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Cognitive Behavioural Therapy for Insomnia: How, for Whom and What about Acceptance?
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.ORCID iD: 0000-0002-3075-4861
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Sleep is essential for survival but a significant minority of the adult population are dissatisfied with their sleep, and 6-10% meet the criteria for insomnia disorder, characterised by difficulties falling asleep at bedtime, waking up in the middle of the night or too early in the morning, and daytime symptoms. Cognitive behavioural therapy for insomnia (CBT-I), an evidence-based sleep-focused intervention, has been suggested as the treatment of choice for chronic insomnia. However, access to specialised sleep therapists is sparse, and a service delivery model based on the principles of ‘stepped care’ has been proposed. Even though CBT-I is shown to be effective, there is a need to continue the development of cognitive behavioural treatments for insomnia. As a complement to traditional interventions, the potential value of acceptance, that is, to make an active choice of openness towards psychological experiences, has been recognized. However, it has not yet been systematically investigated, and specific instruments for studying acceptance in insomnia are lacking.

The present thesis is based on three studies: Study I showed that manual-guided CBT for insomnia delivered by ordinary primary care personnel has a significant effect on perceived insomnia severity, sleep onset latency and wake time after sleep onset. Study II demonstrated that non-responders in Study I reported shorter sleep time at baseline than did responders, a notion that may help select patients for this type of low-end intervention in a stepped care treatment approach. Study III aimed to develop a new assessment instrument for studying acceptance of insomnia, the Sleep Problem Acceptance Questionnaire (SPAQ), resulting in an eight-item questionnaire with two factors; the first being Activity Engagement, persisting with normal activities even when sleep is unsatisfactory, and the second involving Willingness, avoiding fighting and trying to control sleep problems.

In conclusion, the present thesis demonstrates that it is feasible to treat patients with insomnia using CBT-I administrated by ordinary primary care personnel in general practice, and that those with relatively longer initial sleep duration benefit most from treatment, enabling allocation to relevant treatment intensity. In addition, acceptance of sleep difficulties may be quantified using the SPAQ.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 43 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences, ISSN 1652-9030 ; 113
Keyword [en]
Insomnia, cognitive behavioural therapy, sleep, primary care, stepped care, questionnaire, acceptance
National Category
Applied Psychology
Research subject
URN: urn:nbn:se:uu:diva-259605ISBN: 978-91-554-9297-7OAI: diva2:844969
Public defence
2015-09-25, Auditorium Minus, Gustavianum, Akademigatan 3, Uppsala, 10:15 (Swedish)
Available from: 2015-09-02 Created: 2015-08-10 Last updated: 2016-07-20
List of papers
1. Manual-guided cognitive-behavioural therapy for insomnia delivered by ordinary primary care personnel in general medical practice: a randomized controlled effectiveness trial
Open this publication in new window or tab >>Manual-guided cognitive-behavioural therapy for insomnia delivered by ordinary primary care personnel in general medical practice: a randomized controlled effectiveness trial
2013 (English)In: Journal of Sleep Research, ISSN 0962-1105, E-ISSN 1365-2869, Vol. 22, no 6, 688-696 p.Article in journal (Refereed) Published
Abstract [en]

Chronic insomnia is a prevalent problem in primary health care and tends to be more serious than insomnia in the general population. These patients often obtain little benefit from hypnotics, and are frequently open to exploring various options for medical treatment. However, most general practitioners (GPs) are unable to provide such options. Several meta-analyses have shown that cognitive-behavioural therapy (CBT) for insomnia results in solid improvements on sleep parameters, and a few studies have demonstrated promising results for nurse-administered CBT in primary care. The aim of this randomized controlled study was to investigate the clinical effectiveness of manual-guided CBT for insomnia delivered by ordinary primary care personnel in general medical practice with unselected patients. Sixty-six primary care patients with insomnia were randomized to CBT or a waiting-list control group. The CBT group improved significantly more than the control group using the Insomnia Severity Index as the outcome. The effect size was high. Sleep diaries showed a significant, medium-sized treatment effect for sleep onset latency and wake time after sleep onset. However, for all measures there is a marked deterioration at follow-up assessments. Almost half of the treated subjects (47%) reported a clinically relevant treatment effect directly after treatment. It is concluded that this way of delivering treatment may be cost-effective.

