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  • 1. Danielsson, Katarina
    et al.
    Jansson Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Broman, Jan-Erik
    Markström, Agneta
    Cognitive Behavioral Therapy as an Adjunct Treatment to Light Therapy for Delayed Sleep Phase Disorder in Young Adults: A Randomized Controlled Feasibility Study2016In: Behavioral Sleep Medicine, ISSN 1540-2002, Vol. 14, no 2, p. 212-232Article in journal (Refereed)
    Abstract [en]

    Delayed sleep phase disorder (DSPD) is common among young people, but there is still no evidence-based treatment available. In the present study, the feasibility of cognitive behavioral therapy (CBT) was evaluated as an additive treatment to light therapy (LT) in DSPD. A randomized controlled trial with participants aged 16 to 26 years received LT for two weeks followed by either four weeks of CBT or no treatment (NT). LT advanced sleep-wake rhythm in both groups. Comparing LT+CBT with LT+NT, no significant group differences were observed in the primary endpoints. Although anxiety and depression scores were low at pretreatment, they decreased significantly more in LT+CBT compared to LT+NT. The results are discussed and some suggestions are given for further studies.

  • 2. Danielsson, Katarina
    et al.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Broman, Jan-Erik
    Markström, Agneta
    Light Therapy With Scheduled Rise Times in Young Adults With Delayed Sleep Phase Disorder: Therapeutic Outcomes and Possible Predictors2018In: Behavioural Sleep Medicine, ISSN 1540-2002, E-ISSN 1540-2010, Vol. 16, no 4, p. 325-336Article in journal (Refereed)
    Abstract [en]

    Clinical trials with light therapy (LT) for delayed sleep phase disorder (DSPD) are sparse and little is known about factors that are favorable for improvements. In this study, LT with scheduled rise times was conducted at home for 14 days by 44 participants with DSPD aged 16-26 years. Primary outcomes were sleep onset and sleep offset. Potential predictors were demographic characteristics, chronotype, dim light melatonin onset, the number of days the LT lamp was used, the daily duration of LT, daytime sleepiness, anxiety, depression, worry, and rumination. Significant advances were observed in sleep onset and sleep offset from baseline to the end of treatment. The number of days of LT predicted earlier sleep onset and sleep offset.

  • 3. Danielsson, Katarina
    et al.
    Markström, Agneta
    Broman, Jan-Erik
    von Knorring, Lars
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Delayed sleep phase disorder in a Swedish cohort of adolescents and young adults: Prevalence and associated factors2016In: Chronobiology International, ISSN 0742-0528, E-ISSN 1525-6073, Vol. 33, no 10, p. 1331-1339Article in journal (Refereed)
    Abstract [en]

    A delayed sleep-wake and circadian rhythm often occurs during puberty. While some individuals only develop a delayed sleep phase (DSP), others will fulfill the criteria for the diagnosis of delayed sleep phase disorder (DSPD). All previous studies have however not separated DSP from DSPD, and, as a result, the prevalence and associated factors are largely unknown for the two conditions individually. We estimated the prevalence of DSP and DSPD in a Swedish cohort of adolescents and young adults. We also investigated associated factors in the two conditions relative to each other and individuals with no DSP. A questionnaire regarding sleep patterns, demographics, substance use/abuse and symptoms of depression, anxiety, worry and rumination was sent to 1000 randomly selected participants (16-26 years of age) in Uppsala, Sweden (response rate = 68%). DSP was defined as a late sleep onset and a preferred late wake-up time. The DSPD diagnosis was further operationalized according to the Diagnostic and Statistical Manual of Mental Disorders, Edition 5 (DSM-5) criteria including insomnia or excessive sleepiness, distress or dysfunction caused by the DSP and that the sleep problem had been evident for 3 months. DSP occurred at a frequency of 4.6% and DSPD at a frequency of 4% in the investigated cohort. DSP was more common in males and was associated with not attending educational activity or work, having shift work, nicotine and alcohol use and less rumination. DSPD was equally common in males and females and was associated with not attending educational activity or work and with elevated levels of anxiety. Both DSP and DSPD appear to be common in adolescents and young adults in this Swedish cohort. No educational activity or work was associated with both DSP and DSPD. However, there were also apparent differences between the two groups in shift work, substance use and mental health, relative to persons with no DSP. Thus, it seems reasonable to assess DSP and DSPD as distinct entities in future studies.

