I urval från Stockholms universitets publikationsdatabas
Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia
2015. Rikard Sunnhed, Markus Jansson-Fröjmark. Cognitive Therapy and Research 39 (6), 841-852Artikel
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 therapy and behavioral therapy for insomnia disorder
2021. Rikard Sunnhed.Avhandling (Dok)
Insomnia disorder is the second most prevalent mental disorder and the most prevalent sleep disorder. Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the treatment of choice with well-documented effects. Nevertheless, a significant proportion of patients fail to respond, and an even larger proportion fail to remit from the condition. In addition, very little is known about the effects of CBT-I's separate components or about what moderates and mediates their effect. Gaining knowledge about components, predictors, and mediators could be one route for optimizing and tailoring CBT-I and ultimately enhancing outcomes.
The overall aim of this thesis was to advance our theoretical and clinical knowledge about CBT-I by exploring Cognitive Therapy (CT) and Behavior Therapy's (BT) comparative efficacy and their potential moderators and mediators.
To pursue the study aims, one large randomized controlled trial was performed that involved 219 individuals with insomnia disorder randomized to CT, BT, or a waitlist control group. Study 1 examined CT and BT's comparative efficacy against a waitlist control on a broad range of outcomes. Study 2 examined theoretically derived constructs from both therapy models, and insomnia-associated correlates as potential predictors and moderators of outcome for the two therapies. Study 3 examined theoretically driven process variables from the cognitive model as mediators of outcome in both CT and BT.
Study I showed that both therapies outperformed the waitlist and turned out as comparably effective treatments on the majority of outcomes. BT was associated with significantly more adverse events, whereas CT received significantly more minutes of telephone support.
Study II showed that early morning waketime and bedtime variability moderated the effect of both CT and BT. Those experiencing lower early morning waketime and bedtime variability achieved greater insomnia severity reductions in CT. In contrast, those experiencing greater early morning waketime and bedtime variability achieved larger insomnia severity reductions in BT. The findings also showed that greater insomnia severity, waketime after sleep onset, and lower sleep efficiency at baseline predicted greater insomnia severity at posttreatment.
Study III provided evidence that reductions in dysfunctional beliefs and monitoring for sleep during treatment acted as drivers of the reduction in insomnia severity in CT. The results also indicated that reductions in safety behaviors and dysfunctional beliefs mediated reductions in insomnia severity in BT, although not as clear as the drivers of change for CT since they were also reciprocally predicted by reductions in insomnia severity.
Study I indicate that CT and BT achieve similar effects and that both therapies are effective as standalone therapies for insomnia disorder. Study II provided evidence that the two therapies in CBT-I can depend on different patient characteristics at baseline to be effective. The results from study II thus suggest that the therapies in CBT-I could be tailored based on patient's characteristics before treatment to optimize outcomes. Study III provided support for the role of cognitive processes as important routes to remediate insomnia and underscore the value of assessing and targeting dysfunctional beliefs, monitoring, and safety behaviors to achieve reductions in insomnia severity and emphasize the importance of these concepts in understanding insomnia.
Symptom-Specific Effects of Cognitive Therapy and Behavior Therapy for Insomnia
2021. Tessa F. Blanken (et al.). Journal of Consulting and Clinical Psychology 89 (4), 364-370Artikel
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, posttest), 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.
Comparing internet-delivered cognitive therapy and behavior therapy with telephone support for insomnia disorder
2020. Rikard Sunnhed (et al.). Sleep 43 (2)Artikel
Study Objectives: Our aim was to compare the effects of Internet-delivered cognitive therapy (CT) and behavior therapy (BT) against a waitlist (WL) condition to better understand their unique contribution in the treatment of insomnia.
Methods: Two hundred and nineteen participants with insomnia disorder were randomized to CT (n = 72), BT (n = 73), or WL (n = 74). The treatment arms consisted of 10 weekly internet-delivered modules with 15 min of telephone support per week. At pre, post, and follow-up, participants completed measures of insomnia severity, sleep diaries, functional impairment, anxiety, depression, quality of life, adverse events, satisfaction and perception of content, workload, and activity in treatment. Measures of completed exercises, modules, therapist support, and platform logins were also measured at posttreatment.
Results: Moderate to large effect sizes for both CT and BT outperformed the WL on the majority of outcomes, with significant differences in favor of both therapy groups. Both treatment groups had significantly larger proportion of treatment remitters (CT: 35.8%, BT: 40%, WL: 2.7%) and responders (CT: 74.6%, BT 58.6%, WL: 10.8%) compared to the WL at posttreatment. There were no significant differences between the two therapy groups in terms of outcomes, except for sleep onset latency in favor of BT (6 min difference at posttreatment) and adverse events in favor of CT (CT 14.1% vs BT 43.2%).
