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Sleep Medicine Reviews xxx (2018) 1e18

Contents lists available at ScienceDirect

Sleep Medicine Reviews


journal homepage: www.elsevier.com/locate/smrv

CLINICAL REVIEW

The cognitive treatment components and therapies of cognitive


behavioral therapy for insomnia: A systematic review
€ jmark a, *, Annika Norell-Clarke b
Markus Jansson-Fro
a
Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
b
Centre for Research on Child and Adolescent Mental Health, Karlstad University, SE-651 88 Karlstad, Sweden

a r t i c l e i n f o s u m m a r y

Article history: Since the beginning of the twenty-first century, there has been an increased focus on developing and
Received 23 November 2017 testing cognitive components and therapies for insomnia disorder. The aim of the current review was
Received in revised form thus to describe and review the efficacy of cognitive components and therapies for insomnia. A sys-
5 March 2018
tematic review was conducted on 32 studies (N ¼ 1455 subjects) identified through database searches.
Accepted 1 May 2018
Available online xxx
Criteria for inclusion required that each study constituted a report of outcome from a cognitive
component or therapy, that the study had a group protocol, adult participants with diagnosed insomnia
or undiagnosed insomnia symptoms or reported poor sleep, and that the study was published until and
Keywords:
Insomnia
including 2016 in English. Each study was systematically reviewed with a standard coding sheet. Several
Cognitive therapy cognitive components, a multi-component cognitive program, and cognitive therapy were identified. It is
Efficacy concluded that there is support for paradoxical intention and cognitive therapy. There are also other
Systematic review cognitive interventions that appears promising, such as cognitive refocusing and behavioral experiments.
CBT For most interventions, the study quality was rated as low to moderate. We conclude that several
cognitive treatment components and therapies can be viewed as efficacious or promising interventions
for patients with insomnia disorder. Methodologically stronger studies are, however, warranted.
© 2018 Elsevier Ltd. All rights reserved.

Insomnia disorder is characterized by difficulties in initiating other disorders, such as depression. Insomnia disorder is also
sleep at bedtime, frequent or prolonged awakenings, or early- associated with significant direct and indirect costs [3].
morning awakenings with an inability to return to sleep [1,2]. Cognitive behavioral therapy for insomnia (CBT-I) is a time-
These nocturnal symptoms occur despite adequate opportunity for limited and structured treatment for patients with insomnia dis-
sleep and are associated with clinically significant distress or order. The therapy usually consists of several elements, with the
impairment of daytime functioning, including fatigue, decreased most common being psychoeducation about sleep, insomnia, and
energy, mood disturbances, and reduced cognitive functions. A sleep hygiene, components to address dysfunctional sleep behav-
diagnosis of insomnia disorder requires sleep difficulties that are iors, techniques to reduce unhelpful cognitive processes (e.g., be-
present for 3 nights or more per week and lasts for more than 3 liefs and expectations), and various forms of relaxation or
months [1,2]. The prevalence rate of insomnia disorder is approx- mindfulness training [4]. Recent meta-analyses and systematic re-
imately 10% in the population. Insomnia disorder is commonly views have shown that CBT-I improves insomnia symptomatology,
associated with medical as well as mental disorders, and evidence and it is now considered the treatment-of-choice for patients with
clearly shows that insomnia disorder is a risk factor for a host of insomnia disorder [5e7].
Though CBT-I has been demonstrated to have clear efficacy,
several conceptual issues remain largely unanswered. One of these
Abbreviations: BT-I, behavior therapy for insomnia; CBT-I, cognitive behavior issues is the limited evidence for the efficacy of various CBT-I
therapy for insomnia; CT-I, cognitive therapy for insomnia; DSM-5, Diagnostic and components for insomnia disorder [8,9]. While studies examining
Statistical Manual of Mental Disorders, Fifth Edition; MeSH, Medical Subject the efficacy of CBT-I mainly comprise of behavioral and cognitive
Headings; RCT, randomized controlled trial; SD, standard deviation; UCT, uncon-
trolled trial.
strategies in a combined format, very little is known empirically
* Corresponding author. Centre for Psychotherapy Education and Research, 117 63 about each of these elements, particularly so for cognitive com-
Stockholm, Sweden. ponents [10,11]. While it is beneficial for the evidence-base that
E-mail address: markus.jansson-frojmark@ki.se (M. Jansson-Fro€ jmark).

https://doi.org/10.1016/j.smrv.2018.05.001
1087-0792/© 2018 Elsevier Ltd. All rights reserved.

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


Please cite this article in press as: Jansson-Fro
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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M. Jansson-Fro

several behavioral strategies have been explored in a relatively University Library in order to find all studies that evaluated the
detailed manner and demonstrated to have marked efficacy on efficacy of a cognitive component or a cognitive therapy for
their own (e.g., sleep restriction) [12], it is problematic that little insomnia. The search was carried out by using six online biblio-
effort has been made to develop and validate cognitive in- graphic databases [i.e., Medline (Ovid), Psycinfo (Ovid), Embase
terventions. Theoretically, several dominant models of insomnia (Elsevier), Cochrane (Wiley), Cinahl (Ebsco), and Dissertations and
underscore cognitive processes that are implicated in the mainte- Theses (ProQuest)]. The search strategies were developed by two
nance of insomnia [13e16]. In turn, this points to the need to librarians in collaboration with the first author. The strategies were
address cognitive processes in therapy with cognitive or based on several MeSH and keyword search terms. Across the da-
behaviorally-oriented interventions [17]. It is also important to tabases, terms were used to identify studies in which patients with
point out that some of the cognitive processes in these models are insomnia had been included and a cognitive component or therapy
well-researched [18], with evidence supporting the notion that had been employed (e.g., paradoxical intention, imagery, problem
cognitive mechanisms are involved in maintaining insomnia solving, and constructive worry). For a complete description of the
disorder. A second major issue is that although CBT-I is a well- search strategies, see the Supplemental Material (Table S1). Further,
researched and evidence-based intervention, only a smaller frac- the first author reviewed the reference lists of recent reviews and
tion (20e30%) remit from insomnia and a substantial number of meta-analyses of the efficacy of CBT-I. Finally, the reference list of
patients do not benefit at all [4]. Though it is premature at this point each study included in the present review was examined.
to speculate whether or not cognitive components might increase
the number of patients that remit or respond, existing cognitive Selection procedure
models suggest the possibility for further refinement and
improvement for CBT-I. In areas where cognitive processes have As is displayed in Fig. 1, the database search yielded a total of
been more heavily scrutinized (e.g., social anxiety disorder), 4063 records from the six databases, out of which 1609 titles were
development of new or revising of previous therapies has led to the duplicates. One additional record was identified via the reference
development of highly effective treatments (e.g., cognitive therapy list from an included study. Thus, 2455 records were the focus for
for social anxiety disorder [19]). The development and validation of further review. These records were screened via a systematic re-
cognitive therapeutic interventions thus seems central. view web app (https://rayyan.qcri.org). The abstracts of all the titles
Since the end of the 1970's, insomnia-related cognitive com- were initially screened by the first author to exclude irrelevant
ponents have been developed, validated, and revised. Though there studies.
are marked differences between the cognitive interventions in Only peer-reviewed published articles were retained. The in-
terms of content, these interventions share a common theoretical clusion criteria for the studies in the present review were: 1) the
underpinning, namely that a change in cognitive processes is study was a randomized controlled trial, uncontrolled group trial,
necessary to impact insomnia symptomology; not only alterations or experimental group study, 2) the study constituted a report of
in homeostatic and circadian systems [9]. Early cognitive compo- treatment outcome using at least one outcome assessing insomnia
nents, developed during the 70's and 80's, that were investigated in symptomatology (i.e., nighttime and daytime symptoms); 3) a
smaller trials, were paradoxical intention, imagery training, and psychological treatment with a cognitive component/therapy was
distraction. Since the beginning of the twenty-first century, there tested on at least one group and the component/therapy was
has been increased focus on developing and testing cognitive theoretically intended to reverse cognitive processes (e.g., expec-
components for insomnia. The latter work has included the tations, beliefs, attributions, and performance anxiety) [10]; 4) the
development and exploration of interventions that target worry, participants were adults; 5) the participants had been diagnosed
problem-solving, emotional processing, coping with perceived with insomnia (i.e., primary, secondary or comorbid), had undiag-
threats, and sleep misperception. Lately, cognitive therapy, nosed problems initiating or maintaining sleep, or reported poor
uniquely adapted to insomnia disorder, has been described and sleep; 6) the study was published before or during December 2016;
examined [20]. In 2006, it was concluded in a review that there was and 7) the study was published in English. Concerning the
insufficient evidence for cognitive restructuring - probably the population-criterion (e), we included studies in which participants
most commonly used cognitive component in CBT-I manuals - as a were described as having insomnia symptoms or poor sleep (i.e. not
treatment intervention for insomnia disorder [21]. Since 2006, the fulfilling all criteria for insomnia disorder) due to the growing ev-
research field has grown substantially. Yet there has been no sci- idence for and trend in diagnostic systems towards a dimensional
entific attempt to examine the literature so far, thus we believe that view of psychopathology [22,23]. As mindfulness approaches have
it is time to review what is known empirically concerning the recently been examined in reviews [24e26], studies exploring the
cognitive components of CBT-I. The aim of the current systematic efficacy of mindfulness-based stress reduction or mindfulness-
review was therefore to assess the efficacy of cognitive components based cognitive therapy were excluded from this review. In total,
and cognitive therapies for insomnia disorder. 2380 records were excluded based on the criteria described above.
Full-texts of the remaining 75 references were evaluated by the
Methods first author. The second author was consulted in cases of uncer-
tainty concerning inclusion. The two authors discussed disagree-
A systematic review approach was used. A meta-analysis was ments until a negotiated conclusion was reached. At this stage, the
not considered appropriate due to the small number of studies criteria described above for inclusion and exclusion were used. In
available for each cognitive component or therapy and the sub- total, 32 records were included at this stage (the excluded 43
stantial heterogeneity in the methodology and outcomes of studies with reasons for exclusion are displayed in Table S2).
included studies. The review was pre-registered at PROSPERO in
June 2017 (https://www.crd.york.ac.uk/PROSPERO/#index.php). Data extraction

Search strategy The 32 records were then reviewed by two pairs of independent
raters. All four raters were students in their tenth and final term at
An extensive database search was conducted in December 2016 the Master of Science in Clinical Psychology program, and the raters
by two project-independent librarians at Karolinska Institute were paid for their work. Before rating the included studies, all

