Markus Jansson-Fröjmark

A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population

OBJECTIVE The purpose of this study was to examine whether there is a bidirectional relationship between, on one hand, anxiety and depression and, on the other hand, insomnia over the course of a year. METHODS A randomly selected sample of 3000 participants from the general population filled out a baseline survey (N=1812) and a 1-year follow-up survey (N=1498) on anxiety, depression, and insomnia. RESULTS On cross-sectional analyses, bivariate correlations showed that anxiety, depression, and insomnia were significantly intercorrelated (varphi=.31-.54). On prospective analyses, logistic regression analyses demonstrated that anxiety at baseline [odds ratio (OR)=4.27 (8% of variance)] and depression at baseline [OR=2.28 (2% of variance)] were related to new cases of insomnia on follow-up. Furthermore, insomnia at baseline was related to new episodes of high anxiety and high depression on follow-up [OR=2.30 (2% of variance) and OR=3.51 (4% of variance), respectively]. CONCLUSION Evidence suggests that there is a bidirectional relationship between, on one hand, anxiety and depression and, on the other hand, insomnia. This suggests that anxiety, depression, and insomnia are intertwined over time, implying implications for theoretical conceptualizations and interventions.

Is perfectionism related to pre-existing and future insomnia? A prospective study

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

Avoidant Safety Behaviors and Catastrophizing: Shared Cognitive-Behavioral Processes and Consequences in Co-Morbid Pain and Sleep Disorders

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

European guideline for the diagnosis and treatment of insomnia

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).

Psychosocial work stressors for insomnia : a prospective study on 50-60-year-old adults in the working population

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

Are changes in worry associated with treatment response in cognitive behavioral therapy for insomnia

Aim: Little is known about why some patients respond to cognitive behavioral therapy for insomnia, whereas other patients do not. To understand differences in treatment response, there is a dire need to examine processes of change. The purpose was to investigate the long-term association between insomnia-related worry and outcomes following cognitive behavior therapy for insomnia. Methods: Sixty patients with early insomnia (3–12 months duration) received group cognitive behavioral therapy for insomnia. At pretreatment and at a 1-year follow-up, the patients completed questionnaires indexing two domains of insomnia-related worry (sleeplessness and health), insomnia severity, anxiety, and depression as well as sleep diaries. Results: Decreases in the two worry domains were associated with improvements in all of the outcomes, except for sleep onset latency (SOL), at a medium to large level. Reductions in insomnia-related worry were associated with improvements in insomnia severity, wake after sleep onset (WASO), total sleep time (TST), and depression, but not in SOL or anxiety. While reductions in worry for sleeplessness were related to improvements in insomnia severity and TST, decreases in worry for health were associated with enhancements in WASO and depression. Conclusion: The findings suggest that reductions in insomnia-related worry might be one process route in which cognitive behavioral therapy operates to improve insomnia symptomatology. The results are discussed in relation to theory, clinical implications, and future research.

Bidirectionality between pain and insomnia symptoms: a prospective study.

OBJECTIVES The purpose of this study was to investigate whether there is a bidirectional relationship between pain and insomnia symptoms over the course of a year. DESIGN A longitudinal design with a 1-year follow-up was used. METHODS From a randomly selected sample of the adult general population (N= 3,000), 1,746 individuals filled out a baseline and 1-year follow-up survey on pain, insomnia symptoms, anxiety symptoms, and depressive symptoms. RESULTS Pain (OR = 1.64) and anxiety symptoms increased the risk for the incidence of insomnia symptoms (R(2) = .125) and pain (OR = 1.98), anxiety symptoms and depressive symptoms were related to the persistence of insomnia symptoms (R(2) = .212). Gender and anxiety symptoms increased the risk for the incidence of pain (R(2) = .073); and age, insomnia symptoms (OR = 1.49), anxiety symptoms, and depressive symptoms were associated with the persistence of pain (R(2) = .187). CONCLUSION While pain was linked to future insomnia symptoms and insomnia symptoms to the persistence of pain over the course of a year, insomnia symptoms was not associated with the incidence of pain. The results, thus, partly argue against bidirectionality between pain and insomnia symptoms.

Psychometric Properties of an Insomnia-Specific Measure of Worry: The Anxiety and Preoccupation about Sleep Questionnaire

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

The Work and Social Adjustment Scale as a Measure of Dysfunction in Chronic Insomnia: Reliability and Validity

BACKGROUND Dysfunction is an integral part of chronic insomnia. Despite this, very little effort has yet been made to design and psychometrically validate an insomnia-specific measure of dysfunction. AIMS The purpose was to examine the psychometric properties of the Work and Social Adjustment Scale (WSAS) as a measure of dysfunction in chronic insomnia. METHOD Seventy-three patients with chronic insomnia from three subsamples participated. All the patients completed the WSAS, the Insomnia Severity Index (ISI), and sleep diaries over one week. RESULTS An exploratory factor analysis suggested a one-factor solution for the WSAS, determining dysfunction, accounting for 73.7% of the variance. The internal consistency of the WSAS was α = .91. The test-retest reliability for the WSAS items was high at .90-.99 and for the entire scale .99. A cut-off at 17 points was established, discriminating those with subclinical versus moderate or severe clinical insomnia (88% sensitivity and 78% specificity). Evidence of convergent and criterion validity was documented via (1) a significant, positive association between the WSAS and ISI and (2) a higher WSAS score among those with severe clinical insomnia, relative to those with moderate clinical and subthreshold insomnia, as well as a higher WSAS score among those with moderate clinical insomnia relative to those with subthreshold insomnia. The WSAS was also shown to be a treatment-sensitive measure for insomnia patients. CONCLUSIONS The WSAS appears as a reliable and valid measure of dysfunction in chronic insomnia. Additional advantages are its shortness, easiness, and treatment-sensitivity.

The role of sleep-related beliefs to improvement in early cognitive behavioral therapy for insomnia.

The aim of this investigation was to examine whether sleep‐related beliefs, and reductions in such beliefs and attitudes, were related to clinical improvements in sleep and daytime symptoms after cognitive behavioral therapy (CBT). In total, 64 patients with a short history of insomnia (3–12 months) who had participated in a randomized controlled trial with a 1‐year follow‐up and received CBT were included. With stepwise multiple regression analyses, sleep‐related beliefs were linked to clinical improvements in sleep (five outcomes) and daytime symptoms (seven outcomes). Results indicated that sleep‐related beliefs played a small predictive role in clinical improvements in sleep and daytime symptoms after CBT group treatment. Sleep‐related beliefs were predictive of treatment response only with regard to sleep efficiency and sleepiness. Reductions in sleep‐related beliefs were, however, differently related to improvements in sleep and daytime symptoms. Reductions in such beliefs were consistently linked to improvements in daytime symptoms (7–14% of the variance) but not to sleep improvements (except for sleep quality). In all, this might suggest that sleep‐related beliefs play a slightly different role in insomnia than previously envisioned.