Cognitive Therapy and Research

, Volume 39, Issue 6, pp 841–852 | Cite as

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

  • Rikard Sunnhed
  • Markus Jansson-Fröjmark
Original Article


The purpose with the investigation was to examine whether improvements in pre-sleep cognitive arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors mediate the outcomes in in-person CBT-I. Fifty-eight participants with insomnia were administered either cognitive behavioral therapy or belonged to a waitlist. At pre- and post-treatment, participants completed questionnaires and sleep diaries assessing cognitive arousal, unhelpful beliefs about sleep, maladaptive sleep behaviors, insomnia severity, dysfunction, and subjective sleep parameters. Outcome measures were re-administered at a 3-month follow-up. Decreases in cognitive arousal mediated the effect on dysfunction. Reductions in unhelpful beliefs mediated the treatment effect on insomnia severity and dysfunction. Decreases in bedtime variability mediated the outcome on insomnia severity, and reductions in time in bed had a mediating effect on total wake time. Neither rise time variability nor napping mediated the improvements. A reversed model, in which the outcomes were used as mediators, showed less fit with the current data, indicating that change in the psychological processes as mediators of improvement in the outcomes was the most plausible conclusion. These findings are clearly supportive of cognitive-behavioral models of insomnia by highlighting cognitive arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research.


Cognitive behavioral therapy Insomnia Mediation Arousal Beliefs Behavior 



We would like to express our appreciation to Steven J. Linton, Berth Danermark and Sarah Granberg for study design, to Ida K. Flink and Annika Norell-Clarke for working as therapist in the project, to Sparbankstiftelsen Nya for funding and to the two audiology clinics in Örebro and Karlstad for recruitment.

Conflict of Interest

Rikard Sunnhed and Markus Jansson-Fröjmark declare that they have no conflict of interest.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (national and institutional). Informed consent was obtained from all individual subjects participating in the study.

Animal Rights

No animals were used in the current investigation.