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


Please cite this article in press as: Jansson-Fro
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
€jmark, A. Norell-Clarke / Sleep Medicine Reviews xxx (2018) 1e18
M. Jansson-Fro 3

Records idenfied through database Addional records idenfied through


searches other sources
(n = 4063) (n = 1)

Records aer duplicates removed


(n = 2455)

Records screened Records excluded


(n = 2455) (n = 2380)

Full-text arcles assessed for Full-text arcles excluded,


eligibility with reasons: Not a group
(n = 75) study, same sample or
sample overlap, no relevant
outcomes, only abstract or
trial protocol, intervenon
Studies included in review not cognive, not individuals
(n = 32) with sleep difficules
(n = 43)

Fig. 1. PRISMA study inclusion flowchart.

raters were given detailed instructions in a booklet. They were also study report free of suggestion of selective outcome reporting (e.g.,
asked to rate two project-independent studies (i.e., two papers results for all included outcomes are described) [10], intervention
investigating the efficacy of CBT for anxiety and depressive disor- components clearly described (including treatment content and
ders), which was followed by feedback on the ratings by the first dosage), and [11] a study population with verified sleep problems,
author and the other rater in the pair. Each rater used a standard e.g., based on DSM-5 criteria for insomnia disorder [2]. Scores were
extraction sheet to summarize information about the study: study “0” (No), “1” (Partly/unclear), and “2” (Yes), yielding a total quality
design, sample size, diagnosis [i.e., insomnia disorder/primary score range of 0e22. To increase the validity of the quality scores,
insomnia, insomnia symptoms (not fulfilling all criteria for a diag- the quality ratings were conducted independently by the two au-
nosis), or poor sleep (no evidence of insomnia symptoms)], mean thors. Disagreements and uncertainties were discussed among the
age, % women, % study attrition, type of cognitive components or authors until a negotiated final score was reached for each study.
therapies and control conditions, treatment delivery (i.e., dosage Since one included study had been authored by the first author
and format), outcome measures (i.e., insomnia-related nighttime [30], the quality assessment was carried out by the two authors and
and daytime symptoms as well as cognitive processes), and find- a project- and study-independent researcher. Following this, the
ings. Data extraction was completed independently and discrep- total score differed by one point; the lower score, scored by the two
ancies between the two raters in the pairs were resolved through authors, was chosen as the final score for this study.
discussion with the first author.

Results
Assessment of study quality
Study characteristics
Quality assessments of the included studies were indexed. As in
a previous review on insomnia disorder [27], eight modified items After the screening process, 32 papers were included in the
from the Jadad scale [28] together with one item from the Cochrane current review, including a total of 1455 patients. The in-
assessment of bias tool [29], and two insomnia-related study vestigations differed in their design: 29 were RCTs or experimental
quality criteria were used. In total, each study was assessed in terms studies and three were UCTs. The included participants' age and
of their quality based on eleven items [1]: randomization procedure gender varied across studies, but a great majority of the partici-
clearly described [2], allocation concealed for researchers during pants were women (82.7% of participants) and either young adults
the intervention [3], clear description of non-responders, with- (55.5%) or middle-aged adults (37.0%) (calculations based on
drawals, and dropouts, with CONSORT flow chart [4], study objec- studies in which data was available). The definitions of sleep
tives clearly defined [5], outcome measures clearly defined [6], problems differed across studies: 22 included patients with
inclusion and exclusion criteria clearly described [7], sample size insomnia disorder (or primary insomnia), eight included those with
justified (e.g., power calculation) [8], statistical methods clearly insomnia symptoms [defined so due to no assessment of distress or
described, including missing values, intention-to-treat etc. [9], functional impairment [2]], and two studies included participants

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


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behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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M. Jansson-Fro

Table 1
Description of the cognitive components and therapies for insomnia.

Component or therapy Description

Behavioral experiments Behavioral experiments are carefully planned activities, which the patient conducts, with the purpose of testing an unhelpful belief and
formulating more adaptive beliefs based on the experiment's outcome (73). See Cognitive therapy, Reducing clock monitoring and Reducing
sleep misperception for insomnia treatment contexts.
Cognitive program The cognitive program consists of a combination of techniques aimed at affecting maintaining cognitive factors [49]. The cognitive
program includes Cognitive restructuring, Paradoxical intention, Thought stopping and a form of Coping imagery (more detailed descriptions
of every technique are available under specific headings in the table).
Cognitive refocusing Cognitive refocusing is based on cognitive models that delineate arousing thought content as a maintaining factor in insomnia [59].
Cognitive refocusing aims to reduce arousing thought content by instructing patients to choose engaging yet non-arousing thought topics
to focus on, such as the plot in a film or by focusing on external stimuli such as an audiobook [35]. By doing so, it is proposed that this shift
in attention will improve sleep. Patients are instructed to apply cognitive refocusing at bedtime and if they wake up during the night. See
similarities to Distraction and Imagery training.
Cognitive restructuring The use of cognitive restructuring in insomnia is based on models that suggest that dysfunctional beliefs about sleep have a maintaining
role in insomnia (e.g. [15]). Cognitive restructuring commonly means teaching patients to identify individual dysfunctional beliefs,
observe the effect beliefs have on mood, and to restructure beliefs by questioning them and formulating alternative beliefs that are more
realistic.
Cognitive therapy Cognitive therapy for insomnia is based on a cognitive model of insomnia [15,19]. Cognitive therapy aims to reverse a broader range of
cognitive maintaining mechanisms, namely (a) unhelpful beliefs about sleep, (b) sleep-related or sleep-interfering worry and rumination,
(c) attentional bias and monitoring for sleep-related threat, (d) misperception of sleep and daytime deficits, and (e) the use of safety
behaviors that maintain unhelpful beliefs. Cognitive therapy aims to reverse these cognitive maintaining mechanisms during the daytime
and the nighttime through the identification of maladaptive beliefs and strategies, and individually formulated Behavioral experiments to
test beliefs and alter habits.
Constructive worry Constructive worry (also labeled ‘worry control’ in the literature) is based on research showing that many patients with insomnia are
prone to pre-sleep worry and also believe that worry serves a purpose [34]. In constructive worry, the patients are instructed to
deliberately engage in worry outside the bed, early in the evening, and to use problem-solving regarding their concerns. Thus, worry is
moved from the sleep-onset period and the bed, and takes on a more constructive form. Together this is meant to decrease pre-sleep
arousal and thereby decrease involuntarily awake time in bed.
Coping imagery Coping imagery consists of four techniques aimed to alter patients' pre-sleep arousing cognitions [36]. For example, patients are instructed
to imagine emotionally salient situations (both sleep-related and non sleep-related) and to alter the situations mentally in ways what will
give a stronger sense of control (e.g. mentally writing down intrusive thoughts and then erasing them, or mentally putting one's evening
worries in a worry box which will be examined in the morning). For other techniques, patients are instructed to mentally alter upsetting
situations by pairing them with something positive (e.g. imagine that one has super powers and therefore is well equipped to deal with
daytime tasks after a night's poor sleep).
Distraction The purpose with distraction is to disrupt cognitive activities that interferes with sleep by introducing stimuli that will be engaging yet not
arousing for the patients while in bed. Examples of distracting stimuli includes imagining an interesting and engaging situation [62]. See
similarities to Cognitive refocusing and Imagery training.
Imagery training Imagery training is aimed at controlling pre-sleep cognitive arousal by focusing attention on neutral stimuli. Pictures of six neutral objects
are shown to patients and they are taught how to visualize the objects independently [46]. Patients are instructed to use the visualizations
whenever they are unable to fall asleep. See similarities to Cognitive refocusing and Distraction.
Increased visual imagery The ambition to decrease verbal thoughts and increase visual imagery comes from the literature on worry, which suggests that although
thinking (worrying) in images is associated with increased somatic arousal and more distress in short-term, it can also lead to increased
emotional processing which in turn would decrease worry and distress (74). As people with insomnia often are prone to worry in bed, and
worry is associated with sleep problems [15], advice could be given on how to worry more productively. So far, this technique has only
been used experimentally regarding insomnia [37].
Paradoxical intention Paradoxical intention is based on the notion that people with insomnia exacerbate their condition by attempting to control the sleep
process (75). In paradoxical intention, the patient is instructed to attempt to remain awake (as long as possible) rather than trying to fall
asleep. In the original instructions, the patient is asked to lie in bed in a darkened room, keeping his or her eyes open (as long as possible).
The patient is also instructed not to engage in sleep-incompatible behavior (e.g., reading or watching TV). Instructions and rationales for
patients have varied in different paradigms, e.g. that trying to stay awake decreases performance anxiety (Type A rationale) vs trying to
stay awake works as a desensitization of anxiety-provoking thoughts (Type B rationale). Rationales commonly resembles one of the two
abovementioned rationales but exceptions should be noted (e.g. 41).
Pennebaker writing The use of the Pennebaker writing intervention for insomnia is based on research that demonstrates that patients with insomnia engage in
intervention worry and perceive it as a major impediment to sleep [15] and on research that shows that people with insomnia have a tendency to
internalize emotions; thereby suggesting incomplete emotional processing of daily events and hassles [15]. In the Pennebaker writing
intervention, patients are instructed to write their deepest thoughts or emotions down in detail before bedtime. It is believed that the
Pennebaker writing intervention will reduce worry, which, in turn, will promote sleep onset.
Problem solving therapy The use of problem solving therapy is based on research that shows that excessive worry is maintaining insomnia [53]. By improving
problem solving skills, it is believed that worry (and sleep difficulties) will be reduced. In problem solving, the patient is provided
education about the importance of effective problem-solving, types of problem-solving, instructions in rational problem-solving
techniques, and enhancement of problem orientation. The patient may choose to focus on his or her current sleep problem or another
distressing or disruptive problem. See similarities with Constructive worry.
Reducing clock Reduced clock monitoring is based on research demonstrating that paying attention to the time during the night increases worry and
monitoring contributes to difficulties falling asleep [57]. Clients may be simply advised to avoid looking at the clock while lying in bed, as part of a
cognitive refocusing treatment [50] but clock monitoring may also be specifically challenged through a Behavioral experiment, where
clients experimentally test (for example) whether clock monitoring vs not monitoring the clock is associated with better sleep.
Reducing sleep The ambition to reduce sleep misperception is based on research that demonstrates that people with insomnia subjectively overestimate
misperception their sleep problems, which leads to increased worry and exacerbates insomnia according to the cognitive model of insomnia [15]. Sleep
misperception is countered by demonstrating objective sleep data (e.g. from actigraphy) to patients, which in turn is proposed to decrease
worry and thereby improve sleep. Ideally, this is demonstrated through a Behavioral experiment where patients themselves are taught how
to contrast subjective and objective sleep measures from a specific night's sleep rather than just being informed of the results [56].
Thought stopping The use of thought stopping in insomnia is based on the theory that sleep onset latency will decrease if negative sleep-related thoughts at
bedtime will be stopped or decreased [45]. Thought stopping is first practiced with a therapist who intervenes by yelling “stop” after being
given a que that patients are thinking negative thoughts. When patients are confident that they can stop their thoughts independently,
they are instructed to practice the technique at daytime and especially at bedtime.