  • 4. Danielsson, Nanette S.
    et al.
    Harvey, Allison G.
    MacDonald, Shane
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Linton, Steven J.
    Sleep Disturbance and Depressive Symptoms in Adolescence: The Role of Catastrophic Worry2013In: Journal of Youth and Adolescence, ISSN 0047-2891, E-ISSN 1573-6601, Vol. 42, no 8, p. 1223-1233Article in journal (Refereed)
    Abstract [en]

    Depression is a common and debilitating disorder in adolescence. Sleep disturbances and depression often co-occur with sleep disturbances frequently preceding depression. The current study investigated whether catastrophic worry, a potential cognitive vulnerability, mediates the relationship between adolescent sleep disturbances and depressive symptoms, as well as whether there are gender differences in this relationship. High school students, ages 16-18, n = 1,760, 49 % girls, completed annual health surveys including reports of sleep disturbance, catastrophic worry, and depressive symptoms. Sleep disturbances predicted depressive symptoms 1-year later. Catastrophic worry partially mediated the relationship. Girls reported more sleep disturbances, depressive symptoms, and catastrophic worry relative to boys. The results, however, were similar regardless of gender. Sleep disturbances and catastrophic worry may provide school nurses, psychologists, teachers, and parents with non-gender specific early indicators of risk for depression. Several potentially important practical implications, including suggestions for intervention and prevention programs, are highlighted.

  • 5.
    Forsström, David
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Centre for Psychiatry Research, Sweden.
    Hesser, Hugo
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Experiences of Playscan: Interviews with users of a responsible gambling tool2017In: Internet Interventions, ISSN 2214-7829, Vol. 8, p. 53-62Article in journal (Refereed)
    Abstract [en]

    Online gambling, encompassing a wide variety of activities and around-the-clock access, can be a potential risk factor for gamblers who tend to gamble excessively. Yet, the advent of online gambling has enabled responsible gambling (RG) features that may help individuals to limit their gambling behaviour. One of these features is RG tools that track gamblers' behaviour, performs risk assessments and provides advice to gamblers. This study investigated users' views and experiences of the RG tool Playscan from a qualitative perspective using a semi-structured interview. The tool performs a risk assessment on a three-step scale (low, medium and high risk). Users from every risk category were included. Twenty interviews were carried out and analysed using thematic analysis. Two main themes with associated sub-themes were identified: “Usage of Playscan and the gambling site” and “Experiences of Playscan”. Important experiences in the sub-themes were lack of feedback from the tool and confusion when signing up to use Playscan. These experiences counteracted positive attitudes that should have promoted usage of the tool. Providing more feedback directly to users is a suggested solution to increase usage of the RG tool.

  • 6. Hertenstein, Elisabeth
    et al.
    Feige, Bernd
    Gmeiner, Tabea
    Kienzler, Christian
    Spiegelhalder, Kai
    Johann, Anna
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Palagini, Laura
    Rücker, Gerta
    Riemann, Dieter
    Baglioni, Chiara
    Insomnia as a predictor of mental disorders: A systematic review and meta-analysis2019In: Sleep Medicine Reviews, ISSN 1087-0792, E-ISSN 1532-2955, Vol. 43, p. 96-105Article, review/survey (Refereed)
    Abstract [en]

    Previous research has identified insomnia as a predictor for the onset of depression. The aim of this meta-analysis is to investigate whether insomnia also predicts the onset of other mental disorders. Longitudinal studies were eligible for inclusion if they investigated insomnia at baseline (including nighttime- and daytime-symptoms) as a predictor of the later onset of psychopathology within a follow-up time-frame of at least 12 mo. Thirteen primary studies were included. The results suggest that insomnia is a significant predictor for the onset of depression (10 studies, OR 2.83, CI 1.55-5.17), anxiety (six studies, OR 3.23, CI 1.52-6.85), alcohol abuse (two studies, OR 1.35, CI 1.08-1.67, and psychosis (one study, OR 1.28, CI 1.03-1.59). The overall risk of bias in the primary studies was moderate. This meta-analysis provides evidence that insomnia increases the risk for psychopathology. A future research agenda should include more prospective studies using established diagnostic criteria, assessing insomnia at baseline and including long-term follow-up intervals evaluating a wider range of mental disorders. In addition, prospective long-term interventional studies investigating the efficacy of insomnia treatment for the prevention of mental disorders are called for.

  • 7.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Örebro University, Sweden.
    The Work and Social Adjustment Scale as a Measure of Dysfunction in Chronic Insomnia: Reliability and Validity2014In: Behavioural and Cognitive Psychotherapy, ISSN 1352-4658, E-ISSN 1469-1833, Vol. 42, no 2, p. 186-198Article in journal (Refereed)
    Abstract [en]