  1. Bastien, C. H., Vallieres, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2, 297–307. doi: 10.1016/S1389-9457(00)00065-4.CrossRefPubMedGoogle Scholar
  2. Bootzin, R. R., Epstein, D., & Wood, J. M. (1991). Stimulus control instructions. In P. J. Hauri (Ed.), Case studies in insomnia (pp. 19–28). New York: Plenum Publishing Company. doi: 10.1007/978-1-4757-9586-8_2.CrossRefGoogle Scholar
  3. Borbély, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1, 195–204.PubMedGoogle Scholar
  4. Breslau, N., Roth, T., Rosenthal, L., & Andreski, P. (1996). Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biological Psychiatry, 39, 411–418. doi: 10.1016/0006-3223(95)00188-3.CrossRefPubMedGoogle Scholar
  5. Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, 73–86. doi: 10.1016/S0005-7916(00)00012-4.CrossRefPubMedGoogle Scholar
  6. Edinger, J. D., Bonnet, M. H., Bootzin, R. R., Doghramji, K., Dorsey, C. M., Espie, C. A., et al. (2004). Derivation of research diagnostic criteria for insomnia: Report of an American academy of sleep medicine work group. Sleep, 27, 1567–1596.PubMedGoogle Scholar
  7. Edinger, J., Kirby, A., Lineberger, M., Loiselle, M., Wohlgemuth, W., & Means, M. Duke structured interview schedule for DSM-IV-TR and international classification of sleep disorders, second edition (ICSD-2): Sleep disorder diagnoses. Unpublished manual.Google Scholar
  8. Edinger, J. D., & Means, M. K. (2005). Cognitive-behavioral therapy for primary insomnia. Clinical Psychology Review, 25, 539–558. doi: 10.1016/j.cpr.2005.04.003.CrossRefPubMedGoogle Scholar
  9. Edinger, J. D., Olsen, M. K., Stechuchak, K. M., Means, M. K., Lineberger, M. D., Kirby, A., et al. (2009). Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: A randomized clinical trial. Sleep, 32, 499–510.PubMedCentralPubMedGoogle Scholar
  10. Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Coffman, C. J., & Carney, C. E. (2007). Dose–response effects of cognitive-behavioral insomnia therapy: A randomized clinical trial. Sleep, 30, 203–212.PubMedGoogle Scholar
  11. Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., Marsh, G. R., & Quillian, R. E. (2001). Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. Journal of the American Medical Association, 285, 1856–1864. doi: 10.1001/jama.285.14.1856.CrossRefPubMedGoogle Scholar
  12. Espie, C. A. (2002). Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology, 53, 215–243. doi: 10.1146/annurev.psych.53.100901.135243.CrossRefPubMedGoogle Scholar
  13. Espie, C. A., Kyle, S. D., Miller, C. B., Ong, J., Hames, P., & Fleming, L. (2014). Attribution, cognition and psychopathology in persistent insomnia disorder: Outcome and mediation analysis from a randomized placebo-controlled trial of online cognitive behavioural therapy. Sleep Medicine, 15, 913–917. doi: 10.1016/j.sleep.2014.03.001.CrossRefPubMedGoogle Scholar
  14. First, M. B., Gibbon, M., Spitzer, R. L., & Williams, J. B. W. (1997). Structured clinical interview for DSM-IV axis I disorders: Clinician version. Washington, DC: American Psychiatric Press.Google Scholar
  15. Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? Journal of the American Medical Association, 262, 1479–1484. doi: 10.1001/jama.1989.03430110069030.CrossRefPubMedGoogle Scholar
  16. Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to detect the mediated effect. Psychological Science, 18, 233–239.PubMedCentralCrossRefPubMedGoogle Scholar
  17. Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869–893. doi: 10.1016/S0005-7967(01)00061-4.CrossRefPubMedGoogle Scholar
  18. Harvey, A. G., Sharpley, A. L., Ree, M. J., Stinson, K., & Clark, D. M. (2007). An open trial of cognitive therapy for chronic insomnia. Behaviour Research and Therapy, 45, 2491–2501. doi: 10.1016/j.brat.2007.04.007.CrossRefPubMedGoogle Scholar
  19. Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76, 408–420.CrossRefGoogle Scholar
  20. Jansson-Fröjmark, M. (2014). The work and social adjustment scale as a measure of dysfunction in chronic insomnia: Reliability and validity. Behavioural and Cognitive Psychotherapy, 42, 186–198. doi: 10.1017/S135246581200104X.CrossRefPubMedGoogle Scholar