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M. Jansson-Fro 5

with “poor sleep” (based on cutoffs from generic insomnia symp- questions regarding the active mechanisms in the two treatments.
toms questionnaires). Though the majority of studies administered The results were maintained at follow-ups, at which point there
treatment in an individual format, interventions in six studies were were no significant differences between the four groups.
delivered in a group or self-help format. On average, 3.4 sessions
(SD ¼ 2.8, range: 1e22 sessions) were devoted to administering the Cognitive refocusing
cognitive components or therapies [two studies excluded in the Three studies investigated the efficacy of cognitive refocusing in
calculation due to missing data [31,32]]. Sleep diaries were a participants with primary insomnia or insomnia symptoms
common method for assessing outcomes (k ¼ 30 studies), and self- [38,52,59]. The first investigation was a three-armed RCT
report instruments or questions were also prevalent (k ¼ 25 comparing the efficacy of one session of cognitive refocusing
studies). The use of objective sleep recordings was less common (administered as an audiobook) or cognitive refocusing (relaxation
(k ¼ 7 studies). For more details, see Table 2. training) with self-monitoring [38]. All three groups had improved
Concerning control conditions, both passive and active control on subjective sleep parameters and on two cognitive-affective
conditions were used. Nineteen RCTs compared a cognitive measures (anxiety and self-efficacy) at post-treatment. There
component or therapy with a more passive comparator, i.e., psy- were no significant improvements on daytime or additional
choeducation, monitoring, no treatment or a waitlist control cognitive-affective measures. The results were similar at the 2-
[31e49]. Four RCTs used a psychological placebo as a comparator week follow-up. The second study used an uncontrolled trial
[33,34,36,47,50]. One RCT compared a cognitive program with design with ten patients [59]. The investigation showed that four
biofeedback [51]. Eight RCTs used one or several behavioral therapy sessions of cognitive refocusing increased sleep quality at post-
component as a comparator, e.g., stimulus control or relaxation treatment and follow-up and reduced insomnia severity at
[30,31,42,44,45,47,49,52]. Four RCTs compared a cognitive compo- follow-up. Cognitive refocusing did not have a significant impact on
nent or therapy with another cognitive component, mindfulness- sleep diary parameters or arousing sleep content. The third inves-
based intervention, behavior therapy, or cognitive behavior tigation was a RCT comparing the efficacy of one session of cogni-
therapy [39,53e55]. Finally, six studies can be categorized as tive refocusing plus sleep hygiene with sleep hygiene only [52]. The
experimental tests that used a behavioral experiment in which the findings indicated that cognitive refocusing plus sleep hygiene was
comparator consisted of instructing the participants to test an superior to sleep hygiene in reducing insomnia severity at post-
alternate behavior or receiving differing feedback [40,41,56e58]. treatment. Also, cognitive refocusing plus sleep hygiene resulted
Concerning quality assessments of the included studies, the two in more treatment responders, relative to sleep hygiene only.
raters agreed on 324 (92.2%) of the 352 individual study quality However, cognitive refocusing did not lead to superior improve-
ratings. Disagreements were discussed in depth between the two ments on somatic or cognitive pre-sleep arousal.
authors and a final rating was negotiated (Supplemental Material:
Table S3). The mean final total quality rating was 13.1 (SD ¼ 2.7; Cognitive restructuring
range: 8e21; maximum: 22). The two most common methodo- One study examined cognitive restructuring and problem solv-
logical limitations were that the group allocation was not suffi- ing as techniques for those with insomnia disorder [54]. Cognitive
ciently concealed to researchers, and that the studies' sample sizes restructuring plus behavior therapy (i.e., stimulus control, sleep
had not been based on statistical power calculations. hygiene, and progressive relaxation) was compared with problem
solving plus behavior therapy. All patients received behavior ther-
Description of cognitive components and therapies for insomnia apy during one small-group session and were randomized to either
problem solving or cognitive restructuring; both administered
This review identified empirical tests of cognitive components individually across five sessions. The findings indicate that both
and cognitive therapies in the research literature. A description of groups had similar outcomes at post-treatment and follow-up. Both
the components and therapies is available in Table 1. groups improved on sleep onset latency, times waking up, wake
after sleep onset, total sleep time, sleep efficiency, insomnia
Evidence for cognitive components and therapies for insomnia severity, sleep quality, number of responders and remitters,
problem-solving skills and orientations, unhelpful beliefs about
In the following section, we review the evidence for the cogni- sleep, and worry. The only difference between the two groups was
tive components and therapies for insomnia. A description of the that those receiving cognitive restructuring had a faster reduction
included studies is available in Table 2. on unhelpful beliefs about sleep, relative to those who received
problem solving. This study suggests that cognitive restructuring
Cognitive program might be equally effective as problem solving and tentatively that
One study has investigated a combination of cognitive tech- both interventions might have efficacy in their own right.
niques vs biofeedback, with the ambition to test the matching of
patients with treatments [51]. The cognitive program consisted of Cognitive therapy
cognitive restructuring, paradoxical intention, thought stopping Three studies have investigated the efficacy of cognitive therapy
and form of coping imagery. Patients were assigned to treatments for insomnia (CT-I) [20,53,55] (see Table 1 for treatment content).
based on their pre-sleep cognitive arousal: half of those with high The first investigation was an uncontrolled study in which nineteen
arousal were randomized to the cognitive program and the other patients with insomnia were administered CT-I [20]. Due to co-
half to biofeedback, and likewise for those with low arousal. The morbidity and heterogeneity in the therapists' experience with the
cognitive program resulted in significantly greater reduction on protocol, the number of sessions varied from 6 to 22 across the pa-
pre-sleep arousal at post-treatment: those with high pre-sleep tients (mean: 14 sessions). The findings showed that CT-I, at post-
cognitive arousal benefitted more. Both therapies reduced sleep treatment and follow-ups, reduced insomnia severity, sleep onset
onset latency, increased total sleep time and increased sleep quality latency, wake after sleep onset, unhelpful beliefs about sleep, sleep-
at post-treatment. Counter-intuitively, biofeedback was more related worry, cognitive arousal, attention and monitoring for sleep-
beneficial for sleep quality for those with high pre-sleep cognitive related threat, safety behaviors, depression, and anxiety. Also, CT-I
intrusions whereas those with low pre-sleep cognitive intrusions had a positive impact on total sleep time. Finally, none of the pa-
benefitted more from the cognitive program, which raises some tients met criteria for insomnia at post-treatment and follow-ups. In

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


Please cite this article in press as: Jansson-Fro
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
Table 2

6
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
Please cite this article in press as: Jansson-Fro

Description of studies examining cognitive components or therapies for insomnia: Design, sample description, treatment type, treatment delivery, outcomes, findings, and quality score.

Design Sample: Size, diagnosis, Treatment type Treatment delivery Outcomes Findings Quality
age (M), % female, score
% attrition

Cognitive program
Sanavio, 1988 [51] RCT 24, psychophysiological (a) Cognitive program e (a - d) 6 sessions, Sleep diary (SOL, NAW, TST, tension, Cognitive program had a greater 12
insomnia, 39 y, 58%, NR high pre-sleep cognitive individual format SQ), PICI reduction on pre-sleep intrusions at
activation (PSCA) post-treatment. Those with high PSCA
(b) Cognitive program e benefitted more on pre-sleep intrusions
low PCSA from therapies at post-treatment. All
(c) Biofeedback e high therapies reduced SOL, increased TST,
PCSA and increased sleep quality at post-
(d) Biofeedback e low PCSA treatment. Biofeedback meant a greater
reduction on tension at post-treatment.
Those with high PSCA benefitted more

M. Jansson-Fro
from biofeedback on SQ, and those with
low PSCA more from the cognitive
program. Maintained results at 3- and
12-month follow-ups.
€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive

Cognitive refocusing

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Creti, 1998 [38] RCT 52, sleep-onset and/or (a) Cognitive refocusing (a e b) 1 session, Sleep diary (SOL, WASO, TST, SE, SQ, All three groups improved on sleep- 12
-maintenance insomnia, (audiobook) individual format fatigue, daytime function, morning wake and subjective sleep parameters
67 y, 68%, 21% (b) Cognitive refocusing restedness, mental activity, physical (SOL, WASO, TST, SE, SQ, and insomnia
(relaxation) tension), insomnia frequency, distress frequency) and on two cognitive-
(c) Self-monitoring / frequency, SES, SSS, PSAS, ASSQ affective measures (ASSQ and SES) at
randomized to (a) or (b) post-treatment. No significant
improvement on daytime or additional
cognitive-affective measures. No
significant differences in improvement
between the three groups. Similar
findings at 2-weeks follow-up.
Gellis et al., 2013 [52] RCT 62, insomnia symptoms, (a) Cognitive (a e b) 1 session, ISI, PSAS-S, PSAS-C Cognitive refocusing þ Sleep hygiene 19
NR, 65%, 19% refocusing þ Sleep hygiene individual format demonstrated larger reduction on ISI
(b) Sleep hygiene and more responders at post-treatment
than sleep hygiene only. No follow-up.
Gellis, 2012 [59] UCT 10, primary insomnia, 49 y, (a) Cognitive refocusing (a) 4 sessions, Sleep diary (SOL, WASO, NAW, TST, SE), Cognitive refocusing resulted in 14
10%, 0% individual format PSQI, ISI, arousing sleep content reduction on PSQI at post-treatment
and follow-up and reduction on ISI at 1-
month follow-up.
Cognitive restructuring
Pech & O'Kearney, 2013 RCT 47, insomnia disorder, 34 (a) Behavior (a e b) 1 Sleep diary (SOL, NAW, WASO, TST, SE, Following full treatment, both groups 17
[54] e45 y, 62%, 15% therapy þ Cognitive session BT, medication or alcohol), ISI, PSQI, SPSI- improved on SOL, NAW, WASO, TST, SE,
restructuring group format R:S, DBAS, PSWQ medication or alcohol, ISI, PSQI, number
(b) Behavior (a e b) 5 sessions of of responders and remitters, SPSI-R:S,
therapy þ Problem solving PS or CRES, DBAS, and PSWQ at post-treatment and
individual format 1-month follow-up. Behavior
therapy þ Cognitive restructuring
displayed faster reduction on DBAS.
Cognitive therapy
Harvey et al., 2007 [20] UCT 19, primary insomnia, 49 y, (a) Cognitive therapy (a) 6e22 sessions Sleep diary (SOL, WASO, TST), ISI, WSAS, Cognitive therapy reduced ISI, SOL, 11
53%, 0% (mean 14 sessions), DBAS, APSQ, PSAS-C, SAMI, SRBQ, BDI, WASO, DBAS, APSQ, PSAS-C, SAMI,
individual format BAI, diagnosis SRBQ, BDI and BAI, and increased TST, at
post-treatment and 3-, 6-, and 12-
month follow-ups. 0% met criteria for
insomnia at post-treatment and follow-
ups.
Harvey et al., 2014 [53] RCT 188, insomnia disorder, (a) Cognitive therapy (a e c) 8 sessions Sleep diary (SOL, WASO, TST, SE), ISI, All therapies reduced ISI at post- 21
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
Please cite this article in press as: Jansson-Fro

