thought content, were compared at baseline, posttreatment, and at a 1-month follow-up. Adherence was high, and participants showed good ability to engage in the procedure. Significant improvements in sleep quality, insomnia severity, sleep onset latency, total sleep time, and arousing thought content were revealed. Large effect sizes were observed on the majority of sleep variables at follow-up. Preliminary results were encouraging regarding a technique that targets the refocusing of thoughts during the evening in order to improve sleep. Further study regarding the efficacy of this procedure is warranted.
Article
Paradoxical Intention (PI) is a cognitive treatment approach for sleep-onset insomnia. It is thought to operate by eliminating voluntary sleep effort, thereby ameliorating sleep performance anxiety, an aroused state incompatible with sleep. However, this remains untested. Moreover, few PI studies have employed objective sleep measures. The present study therefore examined the effect of PI on sleep effort, sleep anxiety and both objective and subjective sleep. Following a seven-night baseline, 34 sleep-onset insomniacs were randomly allocated to 14 nights of PI, or to a control (no PI) condition. Consistent with the performance anxiety model, participants allocated to PI, relative to controls, showed a significant reduction in sleep effort, and sleep performance anxiety. Sleep-onset latency (SOL) differences between PI participants and controls using an objective sleep measure were not observed, although an underlying trend for significantly lowered subjective SOL amongst PI participants was demonstrated. This may relate to actigraphic insensitivity, or more probably confirms recent suggestions that insomniacs readily overestimate sleep deficit, due to excessive anxiety about sleep. Together, results help determine putative mechanisms underlying PI, have important implications for the clinical application of PI, and emphasize the need for further PI research within an experimental cognitive framework.
Article
We examined the relationships between six emotion-regulation strategies (acceptance, avoidance, problem solving, reappraisal, rumination, and suppression) and symptoms of four psychopathologies (anxiety, depression, eating, and substance-related disorders). We combined 241 effect sizes from 114 studies that examined the relationships between dispositional emotion regulation and psychopathology. We focused on dispositional emotion regulation in order to assess patterns of responding to emotion over time. First, we examined the relationship between each regulatory strategy and psychopathology across the four disorders. We found a large effect size for rumination, medium to large for avoidance, problem solving, and suppression, and small to medium for reappraisal and acceptance. These results are surprising, given the prominence of reappraisal and acceptance in treatment models, such as cognitive-behavioral therapy and acceptance-based treatments, respectively. Second, we examined the relationship between each regulatory strategy and each of the four psychopathology groups. We found that internalizing disorders were more consistently associated with regulatory strategies than externalizing disorders. Lastly, many of our analyses showed that whether the sample came from a clinical or normative population significantly moderated the relationships. This finding underscores the importance of adopting a multi-sample approach to the study of psychopathology.
Article
Poor sleep quality and complaints of insomnia are particularly prevalent in aging individuals. However, not all older people who experience what may be developmentally inevitable sleep disruption complain of insomnia. Psychological therapies for sleep disorder have been explored extensively with younger people but only recently have researchers turned their attention to applying these approaches to the treatment of insomnia in older adults. Recent research has demonstrated that older individuals can benefit from such treatment. However, despite abundant evidence for the importance of cognitive factors in insomnia, there has been a relative lack of attention to the development of cognitive interventions. The present study evaluated a new cognitive-behavioral technique, Countercontrol-Plus Audiobook, aimed directly at disrupting the intrusive thoughts that may interfere with sleep. Forty-one older adults (mean age = 67) with sleep onset and maintenance problems were assigned to one of three intervention conditions: Countercontrol-Plus Audiobook, Countercontrol-Plus Relaxation, and Self-Monitoring Only. All three groups showed significant improvement on various self-report, quantitative and qualitative measures of sleep, although no change was found on daytime sleepiness, fatigue and functioning. Cognitive and somatic presleep variables also showed improvement over the two week treatment period. Gains were generally maintained at a 2-week and 18-month follow-up. Evaluation of clinically significant change demonstrated that most participants still had some degree of sleep problem at post-intervention. Although most participants showed some improvement on quantitative sleep-wake parameters, insomnia distress and anxious presleep cognitions, only 4% to 29% of participants reached the defined clinically significant level of improvement from baseline to post-intervention, with more individuals improving on sleep onset latency and distress frequency than on duration of nocturnal awakenings. Consistent with previous studies, durations of nocturnal awakenings seem to be more resistant to change than latency to sleep onset. The findings are discussed in terms of the multidimensional nature of the insomnia experience and the multiple possible effects of the self-monitoring process.