Conclusions: This study indicates that both Internet-delivered CT and BT are effective as stand-alone therapies for insomnia disorder. Results highlight the need for examining which therapy and subcomponents that are necessary for change.
ClinicalTrials.gov Identifier: NCT02984670
Psychometric Properties of Two Brief Versions of Cognitive, Insomnia-Specific Measures
2020. Markus Jansson-Fröjmark, Rikard Sunnhed. Psychological Reports 123 (3), 966-982Artikel
Aim: The purpose of this study was to examine the psychometric properties of two brief versions of previously validated cognitive process measures in insomnia: the Anxiety and Preoccupation about Sleep Questionnaire and the Sleep-Associated Monitoring Index.
Methods: Two samples (168 students and 219 patients with insomnia disorder) completed original and brief versions of the two measures (Anxiety and Preoccupation about Sleep Questionnaire-Brief version and Sleep-Associated Monitoring Index-Brief version). Also, they filled out sociodemographic questions, sleep items, and the Insomnia Severity Index.
Results: In both samples, the internal consistencies of the two brief versions were acceptable at alpha = .70 to.72. The correlations between the original and brief versions were significant at .79 to .82. The two brief versions were also significantly associated with insomnia severity and nighttime symptomatology. In the student sample, those with likely insomnia disorder (14.9% of the sample) scored significantly higher on the two brief versions, relative to those without insomnia.
Conclusion: The two brief versions, Anxiety and Preoccupation about Sleep Questionnaire-Brief version and Sleep-Associated Monitoring Index-Brief version, displayed acceptable psychometric properties. This implies that the two brief versions might be viable alternatives for use in clinical and research settings.
Mediators of cognitive therapy and behavior therapy for insomnia disorder
Rikard Sunnhed (et al.).
Objective: To examine if the processes in the cognitive model mediate cognitive therapy (CT) and behavior therapy (BT) for insomnia.
Method: Individuals diagnosed insomnia disorder (n=219) were randomized to telephone supported internet-delivered cognitive therapy (n=72), behavior therapy (n=73), or a waitlist (n=74). Cognitive processes (worry, dysfunctional beliefs, monitoring and safety behaviors) proposed to maintain insomnia and treatment outcome (insomnia severity; ISI) were assessed biweekly. Criteria for evaluating mediators were assessed via parallel process growth modeling and cross-lagged panel models.
Results: Parallel process growth modeling showed that dysfunctional beliefs, monitoring and safety behaviors significantly mediated the effects of both CT and BT. Cross-lagged panel models confirmed that dysfunctional beliefs and monitoring, which approached significance, drove the change for CT. In BT, however, prior changes in ISI predicted later changes in worry and monitoring, and reciprocal influences among processes and outcomes were observed for dysfunctional beliefs and safety behaviors. The effect of safety behavior on outcome was significantly larger for BT compared to CT.
Conclusion: Together, the findings support the role of dysfunctional beliefs and monitoring as processes of change in CT, and safety behaviors as a specific mediator in BT. Limited evidence was provided for worry as a mediator. These findings have relevance for the conceptualizations of insomnia, future research, and clinical management.
Predictors and moderators of cognitive therapy and behavior therapy for insomnia disorder
Rikard Sunnhed (et al.).
Introduction: Little is known on what pretreatment patient characteristics the outcome of Cognitive Therapy (CT) and Behavioral Therapy (BT) for insomnia disorder depends on. Identifying for whom treatment is most useful is an essential step toward treatment optimization and personalized care. Therefore, the purpose with this investigation was to examine both theory-driven constructs and insomnia-associated clinical variables as potential predictors and moderators of outcome in CT and BT.
Materials and Methods: One hundred and forty-four participants diagnosed with insomnia disorder were randomized to 10 weekly internet-delivered modules of CT or BT with 15 minutes of telephone support per week. General clinical predictors and theory-driven moderators (cognitive and behavioral processes), assessed in a former RCT, were analyzed using multiple linear regression with insomnia severity as the outcome.
Results: Bedtime variability and early morning waketime interacted with treatment and indicated that lower bedtime variability and early morning waketime were associated with a higher effect for CT, whereas the opposite was true for BT. Waketime after sleep onset, insomnia severity index, and sleep efficiency emerged as predictors that indicated prognostic value of treatment outcome.
Conclusions: Five constructs provided predictive values in the outcome of cognitive therapy and behavior therapy. The moderator findings are in line with the theoretical models of CT and BT and may have implications for future research and clinical practice of CBT-I, should they be replicated. Clinically, this could implicate the ability to match therapy to patient features in order to optimize outcomes.