Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia: A Quasi-Experimental Study

Do changes in beliefs and behaviours moderate improvement in insomnia after acquired brain injury?

Key mechanisms of change in cognitive behavioural therapy for insomnia in the general population encompass changing sleep-related beliefs and behaviours. In a population with acquired brain injury, cognitive behavioural therapy for insomnia is effective as well, but little is known about the mechanisms of change. The aim of this study was to evaluate how changing sleep-related beliefs and behaviours were associated with improvement in insomnia following blended cognitive behavioural therapy for insomnia in a population with acquired brain injury. A secondary analysis was performed on data of a randomized-controlled trial, including 24 participants that received blended cognitive behavioural therapy for insomnia, and 24 participants that received treatment as usual. Results showed that following blended cognitive behavioural therapy for insomnia, significantly more participants improved on dysfunctional beliefs and sleep-related behaviours and this was associated to improvement in insomnia severity. For sleep-related behaviours, the association between improvement on behaviour and improvement on insomnia was significantly moderated by blended cognitive behavioural therapy for insomnia. However, the relation between dysfunctional beliefs and insomnia was not moderated by type of treatment. Similar results were found for acquired brain injury-adapted versions of the questionnaires in which up to half of the items were excluded as they could be regarded as not dysfunctional for people with acquired brain injury. These results show that improvement on insomnia severity is related to improvement in dysfunctional beliefs and behaviours, and cognitive behavioural therapy for insomnia efficacy may be moderated by the improvement in behaviours in particular. A focus on these behaviours can enhance treatment efficacy, but caution is needed regarding the behaviours that may reflect adequate coping with the consequences of the acquired brain injury.

Mechanisms of cognitive behavioural therapy for insomnia

Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.

Challenging beliefs for quality sleep: A systematic review of maladaptive sleep beliefs and treatment outcomes following cognitive behavioral therapy for insomnia

Cognitive behavioral therapy for insomnia (CBT-I) is an empirically supported intervention for insomnia. Given the strong, consistent support of its efficacy, scholars have become increasingly interested in the behavioral and cognitive mechanisms targeted during CBT-I. The purpose of the systematic review was to synthesize findings from the literature regarding the associations among maladaptive sleep beliefs, a cognitive mechanism implicated in maintaining insomnia, and treatment outcomes following CBT-I. The systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies were included in the final sample of reviewed articles and a study quality assessment was performed for all studies included in the review. The results suggested that reductions in maladaptive sleep beliefs were associated with improved insomnia severity; however, reductions in maladaptive beliefs were not associated with changes in sleep efficiency or other sleep parameters. Moreover, in some cases, improved sleep parameters preceded reductions in maladaptive beliefs. Maladaptive sleep beliefs may be an important target for improving insomnia. Targeting maladaptive sleep beliefs may initiate a trickle-down process that limits the influence of other cognitive and behavioral processes maintaining insomnia. Additional investigation is needed to evaluate the directional relationship between improved insomnia symptoms and reduced maladaptive beliefs.

A virtual reality-based mind-body approach to downregulate psychophysiological arousal in adolescent insomnia

Objective

In this study, we describe the rationale, supported by preliminary data, for a novel, digital, immersive virtual reality (VR)-based mind-body approach, designed to reduce bedtime arousal in adolescents with insomnia.

Methods

Fifty-two high-school students (16-20 years; 32 female) with (N = 18) and without (N = 34) DSM-5 insomnia symptoms engaged with 20 min of immersive VR-guided meditation and paced breathing (0.1 Hz) (intervention condition) and 20 min of quiet activity (control condition), right before bedtime, on two separate evenings.

Results

The intervention resulted in acute autonomic and cortical modulation (p < 0.05), leading to reduced physiological arousal (↓heart rate, ↓cortisol) compared with the control condition, with similar effects in adolescents with and without insomnia. No significant changes were detected for cognitive arousal levels. During the intervention, all participants were able to achieve the targeted 0.1 Hz breathing rate, and the majority experienced no discomfort associated with the VR exposure. However, 30-40% of the participants experienced some trouble slowing down their breathing.

Conclusions

The study provides supporting preliminary evidence for the mechanism behind a novel VR-based digital approach, designed to regulate psychophysiological arousal levels by acting on neurocognitive and autonomic pathways. Further studies (e.g. randomized clinical trials) are needed to evaluate the isolated and synergistic effects of its components (e.g. VR vs. VR + paced breathing), and its efficacy, acceptance, and feasibility in alleviating insomnia symptoms in adolescents.