  21. Jansson-Fröjmark, M., Linton, S. J., Flink, I., Granberg, S., Danermark, B., & Norell- Clarke, A. (2012). Cognitive-behavioral therapy for insomnia co-morbid with hearing impairment: A randomized controlled trial. Journal of Clinical Psychology in Medical Settings, 19, 224–234. doi: 10.1007/s10880-011-9275-y.CrossRefPubMedGoogle Scholar
  22. Jansson-Fröjmark, M., & Norell-Clarke, A. (2012). Psychometric properties of the Pre-Sleep Arousal Scale in a large community sample. Journal of Psychosomatic Research, 72, 103–110. doi: 10.1016/j.jpsychores.2011.10.005.CrossRefPubMedGoogle Scholar
  23. Jernelöv, S., Lekander, M., Blom, K., Rydh, S., Ljótsson, B., Axelsson, J., & Kaldo, V. (2012). Efficacy of a behavioral self-help treatment with or without therapist guidance for co-morbid and primary insomnia—A randomized controlled trial. BMC Psychiatry,. doi: 10.1186/1471-244X-12-5.PubMedCentralPubMedGoogle Scholar
  24. Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1–27. doi: 10.1146/annurev.clinpsy.3.022806.091432.CrossRefPubMedGoogle Scholar
  25. Kraemer, H. C., Wilson, G. T., Fairburn, C. G., & Agras, W. S. (2002). Mediators and moderators of treatment effects in randomized clinical trials. Archives of General Psychiatry, 59, 877–883. doi: 10.1001/archpsyc.59.10.877.CrossRefPubMedGoogle Scholar
  26. Krystal, A. D., & Edinger, J. D. (2010). Sleep EEG predictors and correlates of the response to cognitive behavioral therapy for insomnia. Sleep, 33, 669–677.PubMedCentralPubMedGoogle Scholar
  27. Lichstein, K. L., Durrence, H. H., Taylor, D. J., Bush, A. J., & Riedel, B. W. (2003). Quantitative criteria for insomnia. Behaviour Research and Therapy, 41, 427–445. doi: 10.1016/S0005-7967(02)00023-2.CrossRefPubMedGoogle Scholar
  28. Lichstein, K. L., Riedel, B. D., Wilson, N. M., Lester, K. W., & Aguillard, R. N. (2001). Relaxation and sleep compression for late-life insomnia: A placebo-controlled trial. Journal of Consulting and Clinical Psychology, 69, 227–239. doi: 10.1037//0022-006X.69.2.227.CrossRefPubMedGoogle Scholar
  29. Lichstein, K. L., Taylor, D. J., McCrae, C. S., & Thomas, S. J. (2011). Relaxation for insomnia. In M. L. Perlis, M. Aloia, & B. Kuhn (Eds.), Behavioral treatments for sleep disorders: A comprehensive primer of behavioral sleep medicine interventions (practical resources for the mental health professional (1st ed., pp. 45–54). New York: Academic Press.CrossRefGoogle Scholar
  30. Lichstein, K. L., Wilson, N. M., & Johnson, C. T. (2000). Psychological treatment of secondary insomnia. Psychology and Aging, 15, 232–240. doi: 10.1037//0882-7974.15.2.232.CrossRefPubMedGoogle Scholar
  31. Lundh, L. G., & Broman, J. E. (2000). Insomnia as an interaction between sleep-interfering and sleep-interpreting processes. Journal of Psychosomatic Research, 49, 299–310. doi: 10.1016/S0022-3999(00)00150-1.CrossRefPubMedGoogle Scholar
  32. McEnany, G., & Lee, K. A. (2000). Owls, larks, and the significance of morningness/eveningness rhythm propensity in psychiatric-mental health nursing. Issues in Mental Health Nursing, 21, 203–216.CrossRefPubMedGoogle Scholar
  33. Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford Publications.Google Scholar
  34. Morin, C. M. (2006). Cognitive-behavioral therapy of insomnia. Sleep Medicine Clinics, 1, 375–386. doi: 10.1016/j.jsmc.2006.06.008.CrossRefGoogle Scholar
  35. Morin, C. M., & Benca, R. (2012). Chronic insomnia. The Lancet, 379, 1129–1141. doi: 10.1016/S0140-6736(11)60750-2.CrossRefGoogle Scholar
  36. Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: An update of recent evidence (1998–2004). Sleep, 29, 1398–1414.PubMedGoogle Scholar
  37. Morin, C. M., Vallières, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep: Validation of a brief version. Sleep, 30, 1547–1554.PubMedCentralPubMedGoogle Scholar
  38. Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. H. (2002). The work and social adjustment scale: A simple measure of impairment in functioning. British Journal of Psychiatry, 180, 461–464. doi: 10.1192/bjp.180.5.461.CrossRefPubMedGoogle Scholar