cognitive-behavioural therapy, non-pharmacological, sleep disorder, treatment
National Category
Medical and Health Sciences
urn:nbn:se:uu:diva-212305 (URN)10.1111/jsr.12067 (DOI)000326884000012 ()
Available from: 2013-12-10 Created: 2013-12-09 Last updated: 2015-10-01Bibliographically approved
2. Initial Sleep Time Predicts Success in Manual-Guided Cognitive Behavioral Therapy for Insomnia
Open this publication in new window or tab >>Initial Sleep Time Predicts Success in Manual-Guided Cognitive Behavioral Therapy for Insomnia
Show others...
2016 (English)In: Behavioural Sleep Medicine, ISSN 1540-2002, E-ISSN 1540-2010, Vol. 14, no 4, 378-388 p.Article in journal (Refereed) Published
Abstract [en]

Cognitive behavioral therapy produces significant and long-lasting improvement for individuals with insomnia, but treatment resources are scarce. A "stepped care" approach has therefore been proposed, but knowledge is limited on how to best allocate patients to different treatment steps. In this study, 66 primary-care patients with insomnia attended a low-end treatment step: manual-guided cognitive behavioral therapy (CBT) for insomnia delivered by ordinary primary-care personnel. Based on clinically significant treatment effects, subjects were grouped into treatment responders or nonresponders. Baseline data were analyzed to identify predictors for treatment success. Long total sleep time at baseline assessment was the only statistically significant predictor for becoming a responder, and sleep time may thus be important to consider before enrolling patients in low-end treatments.

National Category
Neurology Psychiatry
urn:nbn:se:uu:diva-266762 (URN)10.1080/15402002.2015.1007995 (DOI)000374971100003 ()26323054 (PubMedID)
Available from: 2015-11-10 Created: 2015-11-10 Last updated: 2016-07-20Bibliographically approved
3. Measuring Acceptance of Sleep Difficulties: The Development of the Sleep Problem Acceptance Questionnaire
Open this publication in new window or tab >>Measuring Acceptance of Sleep Difficulties: The Development of the Sleep Problem Acceptance Questionnaire
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2015 (English)In: Sleep, ISSN 0161-8105, E-ISSN 1550-9109, Vol. 38, no 11, 1815-1822 p.Article in journal (Refereed) Published
Abstract [en]

Study Objectives: Acceptance may be an important therapeutic process in sleep medicine, but valid psychometric instruments measuring acceptance related to sleep difficulties are lacking. The purpose of this study was to develop a measure of acceptance in insomnia, and to examine its factor structure as well as construct validity. Design: In a cross-sectional design, a principal component analysis for item reduction was conducted on a first sample (A) and a confirmatory factor analysis on a second sample (B). Construct validity was tested on a combined sample (C). Setting: Questionnaire items were derived from a measure of acceptance in chronic pain, and data were gathered through screening or available from pretreatment assessments in four insomnia treatment trials, administered online, via bibliotherapy and in primary care. Participants: Adults with insomnia: 372 in sample A and 215 in sample B. Sample C (n = 820) included sample A and B with another 233 participants added. Measures: Construct validity was assessed through relations with established acceptance and sleep scales. Results: The principal component analysis presented a two-factor solution with eight items, explaining 65.9% of the total variance. The confirmatory factor analysis supported the solution. Acceptance of sleep problems was more closely related to subjective symptoms and consequences of insomnia than to diary description of sleep, or to acceptance of general private events. Conclusions: The Sleep Problem Acceptance Questionnaire (SPAQ), containing the subscales "Activity Engagement" and "Willingness", is a valid tool to assess acceptance of insomnia.

acceptance; experiential avoidance; insomnia; principal component analysis; psychometric evaluation; scale construction; Sleep Problem Acceptance Questionnaire; willingness
National Category
Applied Psychology
urn:nbn:se:uu:diva-259064 (URN)10.5665/sleep.5170 (DOI)000363740100021 ()
Available from: 2015-07-25 Created: 2015-07-25 Last updated: 2015-12-04Bibliographically approved

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