    Background: Dysfunction is an integral part of chronic insomnia. Despite this, very little effort has yet been made to design and psychometrically validate an insomnia-specific measure of dysfunction. Aims: The purpose was to examine the psychometric properties of the Work and Social Adjustment Scale (WSAS) as a measure of dysfunction in chronic insomnia. Method: Seventy-three patients with chronic insomnia from three subsamples participated. All the patients completed the WSAS, the Insomnia Severity Index (ISI), and sleep diaries over one week. Results: An exploratory factor analysis suggested a one-factor solution for the WSAS, determining dysfunction, accounting for 73.7% of the variance. The internal consistency of the WSAS was alpha = .91. The test-retest reliability for the WSAS items was high at .90-.99 and for the entire scale .99. A cut-off at 17 points was established, discriminating those with subclinical versus moderate or severe clinical insomnia (88% sensitivity and 78% specificity). Evidence of convergent and criterion validity was documented via (1) a significant, positive association between the WSAS and ISI and (2) a higher WSAS score among those with severe clinical insomnia, relative to those with moderate clinical and subthreshold insomnia, as well as a higher WSAS score among those with moderate clinical insomnia relative to those with subthreshold insomnia. The WSAS was also shown to be a treatment-sensitive measure for insomnia patients. Conclusions: The WSAS appears as a reliable and valid measure of dysfunction in chronic insomnia. Additional advantages are its shortness, easiness, and treatment-sensitivity.

  • 8.
    Jansson-Fröjmark, Markus
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Bermas, Mikael
    Kjellen, Andreas
    Attentional Bias in Insomnia: The Dot-Probe Task with Pictorial Stimuli Depicting Daytime Fatigue/Malaise2013In: Cognitive Therapy and Research, ISSN 0147-5916, E-ISSN 1573-2819, Vol. 37, no 3, p. 534-546Article in journal (Refereed)
    Abstract [en]

    The purpose of this study was to examine whether individuals with primary insomnia (PI) have an attentional bias towards insomnia-specific stimuli, relative to normal sleepers (NS). Also, the aim was to determine if the attentional bias was characterized by vigilance or disengagement. A between-groups, matched design was employed. Forty-two individuals completed the study (PI = 21; NS = 21). Participants completed a dot-probe task with stimuli comprising insomnia-specific (fatigue/malaise) and neutral pictures. It was hypothesized that individuals with PI would show greater attentional bias to insomnia-specific stimuli compared with NS. An overall bias effect was noted. This effect was however not due to vigilance; taking into account the reaction times on neutral trials, the PI group and the NS group did not display significantly different results in reaction times to insomnia-specific pictures. On the contrary, the results suggest that the overall bias effect was due to disengagement; the PI group had significantly longer reaction times than the NS group when shifting away from the insomnia-specific pictures, relative to neutral-neutral picture presentations. The findings suggest that individuals with insomnia are not more vigilant than normal sleepers to insomnia-specific stimuli, but instead have greater difficulties in shifting away from such stimuli.

  • 9.
    Jansson-Fröjmark, Markus
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Örebro University, Sweden.
    Danielsson, Katarina
    Markström, Agneta
    Broman, Jan-Erik
    Developing a cognitive behavioral therapy manual for delayed sleep-wake phase disorder2016In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 45, no 6, p. 518-532Article in journal (Refereed)
    Abstract [en]

    This article reports the development of a treatment protocol, based on cognitive behavioral therapy (CBT) principles, for delayed sleep-wake phase disorder (DSWPD). The protocol consists of psychoeducation, presenting a CBT model for DSWPD, case formulation, motivational interviewing, registering sleep in a diary, strategies to improve the rhythm of sleep and wakefulness, relaxation training, cognitive restructuring, strategies to cope with daytime symptoms, constructing an individualized CBT program, and learning how to deal with relapses. Qualitative data, focusing on how the patients perceived the protocol, were collected within the realm of a trial exploring the efficacy of the protocol. These findings highlighted several advantages but also disadvantages of the therapy. It is our hope that this paper might act as a platform for further clinical work and future research efforts in patients with DSWPD.

  • 10.
    Jansson-Fröjmark, Markus
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Norell-Clarke, Annika
    Cognitive Behavioural Therapy for Insomnia in Psychiatric Disorders2016In: Current Sleep Medicine Reports, E-ISSN 2198-6401, Vol. 2, no 4, p. 233-240Article in journal (Refereed)
    Abstract [en]

    Insomnia means difficulties in initiating or maintaining sleep and is commonly comorbid with psychiatric disorders. From being considered secondary to primary psychiatric disorders, comorbid insomnia is now considered an independent health issue that warrants treatment in its own right. Cognitive behavioural therapy for insomnia (CBT-I) is an evidence-based treatment for insomnia. The effects from CBT-I on comorbid psychiatric conditions have received increasing interest as insomnia comorbid with psychiatric disorders has been associated with more severe psychiatric symptomologies, and there are studies that indicate effects from CBT-I on both insomnia and psychiatric symptomology. During recent years, the literature on CBT-I for comorbid psychiatric groups has expanded and has advanced methodologically. This article reviews recent studies on the effects from CBT-I on sleep, daytime symptoms and function and psychiatric comorbidities for people with anxiety, depression, bipolar disorder, psychotic disorders and post-traumatic stress disorder. Future strategies for research are suggested.