47 y, 62%, 11% (b) Behavior therapy (CT and BT: 45 polysomnography (SOL, WASO, TST, treatment; cognitive behavior therapy
(c) Cognitive behavior e60 min; CBT: SE), MFI, WSAS, SF-36 was more effective in decreasing ISI
therapy 75 min), individual than cognitive therapy. There were
format more treatment responders in cognitive
behavior therapy and behavior therapy
at post-treatment and an increase in
treatment responders at 6-month
follow-up in cognitive therapy and
decrease in behavior therapy. A higher
rate of remission was noted in cognitive
behavior therapy than in cognitive
therapy at post-treatment but not at
follow-up. There was an increase in
remission rate in cognitive therapy
from post-treatment to follow-up. A
larger reduction was demonstrated in

M. Jansson-Fro
behavior therapy, relative to cognitive
therapy, on SOL and WASO. All
therapies increased TST. Cognitive
€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive

behavior therapy and behavior therapy


displayed larger reduction on SE at

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post-treatment. Polysomnography
post-treatment: cognitive behavior
therapy and behavior therapy displayed
larger reduction on SOL and larger
increase on SE, behavior therapy larger
reduction on WASO. All therapies
reduced WSAS and mental health
problems (SF-36).
Wong et al., 2015 [55] RCT 64, insomnia disorder, 49 y, (a) Behavior therapy during (a) 4 sessions, ISI, PSQI, sleep diary (TST), actigraphy First phase: Behavior therapy resulted 17
63%, 11% first phase; randomized individual format (TST), DASS in improvements on ISI, PSQI, TST (sleep
into (b), (c), (d) or (e) during (b - c) 4 sessions, diary and actigraphy), depression,
second phase individual format anxiety, and stress. Second phase:
(b) Cognitive therapy Immediate cognitive therapy and
immediately mindfulness-based therapy displayed
(c) Mindfulness-based larger reduction on ISI, PSQ, and TST
therapy immediately than delayed therapy (maintained
(d) Cognitive therapy after results at 3-month follow-up). There
4 weeks was no significant difference between
(e) Mindfulness-based cognitive therapy and mindfulness-
therapy after 4 weeks based therapy during second phase.
Constructive worry
€jmark et al.,
Jansson-Fro RCT 22, insomnia disorder, 56 y, (a) Behavior therapy (a þ b) 4 sessions, Sleep diary (TWT, TST), ISI, APSQ, WSAS Behavior therapy and Behavior 16
2012 [30] 52%, 9% (b) Behavior individual format therapy þ Constructive worry resulted
therapy þ Constructive in improvements on TWT, TST, ISI,
worry APSQ, and WSAS at post-treatment and
follow-up. Behavior
therapy þ Constructive worry displayed
larger reduction on ISI at post-
treatment and 2-weeks follow-up, and
on APSQ at follow-up. Behavior
therapy þ Constructive worry resulted
in more responders at post-treatment
and follow-up. Both interventions were
equally effective on TWT, TST, and
WSAS at post-treatment and follow-up.
(continued on next page)

7
Table 2 (continued )

8
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
Please cite this article in press as: Jansson-Fro

Design Sample: Size, diagnosis, Treatment type Treatment delivery Outcomes Findings Quality
age (M), % female, score
% attrition

Carney & Waters, 2006 RCT 38, primary insomnia, 21 y, (a) Constructive worry (a þ b) 1 session, Sleep diary (SOL, TWT, TST), PSAS, STAI- Constructive worry resulted in 15
[37] 79%, 13% (b) Worry monitoring individual format S, actigraphy (SOL, TWT, TST) reduction on PSAS-C. Constructive
worry demonstrated larger reduction
than other group on PSAS-C. No follow-
up.
Coping imagery
Gould, 1988 [39] RCT 64, insomnia symptoms, 19 (a) Coping imagery (a e c) 6 sessions, Sleep diary (SOL, NAW, TST, SQ, Coping imagery resulted in 13
e80 y, 42%, 25% (b Paradoxical intention individual format restedness, sleep medication), PSAS, improvements on SOL, PSAS-C, and BDI,
(c) Sleep information STAI, BDI and paradoxical intention on SOL, TST,
(d) Waitlist control restedness PSAS-C, and BDI. Paradoxical
intention and coping imagery displayed
larger improvement than the other two

M. Jansson-Fro
groups on SOL. Paradoxical intention,
coping imagery and sleep information
resulted in larger improvement than
waitlist on TST, restedness, and PSAS-C.
€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive

There were maintained effects for the

€jmark, A. Norell-Clarke / Sleep Medicine Reviews xxx (2018) 1e18


active groups at 3-months follow-up.
Distraction
Harvey & Payne, 2002 RCT 50, insomnia symptoms, 22 (a) Imagery distraction (a e c) 1 session, Sleep diary (SOL), thought frequency Imagery distraction and general 12
[61] e23 y, 51%, 18% (b) General distraction individual format rating, thought discomfort rating distraction resulted in larger reduction
(c) No instruction on SOL than control. Imagery
distraction led to larger reduction on
thought discomfort than control. No
follow-up.
Imagery training
Morin & Azrin, 1987 RCT 27, sleep-maintenance (a) Imagery training (a - b) 4 sessions, Sleep diary (WASO, NAW), BDI, STAI Imagery training displayed reduction 13
[44] insomnia, 57 y, 67%, 22% (b) Stimulus control group format on NAW at post-treatment. Stimulus
(c) Waitlist control resulted in larger reduction on
WASO than imagery and waitlist groups
at post-treatment. Stimulus control
displayed larger reduction on BDI than
imagery training at post-treatment.
Imagery training led to reduction on
WASO at 3-month follow-up. Stimulus
control resulted in shorter WASO than
imagery training at 3 month follow-up
(no significant group difference at 12-
month follow-up).
Morin & Azrin, 1988 RCT 28, sleep-maintenance (a) Imagery training (a e b) 6 sessions, Sleep diary (SOL, WASO, NAW, TST, Imagery training resulted in reduction 14
[45] insomnia, 67 y, 63%, 4% (b) Stimulus control group format medication), significant-other insomnia on WASO, medication use and patient
(c) Waitlist ratings, patient insomnia ratings, BDI, insomnia ratings at post-treatment.
STAI Stimulus control displayed larger
reduction than imagery training on TST
and patient insomnia ratings at post-
treatment. Imagery training led to
reduction on SOL and WASO at 3- and
12-month follow-ups.
Woolfolk & McNulty, RCT 51, sleep-onset insomnia, (a) Imagery training (a - d) 4 sessions, Sleep diary (SOL, NAW, TST, difficulty Imagery training groups showed 12
1983 [49] 43 y, 68%, 14% (b) Imagery group format falling asleep, SQ, restedness, tiredness, improvements on SOL, difficulty falling
training þ Muscle-tension relaxed in bed, difficulty controlling asleep, SQ, restedness and difficulty in
release intrusive thoughts), STAI, TAQ controlling intrusive thoughts at post-
(c) Somatic focusing treatment. Imagery training groups
(d) Relaxation displayed larger reduction on SOL than
(e) Waitlist waitlist, and larger decreases on NAW
than the other three groups at post-
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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treatment. Imagery training groups


resulted in larger reductions on SOL
than all the other three groups at 6-
month follow-up.
Increased visual imagery
Nelson & Harvey, 2002 RCT 31, primary insomnia (a) Cope with imagery (a e b) 1 session, Bedtime: Pre- and post-thought speech Imagery group were more distressed 13
[40] (sleep-onset difficulties), before speech threat individual format anxiety questionnaire, post-thought and aroused at bedtime. Imagery group
19.8e20.9 y, 55%, NA (b) Cope with verbal processing questionnaire; waking: SOL, displayed shorter SOL, less anxiety and
thoughts before speech speech anxiety questionnaire, more comfort about giving the speech,
threat resolution about the speech and higher level of resolution on
waking. No follow-up.
Paradoxical intention
Espie et al., 1989 [31] RCT 101, sleep-onset insomnia, (a) Paradoxical intention (a e d) 8 weeks, Sleep diary (SOL, TST, SQ), ZAS, ZDS, Paradoxical intention resulted in 12
45 y, 67%, 17% (b) Relaxation individual format SBRS, ARS reduction on SOL and increase on TST
(c) Stimulus control and SQ. Paradoxical intention led to
(d) Placebo reduction on ZAS, ZDS, and ARS.
(e) No treatment Paradoxical intention was noted to be

