Presleep Cognitive Activity and Thought Control Strategies in Insomnia

Abstract

The aim of this study was to examine presleep cognitive activity and thought control strategies used by individuals with insomnia, with and without comorbid generalized anxiety disorder (GAD), and by good sleepers. Fifty participants were divided into the following comparison groups: (a) individuals with insomnia alone (n = 14), (b) individuals with insomnia and comorbid GAD (n = 16), and (c) good sleepers (n = 20). Participants completed a standardized evaluation including interviews and questionnaires on insomnia, anxiety, presleep cognitive activity, and thought control strategies. Results showed that individuals with insomnia and comorbid GAD reported greater presleep cognitive arousal than individuals with insomnia alone, who in turn reported greater cognitive arousal than good sleepers. Results also showed that individuals with insomnia and comorbid GAD used avoidance as a mean of controlling disturbing presleep cognitions more frequently than the other two groups. Both groups of individuals with insomnia evaluated their presleep thought control strategies as being less effective than good sleepers did. These results support the assertion that higher presleep cognitive arousal plays a role in insomnia and, by distinguishing individuals with insomnia alone (i.e., without comorbid anxiety disorders) from individuals with comorbid GAD, this study further suggests that higher cognitive arousal in individuals with insomnia is not necessarily accounted for by high rates of comorbidity between insomnia and GAD. The main clinical implication of these findings is that the evaluation and treatment of insomnia should consider these cognitive features in order to optimize outcome. Keywords: insomnia; cognitive arousal; thought control strategies; avoidance Cognitive activity has been hypothesized to play an important role in the development and maintenance of insomnia (Borkovec, 1982; Harvey, 2002; Morin, 1993). Experimental manipulations of presleep cognitive activity have shown that higher levels of cognitive activity increase sleep-onset latency in otherwise good sleepers (Ansfield, Wegner, & Bowser, 1996; Gross & Borkovec, 1982; Haynes, Adams, & Franzen, 1981; Tang & Harvey, 2004). Furthermore, individuals with insomnia are more likely to attribute their sleep difficulties to presleep activities involving greater cognitive arousal, such as planning and reappraisal, than to somatic factors such as sweating and palpitations (Lichstein & Rosenthal, 1980). Individuals with insomnia also tend to evaluate their cognitions as more intrusive, unpleasant, negative, worrisome and hard to dismiss, than good sleepers do (Borkovec, Lane, & VanOot, 1981; Harvey, 2000, 2001; Kuisk, Bertelson, & Walsh, 1989). Studies on thought control strategies conducted with nonclinical samples have suggested that avoidance was one of the most frequently used coping strategies to eliminate intrusive thoughts (Freeston, Ladouceur, Provencher, & Biais, 1995; Freeston, Ladouceur, Thibodeau, & Gagnon, 1991). Although it produces an immediate relief, avoidance remains an ineffective and maladaptive long-term strategy compared to problem-solving strategies (Suis & Fletcher, 1985). A number of studies have shown that trying to eliminate thoughts from consciousness may paradoxically increase the frequency of these thoughts during the suppression period (enhancement effect; Trinder & Salkovskis, 1994), or after the attempts to suppress (rebound effect; Clark, Ball, & Pape, 1991; Wegner, 1989), and tend to make them even more intrusive. In many instances, worry and anxiety have been shown to increase intrusive thoughts (Freeston, Dugas, & Ladouceur, 1996; York, Borkovec, Vasey, & Stern, 1987). Individuals with anxiety disorders are known to have more intrusive thoughts (not necessarily at bedtime) and more difficulty coping with them than nonanxious individuals (Borkovec, Shadic, & Hopkins, 1991; York et al. …