Article
Thesis (Ph. D.)--Ball State University, 1982. Includes bibliographical references (leaves [48]-53).
Article
Typescript. Department of Psychology. Thesis--Case Western Reserve University.
Article
This study considers the role of pre-sleep cognitive arousal, worry, and inhibition in sleep onset difficulties. The Pennebaker writing task, which promotes emotional processing by asking people to write about their thoughts, worries, and emotions, has proven effective in several areas of health. Here, the paradigm's ability to reduce pre-sleep cognitive arousal (PSCA) and sleep onset latency (SOL) in people with insomnia was tested. Twenty-eight people with insomnia were randomized to three nights of Pennebaker writing or a control condition, following a one-night baseline. The outcomes of change over baseline at Day 4 in pre-sleep cognitive arousal and SOL were compared. Writing significantly reduced pre-sleep cognitive arousal on one out of two measures, but did not significantly reduce SOL.
Article
Assessed the effectiveness of treatment programs based on progressive relaxation, stimulus control, and paradoxical intention in the context of sleep difficulties for 50 volunteer Ss. The results indicate that each of the therapeutic procedures significantly reduced sleep complaints in contrast to placebo and waiting list control groups. No differences were observed among the 3 active techniques. (1½ p ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
A study by Turner and Ascher (1978) compared the efficacy of progressive relaxation, stimulus control, and paradoxical intention in ameliorating sleep onset insomnia. Results indicated that the three were equally effective. The present study is a partial replication of Turner and Ascher (1978) and focuses on the use of paradoxical intention in reducing sleep difficulties.Twenty-five individuals complaining of sleep discomfort were randomly assigned to three groups: paradoxical intention, placebo control, no treatment control. Clients in the paradoxical intention group were instructed to remain awake while lying in bed in a darkened room. The complete rationale for such a prescription was provided. Those in the placebo group received a pseudo systematic desensitization program.Results indicated that subjects exposed to the paradoxical intention procedure reported significant improvement on several measures of sleep behavior when compared with reports of subjects in either placebo or no-treatment control groups.
Article
The importance of differences in pre-sleep cognitive intrusions in the treatment of sleep-onset insomnia were investigated. Twenty-four patients suffering from persistent psychophysiological insomnia were assessed on a pre-sleep cognitive intrusion inventory and divided into high and low scorers. Within these groups Ss were randomly assigned to either a cognitively focused program (cognitive restructuring. paradoxical instructions and thought stopping) or a psychophysiologically focused method, EMG-biofeedback training. Patients were treated individually for 6 sessions. Within-group comparisons showed that both treatments yielded significant improvement in latency to falling asleep, pre-sleep tension, hours of sleep and sleep quality. Between-group comparisons showed a greater reduction of pre-sleep intrusions in patients treated by the cognitive method and of pre-sleep tension in patients trained in biofeedback, but no differential results were found in outcome variables either after treatments or at 3- and 12-month follow-ups. The results indicate that the use of differential treatments added little to the outcome of therapy, and do not support the hypothesis that greater benefits are gained when the treatment matches the patient's claims of cognitive hyperarousal.
Article
This study compared the effectiveness of paradoxical intention, stimulus control, information and a control group on severe sleep onset insomnia. Results showed that paradoxical intention and stimulus control were equally effective but significantly better than the information and control groups. It is suggested that treatment be adapted for each individual according to data collected from the intensive behavioral analysis of each case.
Article
Compared 4 relaxation treatments—progressive relaxation, progressive relaxation without tension release, imagery with tension release, and imagery without tension release—for sleep onset insomnia with a waiting-list control (no treatment). Analysis of data from 44 19–71 yr old insomniacs recruited from the community showed all treatment conditions to be superior to no treatment in reducing latency of sleep onset and ratings of fatigue. The presence of muscle-tension release was unrelated to outcome. There was a nonsignificant trend for visual imagery treatments to be superior to somatic-focusing treatments in reducing sleep onset latencies. Treatments using visual focusing were superior to somatic-focusing treatments in reducing the number of nocturnal awakenings. At 6 mo follow-up, only the imagery treatments showed significant improvement over pretreatment levels on latency of sleep onset. Visual-focusing treatments produced significantly greater reductions in sleep onset latency at follow-up than did the somatic-focusing treatments. (20 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Although thought suppression is a popular form of mental control, research has indicated that it can be counterproductive, helping assure the very state of mind one had hoped to avoid. This chapter reviews the research on suppression, which spans a wide range of domains, including emotions, memory, interpersonal processes, psychophysiological reactions, and psychopathology. The chapter considers the relevant methodological and theoretical issues and suggests directions for future research.
