Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia?

Abstract

Dysfunctional beliefs and attitudes about sleep are presumed to play an important mediating role in perpetuating insomnia. The present study evaluated the impact of cognitive-behavioral and pharmacological treatments for insomnia on sleep-related beliefs and attitudes and the relationship between those changes and sleep improvements. The participants were older adults with chronic and primary insomnia. They received cognitive-behavior therapy (CBT), pharmacotherapy (PCT), combined CBT+PCT (COMB), or a medication placebo (PLA). In addition to daily sleep diaries and sleep laboratory measures, the participants completed the dysfunctional beliefs and attitudes about sleep scale (DBAS) at baseline and posttreatment, and at 3-, 12- and 24-month follow-up assessments. The results showed that CBT and COMB treatments produced greater improvements of beliefs and attitudes about sleep at posttreatment than PCT and PLA. Reductions of DBAS scores were significantly correlated with improvements of sleep efficiency as measured by daily sleep diaries and by polysomnography. In addition, more adaptive beliefs and attitudes about sleep at posttreatment were associated with better maintenance of sleep improvements at follow-ups. These findings highlight the importance of targeting sleep-related beliefs and attitudes in the treatment of insomnia.

Introduction

Insomnia is a prevalent condition affecting between 9 and 15% of the adult population on a chronic basis and over 25% of people aged over 60 years old (Ford & Kamerow, 1989; Mellinger, Balter, & Uhlenhuth, 1985). Sleep disturbances are frequently associated with fatigue, problems of attention and concentration, and with mood disturbances. Chronic insomnia is also a risk factor for major depression and it carries important health-care costs (Ford & Kamerow, 1989; Simon & VonKorff, 1997)

Insomnia can be secondary to medical, psychiatric, and other sleep disorders (American Sleep Disorders Association, 1990). For primary insomnia, the etiology is often multifactorial involving such factors as hyperarousal, maladaptive sleep habits (e.g. irregular schedule, excessive time spent in bed), and dysfunctional beliefs and attitudes about sleep (e.g. worry over sleep loss and its consequences) (Espie, 1991; Lichstein & Morin, 2000; Morin, 1993). Of those contributing actors, the role of cognitive variables (e.g. intrusive thoughts, beliefs, attitudes, expectations) has received little research attention, despite increasing recognition that they play a critical role in the development and maintenance of insomnia. An example of the influence of cognitions on insomnia is the typical reaction of excessive worrying over sleep loss and its potential consequences. This reaction can increase physiological and emotional arousal (i.e. performance anxiety) and, in a vicious cycle, perpetuate the underlying sleep disturbance. The belief concerning the absolute need for 8 h of sleep each night to feel refreshed and function well during the day is another form of faulty belief. As sleep needs vary across individuals, this belief can lead to emotional distress and exacerbate insomnia when this requirement is not met.

Most studies investigating the role of cognitive processes on insomnia have focused on the impact of pre-sleep or nocturnal cognitions on sleep. These studies have shown that individuals with insomnia report more negative thoughts during nocturnal awakenings than good sleepers (Watts, Coyle, & East, 1994) and that negative presleep cognitions (e.g. thoughts about not falling asleep) are associated with increased subjective (but not objective) sleep difficulties (Van Egeren, Haynes, Franzen, & Hamilton, 1983). Among older adults, highly distressed poor sleepers endorse more negative thoughts about insomnia and other issues (e.g. health, work, and family) during nocturnal awakenings compared to good sleepers and low distressed poor sleepers (Fichten et al., 1998). Although these findings support the view that negative cognitions are related to sleep disturbance, it is not clear whether these situational and automatic thoughts cause insomnia or simply represent an epiphenomenon of poor sleep. Underlying beliefs and attitudes about sleep (i.e. schemas), which are more deeply ingrained than automatic thoughts, are likely to play an even more important role in the development of insomnia. In a study of older adults, participants with chronic insomnia endorsed stronger dysfunctional beliefs and attitudes about sleep than self-defined good sleepers (Morin, Stone, Trinkle, Mercer, & Remsberg, 1993b). Specifically, poor sleepers held stronger beliefs about the potential consequences of insomnia, and worried more about losing control and about the unpredictability of sleep. Edinger et al. (2000) reported similar findings and also found that such faulty beliefs and attitudes about sleep were more closely related to subjective than objective insomnia. Together, these results suggest that sleep-related maladaptive attitudes and beliefs are possibly involved in chronic insomnia and that they represent an important target for treatment.

It is only recently that psychological interventions for insomnia have incorporated cognitive restructuring strategies to directly target faulty beliefs and attitudes about sleep (Edinger, Hoelscher, Marsh, Lipper, & Ionescu-Pioggia, 1992; Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001; Espie, Inglis, Tessier, & Harvey, 2000; Morin, Colecchi, Stone, Sood, & Brink, 1999a; Morin, Kowatch, Barry, & Walton, 1993a; Morin, Stone, McDonald & Jones, 1994; Riedel, Lichstein, & Dwyer, 1995; Sanavio, Vidotto, Bettinardi, Rolleto, & Zorzi, 1990; Verbeek, Schreuder, & Declerk, 1999). Results of these studies suggest that adding cognitive restructuring to behavioral strategies (e.g. stimulus control, sleep restriction) may produce slightly greater benefits than behavioral treatment alone (Lichstein & Riedel, 1994; Morin, Hauri et al., 1999a). However, because cognitive therapy has always been evaluated in the context of multifaceted treatments, the specific contribution of altering maladaptive sleep cognitions in the treatment of insomnia remains unknown.

In a study examining the role of attitudinal change in the treatment of chronic users of hypnotics, Pat-Horenczyk (1998) implemented a medication withdrawal program, followed by CBT focusing on the correction of faulty sleep beliefs and attitudes. Although improvements were noted during withdrawal, it is only with the addition of cognitive therapy that significant changes occurred in attitudes and beliefs. Also, the magnitude of those changes was correlated with subjective sleep measures. While these findings are interesting, they were based on a small sample (n=19) and it is unclear whether the attitudinal changes initiated during withdrawal would have continued without the addition of CBT. It is also intriguing that only subjective sleep measures were associated with the attitudinal change.

Together, those findings suggest that beliefs and attitudes about sleep are involved in the etiology of primary insomnia and that such cognitive variables may represent an important treatment target. Accordingly, the objectives of this study were to compare changes in sleep-related beliefs and attitudes obtained with cognitive-behavioral and pharmacological therapies for insomnia, and to evaluate the relationship between those changes and sleep improvements.