The effect of sleep restriction therapy for insomnia on sleep pressure and arousal: a randomised controlled mechanistic trial

STUDY OBJECTIVES

Sleep restriction therapy (SRT) effectively treats insomnia but mechanisms are poorly understood. Theoretical models suggest that potentiation of sleep pressure and reduction of arousal are key mechanisms of action. To our knowledge this has never been directly tested. We designed a randomised controlled trial with embedded mechanistic measurement to investigate if SRT causally modifies multidimensional assessments of sleep pressure and arousal.

METHODS

Participants aged 25-55 who met DSM-5 diagnostic criteria for insomnia disorder were randomised to four weeks of SRT or time in bed regularisation (TBR), a control intervention that involves prescription of a regular but not reduced time in bed. Sleep pressure was assessed through daily diary appraisal of morning and evening sleepiness, weekly Epworth sleepiness scale (ESS) scores, psychomotor vigilance, and NREM delta power (0.75-4.5Hz) from ambulatory polysomnographic recordings. Arousal was assessed through daily diary appraisal of cognitive arousal, the pre-sleep arousal scale (PSAS), and NREM beta power (15-32Hz). Outcomes were assessed at baseline (2-week period prior to randomisation), during the intervention phase (1-4 weeks post-randomisation), and at 12-week follow-up. We performed intention-to-treat analyses using linear mixed models. For continuous daily measures, the treatment period was split into early (weeks 1-2) and late (weeks 3-4) treatment.

RESULTS

Fifty-six participants (39 females, mean age=40.78±9.08) were assigned to SRT (n=27) or TBR (n=29). The SRT group showed enhanced sleep pressure relative to TBR, reflected in (1) enhanced sleepiness in the evening during early (d=1.17) and late treatment (d=0.92), and in the morning during early treatment (d=0.47); (2) higher daytime sleepiness on the ESS at weeks-1 and -2 (d=0.54, d=0.45); and (3) reduced psychomotor vigilance at week-1 (d=0.34). The SRT group also showed reduced arousal relative to TBR, reflected in lower levels of daily-monitored cognitive arousal during early treatment (d=0.53) and decreased PSAS total score at week-4 and week-12 (ds≥0.39). Power spectral analysis of all night NREM sleep revealed an increase in relative, but not absolute, EEG delta power at week-1 and week-4 (ds≥0.52) and a decrease of relative EEG beta power at week-4 (d=0.11).

CONCLUSION

For the first time we show that SRT increases sleep pressure and decreases arousal during acute implementation, providing support for mechanism-of-action.

An investigation and replication of sleep-related cognitions, acceptance and behaviours as predictors of short- and long-term outcome in cognitive behavioural therapy for insomnia

The objectives were to investigate the potential for sleep-related behaviours, acceptance and cognitions to predict outcome (insomnia severity) of cognitive behavioural therapy for insomnia (CBT-I). Baseline and outcome data from four randomised controlled trials (n = 276) were used. Predictors were the Dysfunctional Beliefs and Attitudes about Sleep-10 (DBAS-10), Sleep-Related Behaviours Questionnaire (SRBQ), and Sleep Problems Acceptance Questionnaire (SPAQ), and empirically derived factors from a factor analysis combining all items at baseline (n = 835). Baseline values were used to predict post-treatment outcome, and pre-post changes in the predictors were used to predict follow-up outcomes after 3-6 months, 1 year, or 3-10 years, measured both as insomnia severity and as better or worse long-term sleep patterns. A majority (29 of 52) of predictions of insomnia severity were significant, but when controlling for insomnia severity, only two (DBAS-10 at short-term and SRBQ at mid-term follow-up) of the 12 predictions using established scales, and three of the 40 predictions using empirically derived factors, remained significant. The strongest predictor of a long-term, stable sleep pattern was insomnia severity reduction during treatment. Using all available predictors in an overfitted model, 21.2% of short- and 58.9% of long-term outcomes could be predicted. We conclude that although the explored constructs may have important roles in CBT-I, the present study does not support that the DBAS-10, SRBQ, SPAQ, or factors derived from them, would be unique predictors of outcome.