Article
The present paper reviews theories and empirical research concerning the role of psychological processes in insomnia. It is argued that two kinds of psychological processes are involved in insomnia: sleep-interfering processes and sleep-interpreting processes. A theoretical model is sketched, where it is argued that psychological vulnerability factors may predispose the individual to (1) respond with sleep-interfering processes to stressful life events, and to (2) engage in dysfunctional sleep-interpreting processes. Examples of the first kind of variables are arousability, slow recuperation after stress, worrying, and emotional conflicts in relation to significant others; examples of the latter are sleep-related beliefs, attitudes, and perfectionistic standards.
Article
This paper critically reviews the evidence base for previously reported conceptual models of the development and persistence of insomnia. Although a number of perspectives have some empirical support, no one approach emerges as preeminent. Importantly, the efficacy of any particular psychological intervention cannot be taken as confirmation of presumed, underlying mechanisms. An integrated psychobiological inhibition model of insomnia is developed that accounts for the research data. The model views insomnia as arising from inhibition of de-arousal processes associated with normal sleep. It is proposed that sleep homeostatic and circadian factors are compromised by impairment of the automaticity and plasticity associated with good sleep, and that cognitive/affective processes activate the clinical complaint of insomnia. Common pathways for the action of cognitive-behavioral interventions are identified, and a research agenda is set for further conceptual and clinical study.
Article
Insomniacs commonly complain that they are unable to get to sleep at night due to unwanted thoughts, worries and concerns. The present study investigated whether brief training in identifying and elaborating an interesting and engaging imagery task for use during the pre-sleep period can reduce unwanted pre-sleep cognitive activity and sleep onset latency. Forty one people with insomnia were given one of three instructional sets to follow on the experimental night; instructions to distract using imagery, general instructions to distract, or no instructions. Based on previous findings reported by Salkovskis & Campbell (1994) 'Behaviour Research and Therapy 32 (1994) 1' and ironic control theory (Wegner, 1994) 'Psychological Review 101 (1994) 34', it was predicted that (1) "imagery distraction" would be associated with shorter sleep onset latency and less frequent and distressing pre-sleep cognitive activity compared to the "no instruction" group and that (2) "general distraction" would be associated with longer sleep onset latency and more frequent and distressing pre-sleep cognitive activity compared to the "no instruction" group. Support was found for the first but not the second prediction. The success of the "imagery distraction" task is attributed to it occupying sufficient "cognitive space" to keep the individual from re-engaging with thoughts, worries, and concerns during the pre-sleep period. In addition, "imagery distraction" involved a very specific alternative cognitive task hence the operating process was given a feature positive search, conditions where mental control is likely to be achieved.
Article
Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.
Article
Randomized clinical trials (RCTs) not only are the gold standard for evaluating the efficacy and effectiveness of psychiatric treatments but also can be valuable in revealing moderators and mediators of therapeutic change. Conceptually, moderators identify on whom and under what circumstances treatments have different effects. Mediators identify why and how treatments have effects. We describe an analytic framework to identify and distinguish between moderators and mediators in RCTs when outcomes are measured dimensionally. Rapid progress in identifying the most effective treatments and understanding on whom treatments work and do not work and why treatments work or do not work depends on efforts to identify moderators and mediators of treatment outcome. We recommend that RCTs routinely include and report such analyses.
Article
Patients with primary insomnia overestimate their sleep onset latency (SOL) and underestimate their total sleep time (TST). The present study aimed to test the utility of a novel behavioural experiment designed to correct distorted perception of sleep among patients diagnosed with primary insomnia. Individuals with primary insomnia were asked to wear an actigraph and keep a sleep diary for three nights. On the following day, half were shown the discrepancy between the data recorded on the actigraph and their sleep diary (Shown-Discrepancy Group), the other half were not shown the discrepancy (No-Demonstration Group). Participants were then asked to wear the actigraph and keep a sleep diary for three further nights. Following the behavioural experiment, the Shown-Discrepancy Group estimated their SOL more accurately and reported less anxiety and preoccupation about sleep compared to the No-Demonstration Group. The theoretical and clinical implications of these findings are discussed.