M. Jansson-Fro
inferior to stimulus control the first
three weeks on SOL. There was
maintained effect for paradoxical
€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive

intention at four follow-ups (the last at

€jmark, A. Norell-Clarke / Sleep Medicine Reviews xxx (2018) 1e18


17 month). Paradoxical intention
displayed increased SQ at follow-ups.
Fogle & Dyal, 1983 [32] RCT 35, insomnia symptoms, (a) Paradoxical intention: (a e c) 3 weeks, Sleep performance anxiety (8-item Both forms of paradoxical intention led 12
41 y, NR, 6% “Give-up-trying” (GUT) booklets scale), sleep efficiency, morning to larger reduction in sleep
(b) Paradoxical intention: restedness performance anxiety than control. All
“Try-giving-up” (TGU) three groups improved on sleep
(c) Control information efficiency. No follow-up.
Ascher & Turner, 1979 RCT 25, primary insomnia, 39 y, (a) Paradoxical intention (a e b) 4 sessions, Sleep diary (SOL, NAW, restedness, Paradoxical intention resulted in larger 11
[33] 60%, NR (b) Placebo individual format difficulty falling asleep) reduction than the other groups on SOL,
(c) No treatment NAW and difficulty falling asleep at
post-treatment. No follow-up.
Ascher & Turner, 1980 RCT 40, poor sleep, 37 y, NR, NR (a) Paradoxical intention 1 (a e c) 4 sessions, Sleep diary (SOL, NAW, restedness, Paradoxical intention 1 led to larger 8
[34] (b) Paradoxical intention 2 individual format difficulty falling asleep, TST) reduction than no-treatment group on all
(c) Placebo outcomes at post-treatment; paradoxical
(d) No treatment intention 1 displayed larger decrease
than paradoxical intention 2 and placebo
on SOL, NAW and restedness at
post-treatment. No follow-up.
Broomfield & Espie, RCT 34, primary insomnia, 25 y, (a) Paradoxical intention (a e b) 1 session, Sleep diary (SOL, SE, effort to sleep), Paradoxical intention resulted in larger 12
2003 [35] 56%, 6% (b) Monitoring control individual format SAS, SPAQ, actigraphy (SOL, SE) reduction on sleep effort, SAS, and SPAQ
at post-treatment. No follow-up.
Buchanan, 1988 [36] RCT 51, insomnia symptoms, (a) Paradoxical intention (a e b) 3 sessions, Sleep diary (SOL, SE, morning Paradoxical intention led to larger 13
NR, NR, 35% (b) Quasi-desensitization individual format restedness), SPAS reduction than waitlist on sleep
control performance anxiety at post-treatment
(c) Wait-list control and 3-week follow-up.
Gould, 1988 [39] RCT 64, insomnia symptoms, 19 (a) Paradoxical intention (a e c) 6 sessions, Sleep diary (SOL, NAW, TST, SQ, Paradoxical intention resulted in 13
e80 y, 42%, 25% (b) Coping imagery individual format restedness, sleep medication), PSAS, improvements on SOL, TST, restedness
(c) Sleep information STAI, BDI PSAS-C, and BDI. Coping imagery led to
(d) Waitlist control improvements on SOL, PSAS-C, and BDI.
Paradoxical intention and coping
imagery displayed larger improvement
than the other two groups on SOL.
Paradoxical intention, coping imagery
and sleep information resulted in larger
improvement than waitlist on TST,
restedness, and PSAS-C. There were
maintained effects for the active groups
at 3-month follow-up.
(continued on next page)

9
Table 2 (continued )

10
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
Please cite this article in press as: Jansson-Fro

Design Sample: Size, diagnosis, Treatment type Treatment delivery Outcomes Findings Quality
age (M), % female, score
% attrition

Ladouceur & Gros- RCT 27, insomnia symptoms, (a) Paradoxical intention (a e c) 4 sessions, Sleep diary (SOL) Paradoxical intention and stimulus 8
Louis, 1986 [42] 42 y, 67%, NR (b) Stimulus control group format control displayed larger reduction on
(c) Sleep information SOL than the other two groups at post-
(d) Monitoring control treatment and 2-month follow-up.
Paradoxical intention and stimulus
control were equally effective at post-
treatment and follow-up.
Ott et al., 1983 [46] RCT 56, sleep-onset insomnia, (a) Paradoxical intention (a e c) 1 session, Sleep diary (SOL, NAW, SQ, medication), Paradoxical intention resulted in 11
18e55 y, 61%, NR (b) Paradoxical individual format sleep monitoring device (SOL) reduction on subjective and objective
intention þ feedback SOL for the first week and this was
(c) Feedback maintained for the second week.
(d) No treatment Paradoxical intention þ feedback

M. Jansson-Fro
displayed deterioration on subjective
and objective SOL. Feedback only led to
reduction on SOL. No follow-up.
Turner & Ascher, 1979 RCT 50, primary insomnia, 39 y, (a) Paradoxical intention (a e d) 4 sessions, Sleep diary (SOL, NAW, restedness, TST, Paradoxical intention resulted in larger 12
€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive

[47] 50%, NR (b) Stimulus control (c) individual format sleep medication) improvement than placebo and waitlist

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Progressive relaxation on SOL, NAW, restedness, difficulty
(d) Placebo falling asleep, and sleep medication at
(e) Waitlist post-treatment; no difference emerged
between paradoxical intention,
stimulus control, and progressive
relaxation at post-treatment. No
follow-up.
a
Barach, 1982 [62] UCT 28, insomnia symptoms, (a) Paradoxical intention (a) 4 sessions, Sleep diary (11 items), STAI-S, BDI Paradoxical intention resulted in 12
24 y, 70%, 29% individual format reduction on five sleep diary outcomes
(SOL, TST, restedness upon awakening,
use of sleep medication, and difficulty
falling asleep) at post-treatment. There
were maintained improvements at 6-
week follow-up for SOL, restedness
upon awakening, and difficulty falling
asleep.
Pennebaker writing intervention
Harvey & Farrell, 2003 RCT 45, poor sleep, 22e24 y, (a) Pennebaker writing (a e c) 1 session, Sleep diary (SOL) Pennebaker writing intervention led to 12
[41] 45%, 7% intervention individual format larger reduction on SOL than no writing
(b) General writing condition. No follow-up.
(c) No writing
Mooney et al., 2009 RCT 28, primary insomnia, 33 y, (a) Pennebaker writing (a e b) 1 session, Sleep diary (SOL), PSAS-C, mental Pennebaker writing intervention 13
[43] 64%, 4% intervention individual format alertness resulted in larger reduction on mental
(b) Monitoring control alertness at post-treatment. No follow-
up.
Problem solving therapy
Pech & O'Kearney, 2013 RCT 47, insomnia disorder, 34 (a) Behavior (a e b) 1 session BT, Sleep diary (SOL, NAW, WASO, TST, SE, Following full treatment, both groups 17
[54] e45 y, 62%, 15% therapy þ Problem solving group format medication or alcohol), ISI, PSQI, SPSI- improved on SOL, NAW, WASO, TST, SE,
(b) Behavior (a e b) 5 sessions of R:S, DBAS, PSWQ medication or alcohol, ISI, PSQI, number
therapy þ Cognitive PS or CRES, of responders and remitters, SPSI-R:S,
restructuring individual format DBAS, and PSWQ at post-treatment and
1-month follow-up. Behavior
therapy þ Cognitive restructuring
displayed faster reduction on DBAS.
behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
Please cite this article in press as: Jansson-Fro

Reducing clock monitoring


Tang et al., 2007 RCT 30, poor sleepers, 32e37 y, (a) Not monitor clock e (a - b) 1 session, Sleep diary (SOL, pre-sleep worry), Clock monitors were more likely to be 13
[58],a,b 50%, NR poor sleepers individual format actigraphy (SOL) awake due to worry about sleep onset.
(b) Monitor clock e poor Clock monitors displayed longer SOL
sleepers than non-clock monitors (sleep diary
and actigraphy). Clock monitors
overestimated their SOL more than
non-clock monitors. No follow-up.
Reducing sleep misperception
Tang & Harvey, 2004 RCT 42, primary insomnia, 23 (a) Visual feedback: Shown (a - b) 1 session, Sleep diary (SOL, TST), actigraphy (SOL, Visual feedback resulted in larger 13
[56] e25 y, 65%, 5% discrepancy between individual format TST), APSQ reduction on subjective SOL and APSQ
subjective and objective than control group. Subjective TST
sleep estimates increased for both groups. No follow-
(b) Not shown discrepancy up.
Tang & Harvey, 2006 RCT 48, primary insomnia, 29 (a) Visual feedback: Shown (a - b) 1 session, Sleep diary (SOL, TST), actigraphy (SOL, Visual feedback resulted in larger 14
[57] e34 y, 56%, 8% discrepancy between individual format TST), APSQ, ISQ, ISI, sleep perception, reduction on APSQ, ISQ, ISI, and sleep

M. Jansson-Fro
subjective and objective sleep distress distress than verbal feedback. Visual
sleep estimates feedback led to more positive sleep
(b) Verbal feedback about perception. Subjective SOL decreased
€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive

discrepancy and TST increased for both groups. A

€jmark, A. Norell-Clarke / Sleep Medicine Reviews xxx (2018) 1e18


reduced discrepancy was noted
between subjectively- and objectively-
measured SOL and TST for both groups.
No follow-up.
Thought-stopping
Villiotis, 1982 [48] RCT 38, insomnia symptoms, (a) Thought-stopping (a - b) 2 sessions, Sleep diary (SOL, difficulty falling Thought-stopping resulted in larger 11
20 y, 63%, 13% (b) Awareness condition individual format asleep) reduction on SOL and difficulty falling
(c) Monitoring control asleep than the two other groups. No
follow-up.

Note. APSQ ¼ Anxiety and Preoccupation about Sleep Questionnaire, ARS ¼ Analogue Rating Scale (indexing daytime functioning), ASSQ ¼ Anxious Self-Statement Questionnaire, BAI ¼ Beck Anxiety Inventory, BDI ¼ Beck
Depression Inventory, BT-I ¼ behavior therapy for insomnia, CBT-I ¼ cognitive behavior therapy for insomnia, CR ¼ cognitive refocusing, CT-I ¼ cognitive therapy for insomnia, DASS ¼ Depression, Anxiety and Stress Scale,
DBAS ¼ Dysfunctional Beliefs and Attitudes about Sleep scale, ISI ¼ Insomnia Severity Index, ISQ ¼ Insomnia Symptom Questionnaire, MFI ¼ Multidimensional Fatigue Inventory, NR ¼ not reported, NAW ¼ number of
awakenings, PI ¼ paradoxical intention, PICI ¼ Pre-sleep Intrusive Cognitions Inventory, PS ¼ problem solving, PSAS ¼ Pre-Sleep Arousal Scale, PSAS-C ¼ Pre-Sleep Arousal Scale e cognitive subscale, PSAS-S ¼ Pre-Sleep Arousal
Scale e somatic subscale, PSQI ¼ Pittsburgh Sleep Quality Index, PSWQ ¼ Penn State Worry Questionnaire, RCT ¼ randomized controlled trial, SAMI ¼ Sleep Associated Monitoring Index, SAS ¼ Sleep Anxiety Scale, SBRS ¼ Sleep
Behavior Self-Rating Scale-modified, SE ¼ sleep efficiency, SES ¼ SelfeEfficacy Scale, SF-36 ¼ SF-36 Health Survey, SQ ¼ sleep quality, SOL ¼ sleep onset latency, SPAQ ¼ Sleep Performance Anxiety Questionnaire, SPAS ¼ Sleep
Performance Anxiety Scale, SPSI-R:S ¼ Social Problem-Solving InventoryeRevised: Short-Form, SRBQ ¼ Sleep Related Behaviors Questionnaire, SSS ¼ Stanford Sleepiness Scale, STAI ¼ State-Trait Anxiety Inventory, STAI-S ¼
State-Trait Anxiety Inventory-State, TAQ ¼ Trimodal Anxiety Questionnaire, TST ¼ total sleep time, TWT ¼ total wake time, UCT ¼ uncontrolled trial, WASO ¼ wake after sleep onset, WSAS ¼ Work and Social Adjustment Scale,
ZAS ¼ Zung Self-Rating Anxiety Scale, ZDS ¼ Zung Self-Rating Depression Scale.
a
As a portion of the study participants were good sleepers, they were excluded from the current review.
b
Of the two studies that were presented in the paper, one investigation was excluded because it did not test a cognitive component that would be feasible to implement in a therapeutic setting.