How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change

Insomnia is prevalent and debilitating, comprising sustained difficulties initiating or maintaining sleep. Cognitive-behavioural therapy for insomnia (CBT-I) is a multicomponent intervention recommended as the first-line treatment, but the mediators of change remain unclear. This systematic review and meta-analysis aimed to synthesise and evaluate the evidence for potential mediators of CBT-I. Searches were performed for studies published until February 2021, reporting on mediation analyses with CBT-I. Seventeen unique samples of adults with insomnia (20 studies, N = 3125) were included. Two-stage structural equation modelling was applied to the available data, where 7 studies examined the cognitive mediator, 'dysfunctional beliefs about sleep', 5 studies examined a hyperarousal mediator, and 3 studies examined the behavioural mediator, 'time in bed'. There was evidence in support of changes in dysfunctional beliefs as a cognitive mediator of insomnia symptom improvement following CBT-I. There was more limited evidence in support of changes in hyperarousal-related mediators, and no significant effect of time in bed as a mediator. Numerous studies recorded diary-based measures of potential behavioural mediators, but analyses of these variables were not typically conducted. The most serious limitation of the evidence base is that the temporal precedence of mediator changes cannot be established. Future studies should consider: i) using mid-treatment measurements of mediator changes; ii) reporting on mediator psychometric properties; and iii) explicitly stating analyses as pre-specified or exploratory.

Changes in dysfunctional beliefs about sleep after cognitive behavioral therapy for insomnia: A systematic literature review and meta-analysis

Cognitive behavioral therapy for insomnia (CBT-I) is the preferred treatment for chronic insomnia and sleep-related cognitions are one target of treatment. There has been little systematic investigation of how sleep-related cognitions are being assessed in CBT-I trials and no meta-analysis of the impact of CBT-I on dysfunctional beliefs about sleep, a core cognitive component of treatment. Academic Search Complete, Medline, CINAHL and PsychInfo from 1990 to 2018 were searched to identify randomized controlled trials of CBT-I in adults (≥18 years) reporting some measure of sleep-related cognitions. Sixteen randomized controlled trials were identified comparing 1134 CBT-I and 830 control subjects. The Dysfunctional Beliefs and Attitudes about Sleep Scale was utilized almost exclusively to assess sleep-related cognitions in these trials. Hedge's g at 95% confidence interval (CI) was calculated to assess CBT-I effect size at post-treatment compared to controls. CBT-I significantly reduced dysfunctional beliefs about sleep (g = -0.90, 95% CI -1.19, -0.62) at post-treatment. Three trials contributed data to estimate effect size for long-term effects (g = -1.04, 95% CI -2.07, -0.02) with follow up time ranging from 3 to 18 mo. We concluded that cognitive behavioral therapy for insomnia has moderate to large effects on dysfunctional beliefs about sleep.

The contribution of participant, treatment, and outcome factors to treatment satisfaction

Treatment satisfaction, which refers to the positive appraisal of process and outcome attributes of a treatment, is a prominent indicator of quality care. Although it is known that participant, treatment, and outcome factors influence treatment satisfaction, it remains unclear which factors contribute to satisfaction with each process and outcome attribute. In this study, we examined the extent to which participant (age, gender, education, race, employment), treatment (type of therapy, method of assignment to therapy), and outcome (self-reported improvement in outcome) factors contribute to satisfaction with the process and outcome attributes of therapies for insomnia. This study consists of a secondary analysis of data obtained from a partially randomized preference trial in which persons with chronic insomnia (N = 517) were assigned to treatment randomly or by preference. Four types of behavioral therapies were included: sleep hygiene, stimulus control therapy, sleep restriction therapy, and multi-component therapy. Self-reported improvement in insomnia and satisfaction were assessed with validated measures at post-test. Multiple regression analysis was used to examine which factors influenced satisfaction with each treatment attribute. The findings showed that treatment and outcome, more so than participant, factors influenced satisfaction with the process and outcome attributes of the behavioral therapies for insomnia. Future research on satisfaction should explore the contribution of treatment (type and preference-matching) and outcome factors on satisfaction to build a better understanding of treatment attributes viewed favorably. Such understanding has the potential to inform modifying or tailoring treatments to improve their acceptance to participants and optimize their effectiveness.

Insomnia identity

Insomnia identity refers to the conviction that one has insomnia, and this sleep complaint can be measured independently of sleep. Conventional wisdom predicts that sleep complaints are synchronous with poor sleep, but crossing the presence or absence of poor sleep with the presence or absence of insomnia identity reveals incongruity with expected patterns. This review of existing research on insomnia identity processes and influence finds that about one-fourth of the population are uncoupled sleepers, meaning there is an uncoupling of sleep and sleep appraisal, and daytime impairment accrues more strongly to those who endorse an insomnia identity. Research supports the conclusion that there is a cost to pathologizing sleep. Individuals claiming an insomnia identity, regardless of sleep status, are at greater risk for a range of sequelae including self-stigma, depression, suicidal ideation, anxiety, hypertension, and fatigue. A broad research agenda is proposed with hypotheses about the sources, clinical mechanisms, and clinical management of insomnia identity.