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The association between sleep-related cognitions, psychological flexibility, and insomnia symptoms


The cognitive-behavioral model of insomnia proposes that arousal, cognitions, behaviors, and perceived consequences play an important role in maintaining insomnia symptoms. The metacognitive model of insomnia expands this idea by defining cognitive activity as primary arousal and how one interprets those thoughts as a secondary arousal. Because primary and secondary processes mutually influence each other, the content of maladaptive sleep-related thoughts can impact the maintenance of insomnia disorder more strongly if one is rigidly attached to them.


To investigate if psychological inflexibility moderates the relationship between dysfunctional beliefs about sleep and insomnia severity.


Data were collected from online surveys responded by 642 adults, aged 18 to 59 years, who reported experiencing insomnia symptoms. Participants completed self-report questionnaires, including, Hospital Anxiety and Depression Scale (HADS), Insomnia Severity Scale (ISI), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16) and Acceptance and Action Questionnaire (AAQ-II). A linear model (estimated using OLS) was fitted to predict ISI scores from DBAS-16 and AAQ-II with age, sex and HADS subscales as covariates. An interaction term was added between DBAS-16 and AAQ-II.


All continuous parameters were standardized prior to data analysis. Mean age was 38.6 ± 10.4 years. The results of the regression indicated that the model significantly predicted insomnia severity (F(7, 634) = 42.95, p < .001, R2adj = 0.314), accounting for 31,4% of the variance. The effect of Anxiety was a significant positive predictor of ISI scores (β = 0.15, 95% CI [0.06, 0.25], t(634) = 3.30, p = 0.001), as were DBAS-16 (β = 0.40, 95% CI [0.32, 0.47], t(634) = 10.51, p < 0.001) and AAQ-II (β = 0.12, 95% CI [0.02, 0.22], t(634) = 2.39, p = 0.017). There was a significant and positive interaction effect between DBAS-16 and AAQ-II (β = 0.001, 95% CI [0.0001, 0.002], t(634) = 2.20, p = 0.028), such that DBAS-16 slope predicting ISI scores became significantly more positive with greater scores on AAQ-II.


Insomnia severity scores were influenced by higher scores on anxiety, dysfunctional beliefs about sleep and psychological inflexibility. Although very small, the significant interaction effect indicates that the prediction effect of dysfunctional beliefs about sleep may become more positive for additional levels of psychological inflexibility.


Insomnia, Sleep-related cognitions, Psychological flexibility


Área Clínica


Universidade de São Paulo - São Paulo - Brasil


Marwin Machay Indio Brasil Carmo, Renatha El Rafihi-Ferreira