11
12 €jmark, A. Norell-Clarke / Sleep Medicine Reviews xxx (2018) 1e18
M. Jansson-Fro

the second investigation [53], CT-I was compared with cognitive instructed to use distraction at bedtime: the first group was asked
behavior therapy (CBT-I) and behavior therapy (BT-I) for those with to employ imagery of a pleasant but non arousing situation and the
insomnia disorder. (The CBT-I consisted of standard behavioral other group was instructed to distract from worries and concerns
techniques plus the treatment content of CT-I). All therapies were but given no instructions on how. (Examples of strategies that the
administered during eight sessions, but CBT-I had slightly longer general distraction group employed included going through the
sessions than CT-I and BT-I. All therapies reduced insomnia severity, day's events, counting, listening to music, or meditating). A third
although CBT-I had a greater effect. There were also more responders group was instructed to follow their usual bedtime routines. The
in CBT-I and BT-I at post-treatment, relative to CT-I. However, there findings indicated that both groups that had used distraction re-
was an increase in the number of responders in CT-I and a decrease in ported a larger reduction on subjective sleep onset latency, relative
responders in BT-I from post-treatment to follow-up. Also, there was to the control group. Also, those who used imagery distraction
a higher rate of remission in CBT-I than in CT-I at post-treatment displayed a greater decrease on thought discomfort than the other
(this was not the case at follow-up), and there was an increase in conditions. To conclude, there is support for distraction as a tech-
the remission rate in CT-I from post-treatment to follow-up. On nique to shorten sleep onset latency but whether the active
sleep diary parameters at post-treatment, BT-I outperformed CT-I on mechanism is, as proposed, engaging one's mind so that distressing
sleep onset latency and wake after sleep onset, and CBT-I and BT-I thoughts will be less likely or the visual thinking itself is unclear.
was superior to CT-I on sleep efficiency. All therapies increased to- A related study found that worrying in images was superior to
tal sleep time. On polysomnography at post-treatment, CBT-I and BT- verbal worry regarding sleep onset when dealing with a stressor
I outperformed CT-I on sleep onset latency and sleep efficiency, and [40]. Participants with primary insomnia were informed at bedtime
BT-I was superior to CBT-I and CT-I on wake after sleep onset. Finally, that they would have to perform a speech in front of a camera the
all therapies reduced dysfunction and mental health problems. The following day. Half of the participants had been given instructions
third study investigated four sessions of standard CBT-I [60] with the on how to worry in images whereas the other half had been
addition of four sessions of CT-I or mindfulness [55]. (The CBT-I instructed on how to worry in verbal thoughts. Although the image
included the cognitive techniques constructive worry and cogni- group reported greater distress and higher arousal after the time
tive restructuring). Both additional treatments after CBT-I were spent worrying before sleep onset, both groups were equally con-
associated with further significant improvements on insomnia cerned about their future speech before they fell asleep. The image
severity, objective and subjective total sleep time, wake after sleep group reported shorter sleep onset latency the night before the
onset, and sleep efficiency but there were no differences between speech and less anxiety about giving the speech during the
the treatments. Together, the results from the three studies suggest following day. Together, the studies suggest that thinking in images
that CT-I with a focus on behavioral experiments leads to improve- may be superior to verbal thinking regarding sleep onset latency.
ments on a plethora of insomnia-related outcomes, and that it adds
further improvements after behavioral insomnia techniques (with Imagery training
or without more traditional cognitive insomnia techniques). A Three investigations have examined imagery training in people
combination of BT-I and CT-I yields stronger effects than either part with sleep-onset or sleep-maintenance insomnia [44,45,49]. In the
alone. Whether this is more or less efficient than the addition of first study [49], four groups (imagery training, imagery training
mindfulness is a question for future research. To conclude, there is combined with muscle tension-release, somatic focusing, and pro-
support for the use of CT-I. gressive relaxation), were compared with a waitlist. All active groups
improved on sleep onset latency and tiredness. The imagery training
Constructive worry conditions were superior to the other three groups on the number of
Two studies have investigated the efficacy of constructive worry awakenings, and on sleep onset latency at follow-up but not post-
in volunteers with insomnia disorder or students with primary treatment. The second investigation compared imagery training
insomnia [30,37]. In the first study [37], constructive worry was with stimulus control and a waitlist condition [44]. The findings
compared with instructions to record worries and complete worry showed that imagery training and stimulus control resulted in sig-
questionnaires. Both interventions consisted of only one session nificant reductions on the number of awakenings at post-treatment
(15 min). Only constructive worry was associated with a significant compared to waitlist. However, stimulus control was superior to
decrease in cognitive pre-sleep arousal after the intervention, and imagery training on decreasing the duration of awakenings at post
this was significantly lower than the comparison group. However, treatment and follow-up, and on depression. There were no differ-
there were no significant differences on other outcomes such as ences between the groups on state and trait anxiety. In the third
state anxiety, and subjective or objective (actigraphy) sleep mea- study [45], imagery training was compared with stimulus control
sures. In the second investigation [30], constructive worry plus and a waitlist condition. Both active treatments had significant re-
behavior therapy (i.e., sleep restriction and stimulus control) was ductions of time awake during the night and use of sleep medication.
compared with behavior therapy only. Both interventions were Although imagery training was associated with a decrease in sleep
administered across four sessions. The results indicated that both onset latency at post treatment, stimulus control was superior. The
interventions produced improvements in total wake time, total reductions in sleep onset latency were maintained at follow-up, at
sleep time, insomnia severity, worry, and dysfunction. The com- which point there was no significant difference between the treat-
bined therapy resulted in significantly larger reductions on ment groups. Stimulus control had superior improvements on total
insomnia severity at mid-treatment, post-treatment and follow-up, sleep time compared to imagery training at post-treatment. Imagery
and more marked improvements on worry at follow-up. Also, the training was not associated with decreases in the number of awak-
combined intervention led to more treatment responders, relative enings, total sleep time, depression or anxiety. To conclude, the re-
to behavioral therapy only. Together, the two studies indicate that sults from the three studies are mixed. Imagery training seem
constructive worry reduces cognitive arousal. The findings on other somewhat superior to various forms of somatic relaxation tech-
outcomes are mixed across the two investigations. niques but (mostly) inferior to stimulus control on sleep outcomes.

Distraction and increased visual imagery Paradoxical intention


One study has investigated distraction as a cognitive component Eleven studies investigated paradoxical intention in those with
for people with insomnia symptoms [61]. Two groups were insomnia symptoms, sleep-onset insomnia or primary insomnia

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M. Jansson-Fro 13

[31e36,39,42,46,47,62]. Overall, the rationale and instructions for was superior to no treatment on all outcomes at post-treatment.
paradoxical intention differ slightly across studies. Also, Type A administration had a better outcome on sleep onset
First, we present studies that have investigated the most com- latency, number of awakenings, and restedness than Type B and
mon form of paradoxical intention administration (type A) [33]. placebo at post-treatment. In a second study, two versions of par-
The type A rationale is based on that sleep-related performance adoxical intention were compared [32]. While half of the partici-
anxiety is likely to result in sleep difficulties, mainly sleep-onset pants were given the performance-anxiety rationale (i.e., Type A),
insomnia. In the type A administration, the patient is instructed the other half was not provided with the Type A rationale but also
to remain awake for as long as possible under sleep-compatible asked to give up all deliberate sleep efforts, without trying to stay
conditions natural for the onset and maintenance of sleep (e.g., awake longer. Compared with a control condition, both types of
lights out) and not to move around or engage in behavior specif- paradoxical intention resulted in larger reductions in sleep per-
ically designed to prevent sleep. In one early study [33], paradoxical formance anxiety. All three groups had improved at a similar rate
intention, placebo and a no-treatment condition were compared. on sleep efficiency. In a later study [39], the Type A rationale was
The findings demonstrated that paradoxical intention was superior used, but the instructions differed compared with other studies.
to the other two groups on sleep onset latency, number of awak- Instead of the previously described Type A instructions, several
enings, and difficulty falling asleep at post-treatment. In a second paradoxical interventions designed to address each of four hy-
investigation [33], the rationale is not specifically stated but ap- pothesized cognitive components of insomnia were used (i.e.,
pears to have been Type A-based (the instructions to the patients recording thoughts, write a summary of the past day's events, and
randomized to paradoxical intention were nevertheless typical for exaggerate the possible consequences of unresolved problems and
Type A). In the study, paradoxical intention, stimulus control, negative consequences of sleep loss). When comparing this version
relaxation, placebo and waitlist conditions were compared. The of paradoxical intention with coping imagery, sleep information,
findings showed that paradoxical intention was superior to the and a waitlist control, paradoxical intention resulted in improve-
waitlist on sleep onset latency, number of awakenings, restedness, ments on two sleep diary measures as well as on pre-sleep arousal
and medication use at post-treatment, but there were no differ- and depression. Also, both paradoxical intention and coping im-
ences on the outcomes when comparing with stimulus control and agery showed larger improvement on sleep onset latency.
relaxation. In a later study [62], paradoxical intention was exam- Compared with the waitlist, the three active conditions had a larger
ined in an uncontrolled study. Paradoxical intention resulted in increase on total sleep time. The improvements for paradoxical
subjective sleep improvements on approximately half of the sleep intention were maintained at the 3-month follow-up. In the fourth
diary measures (e.g., sleep onset latency and total sleep time) and and final study [46], Type B (with and without feedback on the
some of these improvements were maintained at the 6-week participants' sleep onset latency) was compared with feedback only
follow-up. Later, paradoxical intention was compared with quasi- and a no-treatment group. Although paradoxical intention without
desensitization and a waitlist condition in patients who had first feedback resulted in improvements on subjective and objective
been matched according to three variables (i.e., performance anx- sleep onset latency, paradoxical intention with feedback led to
iety, caffeine consumption, and alcohol consumption) and then deterioration on sleep onset latency.
randomized [36]. Paradoxical intention was superior to the waitlist
condition in reducing sleep performance anxiety at post-treatment Pennebaker writing intervention
and follow-up, but no statistical group differences were demon- Two investigations have examined the use of the Pennebaker
strated for the three sleep diary measures at the two time-points. writing intervention in those with poor sleep or primary insomnia
The fifth investigation [42] investigated paradoxical intention, [41,43]. In the first study [41], the Pennebaker writing intervention
stimulus control, sleep information, and a control condition. The was compared with two control conditions: writing about hobbies
findings showed that paradoxical intention and stimulus control and interests in general, and no writing. The only outcome was
resulted in larger reduction on sleep onset latency than the other subjective sleep onset latency. The findings showed that the Pen-
two groups at post-treatment and follow-up; there were no dif- nebaker writing intervention resulted in a larger reduction in sleep
ferences in outcome between paradoxical intention and stimulus onset latency, relative to the no writing group. There was no sig-
control. In a later study [31], paradoxical intention was compared nificant difference compared to the other writing group. In the
with stimulus control, relaxation, placebo and no treatment. The second investigation [43], the Pennebaker writing intervention was
findings showed that paradoxical intention reduced sleep onset compared with instructions to complete questionnaires on worries
latency and increased total sleep time and sleep quality. Also, par- in volunteers with primary insomnia. There was only one signifi-
adoxical intention decreased anxiety, depression, and functional cant difference between the groups: a larger decrease in mental
impairment. The effect of paradoxical intention was shown to be alertness for those who used the Pennebaker writing intervention,
maintained at follow-ups and one measure further improved (sleep but there were no differences regarding sleep onset latency or pre-
quality). In the final investigation [35], paradoxical intention was sleep arousal. To conclude, there is currently mixed support for the
compared with a control condition. Paradoxical intention, relative use of the Pennebaker writing intervention in insomnia.
to the control, was superior in decreasing sleep effort, sleep anxiety,
and sleep performance anxiety at post-treatment. There were, Problem solving
however, no group differences on the remaining sleep diary As there were only one study investigating problem solving in
parameters. insomnia [54], and this study also investigated cognitive restruc-
In four studies, the rationale and/or instructions differed turing, the results for both techniques are displayed under Cogni-
compared with the abovementioned investigations. In the first of tive restructuring.
these studies, the Type A administration was compared with a
version with a different rationale-giving (labeled Type B) [34]. The Reducing clock monitoring
Type B administration is based on the rationale that patients need One investigation examined clock monitoring in relation to
to become aware of anxiety-provoking thoughts, but the specific sleep disturbance [58]. In the study, poor sleepers were asked to
instructions are identical with Type A. In the study [34], Type A and either to monitor or not to monitor the clock while in bed. The
Type B paradoxical intention administration were studied along- findings suggested that clock monitors were more likely to be
side placebo and a no-treatment condition. Type A administration awake because of pre-sleep worry. Also, clock monitors had longer