  39. Nicassio, P. M., Mendlowitz, D. R., Fussell, J. J., & Petras, L. (1985). The phenomenology of the pre-sleep state: The development of the Pre-Sleep Arousal Scale. Behavior Research and Therapy, 23, 263–271. doi: 10.1016/0005-7967(85)90004-X.CrossRefGoogle Scholar
  40. NIH. (2005). National Institutes of Health state of the science conference statement: Manifestations and management of chronic insomnia in adults. Sleep, 28, 1049–1057.Google Scholar
  41. Nock, M. K. (2007). Conceptual and design essentials for evaluating mechanisms of change. Alcoholism, Clinical and Experimental Research, 31, 4–12. doi: 10.1111/j.1530-0277.2007.00488.x.CrossRefGoogle Scholar
  42. Ohayon, M. M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6, 97–111. doi: 10.1053/smrv.2002.0186.CrossRefPubMedGoogle Scholar
  43. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in simple and multiple mediator models. Behavior Research Methods, Instruments, and Computers, 40, 879–891.CrossRefGoogle Scholar
  44. Roth, T., & Ancoli-Israel, S. (1999). Daytime consequences and correlates of insomnia in the United States: Results of the 1991 National Sleep Foundation Survey. II. Sleep, 22, 354–358.Google Scholar
  45. Rucker, D. D., Preacher, K. J., Tormala, Z. L., & Petty, R. E. (2011). Mediation analysis in social psychology: Current practices and new recommendations. Social and Personality Psychology Compass, 5(6), 359–371.CrossRefGoogle Scholar
  46. Rybarczyk, B., Lopez, M., Benson, R., Alsten, C., & Stepanski, E. (2002). Efficacy of two behavioral treatment programs for comorbid geriatric insomnia. Psychology and Aging, 17, 288–298. doi: 10.1037//0882-7974.17.2.288.CrossRefPubMedGoogle Scholar
  47. Rybarczyk, B., Stepanski, E., Fogg, L., Barry, P., Lopez, M., & Davis, A. (2005). A placebo-controlled test of cognitive-behavioral therapy for comorbid insomnia in older adults. Journal of Consulting and Clinical Psychology, 73, 1164–1174. doi: 10.1037/0022-006X.73.6.1164.CrossRefPubMedGoogle Scholar
  48. Schwartz, D. R., & Carney, C. E. (2012). Mediators of cognitive-behavioral therapy for insomnia: A review of randomized controlled trials and secondary analysis studies. Clinical Psychology Review, 32, 664–675. doi: 10.1016/j.cpr.2012.06.006.CrossRefPubMedGoogle Scholar
  49. Smith, M. T., Huang, M. I., & Manber, R. (2005). Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25, 559–592. doi: 10.1016/j.cpr.2005.04.004.CrossRefPubMedGoogle Scholar
  50. Spielman, A. J., Caruso, L. S., & Glovinsky, P. B. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10, 541–553.PubMedGoogle Scholar
  51. Spoormaker, V. I., Verbeek, I., van den Bout, J., & Klip, C. (2005). Initial validation of the SLEEP-50 questionnaire. Behavioral Sleep Medicine, 3, 227–246. doi: 10.1207/s15402010bsm0304_4.CrossRefPubMedGoogle Scholar
  52. Tremblay, V., Savard, J., & Ivers, H. (2009). Predictors of the effect of cognitive behavioral therapy for chronic insomnia comorbid with breast cancer. Journal of Consulting and Clinical Psychology, 77, 742–750. doi: 10.1037/a0015492.CrossRefPubMedGoogle Scholar
  53. Vincent, N., & Walsh, K. (2013). Hyperarousal, sleep scheduling, and time awake in bed as mediators of outcome in computerized cognitive-behavioral therapy (cCBT) for insomnia. Behaviour Research and Therapy, 51, 161–166. doi: 10.1016/j.brat.2012.12.003.CrossRefPubMedGoogle Scholar
  54. Vitiello, M. V., McCurry, S. M., & Rybarczyk, B. D. (2013). The future of cognitive behavioral therapy for insomnia: What important research remains to be done? Journal of Clinical Psychology, 69, 1013–1021. doi: 10.1002/jclp.21948.CrossRefPubMedGoogle Scholar
  55. Vitiello, M. V., Rybarczyk, B., Von Korff, M., & Stepanski, E. J. (2009). Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. Journal of Sleep Medicine, 5, 355–362.Google Scholar
  56. Webb, W. B. (1988). An objective behavioral model of sleep. Sleep, 11, 488–496.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of PsychologyStockholm UniversityStockholmSweden
  2. 2.Center for Health and Medical Psychology (CHAMP), School of Law, Psychology, and Social WorkÖrebro UniversityÖrebroSweden

Personalised recommendations