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


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behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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M. Jansson-Fro

sleep onset latency than non-clock monitors (as indexed by sleep demonstrated to be efficacious in its own right (although possibly
diary and actigraphy). Finally, clock monitors overestimated their inferior to CBT-I in the acute treatment phase) and effective as an
sleep onset latency more than those who did not monitor a clock; adjunct treatment to behavior therapy. Another main finding was
the final finding might be interpreted as a larger sleep misper- that the following components are promising but need further
ception in those who monitored the clock. studies: cognitive refocusing, cognitive restructuring, constructive
worry, problem solving, imagery training, and behavioral experi-
Reducing sleep misperception ments to reduce clock monitoring and sleep misperception. Due to
Two studies examined if behavioral experiments could reduce methodological shortcomings and mixed findings, the effects from
sleep misperception in those with primary insomnia [56,57]. In the the following components are unclear: the cognitive program,
first investigation [56], one group was visually shown the coping imagery, distraction and increased visual imagery, the
discrepancy between subjective (assessed with sleep diary) and Pennebaker writing intervention, and thought stopping. Also,
objective (actigraphy) sleep estimates during one session. The other based on literature that has demonstrated that suppression is
group was not shown the discrepancy. The findings demonstrated associated with psychopathology (i.e., anxiety, depression, and
that only the group who was visually shown the discrepancy dis- eating disorders) [63,64], it should be emphasized that the clinical
played a reduction in subjective sleep onset latency, thereby indi- benefits of thought stopping in insomnia disorder should be
cating a decrease in sleep misperception. The shown-discrepancy questioned.
group also reported a reduction on sleep-related worry, a finding
not paralleled in the control group. Both groups displayed an in- Methodological considerations and quality of evidence
crease in subjective total sleep time. There were no significant
changes for the two groups on actigraphy estimates. In the second The designs varied between the included studies. The majority
study [57], a similar methodological approach was used as in Tang of investigations were RCTs or experimentally-oriented studies, but
and Harvey [56] in that one group was visually shown the three were uncontrolled investigations [20,59,62] which makes it
discrepancy between subjective and objective sleep estimates possible that the observed effects in these studies might be due to
during one session. In the second study, however, the control group uncontrolled factors, such as therapist contact and spontaneous
was given verbal feedback about the discrepancy between subjec- recovery. On the other hand, all three components that were
tive and objective sleep estimates. The results showed that only the investigated through uncontrolled studies (i.e., paradoxical inten-
group who was visually shown the discrepancy displayed a tion, cognitive therapy, and cognitive refocusing) had also been
reduction in sleep-related worry, insomnia symptoms, insomnia examined in several RCTs with positive results. Nevertheless, it is
severity, and sleep distress. Also, the shown-discrepancy group had important to bear in mind that uncontrolled trials likely exaggerate
a larger decrease in sleep misperception, relative to the control the efficacy of a therapeutic intervention [65], and that well-
group. As in the study by Tang and Harvey [56], there was no sig- designed RCTs provide more robust estimates of effect. Another
nificant changes for the groups on objective sleep estimates. design-related issue concerning the identified studies was that few
investigations used a placebo condition to control for non-specific
Thought stopping factors (e.g., therapist contact and reasonable rationale for the
In one study, thought stopping was examined in a RCT among cognitive component) and consisting only of treatment elements
participants with insomnia symptoms [48]. Compared with two without demonstrated efficacy for insomnia disorder [31,33,34,47].
control conditions, thought stopping was more effective in Of note is that all the four studies employing a placebo component
reducing the two outcomes sleep onset latency and perceived dif- evaluated the efficacy of paradoxical intention. Though ethical
ficulty falling asleep. concerns and the lack of rigorously-developed placebo conditions
might hamper the use of such conditions in research on insomnia
Discussion disorder, the reviewed research field would benefit from being able
to minimize possible placebo effects in statistical analyses.
Summary of main results A common methodological issue with the analyzed studies was
the small sample sizes. Out of the studies that included control
The aim was to review the empirical evidence regarding conditions, there were on average 17.0 (SD ¼ 10.4) patients per
cognitive components and cognitive therapies of CBT-I. The treatment arm. Studies failing to demonstrate any significant dif-
included studies investigated a number of cognitive single- ferences between treatment arms on specific insomnia symptoms
components (i.e., cognitive refocusing, cognitive restructuring, or severity (e.g. SOL or the ISI) had an average of 14.9 (SD ¼ 4.5)
constructive worry, distraction and increased visual imagery, im- patients per treatment arm whereas studies that did find differ-
agery training, paradoxical intention, the Pennebaker writing ences had 18.9 (SD ¼ 13.7) participants per arm. Thus, Type 2 errors
intervention, problem solving, interventions to reduce clock are likely, especially when active treatments were compared. Only
monitoring and sleep misperception, and thought stopping), a three studies reported power calculations prior to trial start
multi-component cognitive program, and cognitive therapy. [43,52,53].
Although the theoretical framework and content of the compo- The patient characteristics were rather homogeneous and more
nents and therapies were often distinct, it should be noted some so for older studies than newer ones. Remarkably, only eleven in-
components were similar (e.g., cognitive refocusing and imagery vestigations included participants with insomnia disorder, i.e. pri-
training). As such, it is difficult to view all of these interventions as mary, secondary, or comorbid insomnia [20,30,40,45,51,53e57,59].
separate treatment components. The participants in the remaining studies were categorized as
Based on the sheer number of investigations, the methodolog- having insomnia symptoms or poor sleep. Of note is that all eleven
ical quality of studies, and the consistency of results, one main studies that included patients with insomnia disorder demon-
finding was that there is support for paradoxical intention and strated improvements on at least one insomnia symptom, whereas
cognitive therapy. Both interventions have been evaluated with four studies that tested cognitive components on participants with
positive results among patients with insomnia disorder in RCTs. subclinical insomnia failed to do so. It is possible that patients with
Paradoxical intention has been shown to outperform placebo and clinical insomnia might benefit more from cognitive components,
passive control conditions. Cognitive therapy has been although the negative findings in some studies may have been

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


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behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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M. Jansson-Fro 15

influenced by multiple factors (e.g., sample size and type of one month [30,38]. The absence of follow-ups with reasonable
outcome). A recommendation for future research is therefore to length for approximately half of the studies makes conclusions
focus more strongly on patients with insomnia disorder. It is also difficult to draw regarding the long-term benefits for several of the
noteworthy that most early studies (1980e2000) only included components included in this review; this appears particularly
patients with sleep onset insomnia. As such, the effects from evident for cognitive refocusing, constructive worry, distraction,
several cognitive components (e.g., coping imagery) on sleep increased visual imagery, the Pennebaker writing intervention,
maintenance insomnia and early awakenings are unknown. Also, reducing clock monitoring and sleep misperception, and thought
most studies to date have excluded participants with comorbid stopping. On the other hand, long-term follow-ups have been used
problems, although in reality comorbid problems such as psychi- in studies investigating the cognitive program, cognitive restruc-
atric diagnoses or chronic pain are more common than “pure” turing, cognitive therapy, coping imagery, imagery training, para-
insomnia [66]. The effects from cognitive interventions on more doxical intention, and problem-solving; though not a sign of
complicated patients are largely unknown but it should be noted efficacy in itself, those components and therapies have at least been
that some studies that have included patients with anxiety di- investigated over longer periods of time.
agnoses have demonstrated large effects on insomnia, albeit with As a final note, it is important to mention that the quality
extended treatment durations (e.g., 19). The needed duration or assessment demonstrated that the quality of the studies can be
dose may need to be adjusted in case of comorbidities. viewed as moderate on average (mean: 13.1 points). However, for
Study attrition varied greatly across studies. About one fifth of several cognitive components, none of the studies examining those
the investigations did not report attrition. Among those papers that interventions exceeded the quality score mean; this was apparent
did report attrition rates, a majority of investigations reported a for the cognitive program, coping imagery, distraction, increasing
relatively small percentage (0e19%), while five investigations had a visual imagery, the Pennebaker writing intervention, reducing
percentage of dropouts larger than 20% [36,38,39,44,62]. De- clock monitoring, and thought stopping. It should also be pointed
scriptions of attrition in the five studies with more than 20% out that the quality scores for studies evaluating paradoxical
dropouts were that participants stopped their study participation intention were limited (range 8e13 points), possibly due to that the
during the treatment phase, that they started using medications reporting standards in the 1970's and 1980's were not as formalized
during the study period (an exclusion criterion in some trials), that as they are now. Thus, due to the restricted quality scores for par-
they disliked treatment, or that they reported an illness or need for adoxical intention, we believe that it is reasonable to regard para-
surgery during the study period. doxical intention as resulting in positive effects but that these
Another issue of methodological diversity regards the differ- improvements should be viewed in light of the extant studies with
ences in dosage, as the treatment lengths ranged between one and low-to-moderate quality. Finally, the quality of four studies were
14 sessions (M ¼ 3.4) (for an exception see [20], and individual rated as high (i.e., 75% of the maximum score or more) [52e55].
sessions lasted between 15 and 75 min. Hypothetically, it could be This implies that a few cognitive components and therapies have
suspected that longer treatments are more efficacious, at least for been examined in well-designed studies and enables stronger
some components that takes time and effort to implement and that conclusions. As a result of the well-designed investigations, stron-
leads to gradual improvement over longer periods of time. It should ger conclusions can be drawn particularly for cognitive therapy
also be noted that a relatively large part of the identified studies [53,55]. Though two additional studies were rated as with high
administered the components or therapies at only one session; quality, stronger conclusions are limited for 1) cognitive restruc-
future research might focus on determining the optimal dose of turing and problem-solving by being examined in only study and
sessions per component or therapy to reach full efficacy. Related to without a comparison group (e.g., waitlist or placebo condition)
treatment length is type of treatment delivery. In this review, most [54] and 2) cognitive refocusing by being explored among partici-
studies used an individual treatment format (81%), whereas the pants with subclinical insomnia (i.e., insomnia symptoms), with no
remaining investigations administered the components or thera- follow-up assessment, and the somewhat mixed evidence across
pies as group format or self-help formats. Since we did not quan- the three studies investigating cognitive refocusing.
titatively determine the efficacy overall, we are unable to assess
potential, differential efficacy from various forms of treatment Putative mechanisms
format. Previous evidence on CBT-I at least support the notion that
group and self-help formats are efficacious in their own right If cognitive components and therapies lead to improvement in
[67,68]. insomnia symptomatology, it will be vital to investigate the
An inclusion criterion for the current review was that studies mechanisms through which this occurs. As stated above, roughly
must report insomnia-related outcomes (i.e., nighttime and/or half of the included studies (k ¼ 19) included measures of cognitive
daytime symptomatology). Whereas many investigations did processes. Based on the nineteen studies, evidence indicates that
assess nighttime symptoms, usually with a sleep diary, or global the reduction of the following processes might act as possible
symptoms (e.g. with the ISI), fewer studies examined daytime mechanisms: 1) intrusive cognitions for the cognitive program [51],
symptomatology. There were also investigations that used a very 2) problem-solving ability, unhelpful beliefs about sleep, and worry
limited number of outcomes [41,42,48]. A related limitation was for cognitive restructuring and problem-solving [54], 3) unhelpful
that only nineteen studies (59%) reported on the cognitive pro- beliefs about sleep, worry, cognitive pre-sleep arousal, attentional
cesses that the component or therapy was intended to reverse bias and monitoring, and safety behaviors for cognitive therapy
[20,30,32,35e40,43,49,51,52,54,56e59,61]. Though efficacy on [20], 4) cognitive pre-sleep arousal and worry for constructive
insomnia symptomatology is crucial to demonstrate, it is also worry [30,37], 5) pre-sleep arousal for coping imagery [39], 6)
important to show that the cognitive intervention has an impact on thought discomfort for distraction [61], 7) resolution for increased
the proposed cognitive processes (e.g., reduction on performance visual imagery [40], 8) sleep effort, sleep performance anxiety, and
anxiety for paradoxical intention and worry for cognitive therapy). mental alertness for paradoxical intention [32,35,36,39,43], 1) pre-
The length of assessment varied greatly across studies. In total, sleep worry for reducing clock monitoring [58], and j) worry for
only fifteen studies (47%) assessed efficacy at follow-ups decreasing sleep misperception. It is however important to note
[20,30,31,36,38,39,42,44,45,49,51,53,54,55,59,62]. Also, in two that all nineteen investigations analyzed the cognitive processes as
studies, the length of the follow-up period was limited to less than outcomes and not as mediators, thereby limiting the possibility to

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


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behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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M. Jansson-Fro

draw strong conclusion concerning putative mechanisms [69]. It is this review analyzed cognitive processes purely as outcomes, it is
also important to emphasize that some studies failed to show that vital to move the field forward towards a focus on mediational
cognitive processes were modified following treatment: pre-sleep analyses. This would pave way for evidence-based explanations for
arousal for cognitive refocusing [38,52,59] and difficulty control- how or why cognitive components and therapies produce change
ling intrusive thoughts for imagery training [49]. In a recent study, [70]. The exploration of moderators is another area for scrutiny
cognitive mediators were analyzed for CT-I and BT-I [17]. The [69]. On a conceptual level, moderators identify on whom and
findings showed that worry, unhelpful beliefs, and monitoring for under what circumstances treatments have different effects. In
sleep-related threat mediated outcomes for both CT-I and BT-I. It is relation to this review, it is possible that socioedemographic pa-
thus possible that cognitive processes are important treatment rameters, symptomatic burden, or cognitive processes moderate
targets not only for cognitive components but also for more the efficacy of cognitive components and therapies.
behaviorally-oriented interventions. On the basis of these findings,
it seems apparent that cognitive processes are often modified as Conclusions
expected through cognitive components and therapies. Whether or
not these processes work as mechanisms of change is, however, We conclude that there is support for a few components and
mainly unknown. therapies for patients with insomnia disorder. More specifically,
evidence suggest that paradoxical intention and cognitive therapy
Limitations of the current review appears efficacious in their own right. There are also other
cognitive components that appears promising. Although that the
There are a number of methodological limitations in the current research field has grown substantially over the past decade,
review. First, the included studies displayed high levels of clinical several methodological limitations hamper the possibility to draw
(e.g., diagnosis vs poor sleep) and methodological (e.g., design, strong conclusions. Based on that several cognitive components
outcome measures, and interventions) diversity. Thus, the current and therapies seems efficacious and promising, future research is
review is limited by this diversity, and our conclusions should needed to gain insight into their efficacy, mechanisms of change,
therefore be interpreted with caution. Second, due to a small and moderators.
number of studies per cognitive component or therapy, we did not
perform a quantitative assessment of efficacy (i.e., a meta-analysis).
A possible exception to this rationale is paradoxical intention, for
which eleven studies were identified in the search process. Third, Practice points
the current review did not formally assess treatment-relevant do-
mains in the included studies that might have importance for the  There is evidence of efficacy for two cognitive compo-
interpretation of findings. For example, the examined components nents and therapies: paradoxical intention and cognitive
and therapies might differ in terms of acceptability, adherence therapy. Both paradoxical intention and cognitive therapy
rates, credibility and expectancy ratings, adverse events, and (as formulated by Allison G. Harvey) have been validated
perceived usefulness. Finally, regarding the study quality assess- in several trials but are not integrated in current CBT-I.
ment, it should be emphasized that the majority of the eleven  Several other cognitive components and therapies are
assessed domains concerned elements of study reporting (e.g., promising but there is a need of more robust studies
randomization procedure clearly described). Since fewer study before more firm conclusions can be drawn.
quality items were directly related to design characteristics (e.g.,  The most commonly used cognitive CBT-I component,
sample size justified), a potential risk with our quality assessment is cognitive restructuring, has been scarcely investigated.
that scores for less well-designed studies might have been inflated  Until there are more studies, we recommend the use of
in relation to more well-designed investigations. CBT-I manuals whose efficacy have been evaluated or
include sufficiently evaluated cognitive components.
Future directions

There are several areas that need further scientific scrutiny.


Methodologically more robust study designs when investigating Research agenda
cognitive components and therapies are warranted. Specifically,
attempts to compare several active treatments needs to be pre- Future research should aim to:
ceded by power calculations. Further, investigations should aim to
assess efficacy on a broad set of outcomes, such as sleep diaries,  Compare the effects of cognitive techniques in sufficiently
insomnia-related measures, and putative mechanisms of change. statistically powered RCTs with follow-up assessments
Future studies should also aim to assess treatment-relevant do- and test various doses and delivery formats of the
mains, such as acceptability, adherence rates, and adverse events. components.
Another similar area for future research is using dismantling de-  Test the effects of cognitive interventions on sleep diaries,
signs to examine the unique as well as the synergetic effects of insomnia measures, and putative mechanisms of change.
cognitive techniques combined with behavioral techniques in CBT-  Dismantle the cognitive techniques in commonly used
I. The potential benefits to clinical practice of dismantling designs is CBT-I packages so that the unique as well as the syner-
the identification of the necessary and sufficient components of getic effects of cognitive components combined with
treatment, thereby providing important insight into how insomnia behavioral techniques can be established.
could be managed more effectively. Finally, studies are needed that  Investigate whether several factors (e.g., socio
explore the optimal dose of cognitive components and therapies edemographic parameters, insomnia disorder versus
and possible differential effects for various treatment formats (e.g., comorbid insomnia versus subclinical insomnia, and
individual vs group format). global symptomatic burden) moderate the efficacy of
Two final important areas for future research are putative cognitive components and therapies.
mechanisms (mediators) and moderators. As all investigations in

€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


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behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001
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M. Jansson-Fro 17

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olinska Institute Library (Klas Moberg and Carl Gornitzki) for car- [21] Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psy-
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2005;114(1):96e110.
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€ jmark M, Norell-Clarke A, The cognitive treatment components and therapies of cognitive


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behavioral therapy for insomnia: A systematic review, Sleep Medicine Reviews (2018), https://doi.org/10.1016/j.smrv.2018.05.001