  • 11.
    Jansson-Fröjmark, Markus
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Örebro University, Sweden.
    Norell-Clarke, Annika
    Linton, Steven J.
    The role of emotion dysregulation in insomnia: Longitudinal findings from a large community sample2016In: British Journal of Health Psychology, ISSN 1359-107X, E-ISSN 2044-8287, Vol. 21, no 1, p. 93-113Article in journal (Refereed)
    Abstract [en]

    ObjectivesThe purpose of this longitudinal investigation was to examine the association between emotion regulation and future insomnia (incidence and persistence). DesignA longitudinal study in the general population. MethodsA survey was sent out to 5,000 individuals in the community. To those who returned the baseline questionnaire (n=2,333), two follow-up surveys, 6 and 18months later, were sent out and then completed by 1,887 and 1,795 individuals, respectively. The survey contained information about demographic factors, insomnia symptomatology, the Difficulties in Emotion Regulation Scale, anxiety, and depression. ResultsThe findings suggested that emotion regulation at baseline was not associated with the incidence or persistence of insomnia. Overall, the effect sizes were very small to medium. When examining changes in emotion regulation over time, a different pattern emerged. Partial support was established for the notion that decreases in emotion regulation were related to incident and persistent insomnia, as a decrease in emotion regulation was associated with a higher likelihood of future insomnia. Yet, the effect sizes were very small to small. ConclusionThis study does partly point towards a longitudinal association between emotion dysregulation and insomnia. This might have implications for the conceptualization and management of insomnia as well as for future research.

  • 12.
    Johansson, Magnus
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. Örebro University, Sweden.
    Norell-Clarke, Annika
    Linton, Steven J.
    The role of psychiatric and somatic conditions in incidence and persistence of insomnia: A longitudinal, community study2016In: Sleep Health, ISSN 2352-7218, E-ISSN 2352-7226, Vol. 2, no 3, p. 229-238Article in journal (Refereed)
    Abstract [en]

    Objective: The objective was to investigate the role of psychiatric and somatic conditions in incident and persistent insomnia. Design: This was a prospective study with 3 measurement points over 1.5 years. Setting: The participants were sent a survey to their home addresses. Participants: A survey was sent out to 5000 random individuals (18-70 years) in 2 Swedish counties. To those who returned the baseline questionnaire (n = 2333), 2 follow-up surveys (6 and 18 months later) were sent out and completed by 1887 and 1795 individuals, respectively. Measurements: The survey contained questions about sociodemographic factors and insomnia symptomatology, the Hospital Anxiety and Depression Scale, and items assessing 12 forms of somatic conditions (eg, heart disease and headache). Results: Baseline depression, headache, and number of psychiatric and somatic conditions were found to be independent risk factors for incident insomnia. Also, deterioration in depression and heart disease status and increased number of conditions over time increased the risk for insomnia incidence. Anxiety; depression; pain in neck, back, or shoulders; and headache at baseline were found to significantly discriminate between those with persistent insomnia and those with persistent normal sleep. Those with persistent insomnia also reported a higher number of conditions relative to those with persistent normal sleep. None of the psychiatric or somatic conditions were found to be associated with persistence of insomnia relative to remission of insomnia. Conclusion: The current study suggests that both psychiatric and somatic conditions are involved in the incidence but not in the persistence of insomnia. Clinical and theoretical implications of the results are discussed.

  • 13.
    Lundh, Lars-Gunnar
    et al.
    Lunds universitet.
    Jansson Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Sömnstörningar2013In: KBT inom psykiatrin / [ed] Lars-Göran Öst, Stockholm: Natur och kultur, 2013, 2, p. 265-282Chapter in book (Other academic)
  • 14. Norell-Clarke, Annika
    et al.
    Jansson Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Örebro University, Sweden.
    Tillfors, Maria
    Holländare, Fredrik
    Engström, Ingemar
    Group cognitive behavioural therapy for insomnia: Effects on sleep and depressive symptomatology in a sample with comorbidity2015In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 74, p. 80-93Article in journal (Refereed)
    Abstract [en]

    To investigate the effects of group CBT for insomnia (CBT-I) on insomnia and depressive symptomatology in a comorbid sample through a randomised controlled trial with a 6 month follow-up. 64 participants were recruited through advertisements and randomised to receive CBT-I or an active control (relaxation training: RT) during four group sessions. Insomnia Severity Index and BDI-II were the primary outcome measures, assessed pre-treatment, post-treatment and at 6 month follow-up. Insomnia and depressive diagnoses, and functional impairment were assessed before and after treatment, whereas sleep diary data was gathered continuously from one week before treatment until after treatment. CBT-I was more efficient than RT in reducing insomnia severity and equally effective in reducing depressive symptoms, although CBT-I was associated with a higher proportion of remitted persons than RT, regarding both insomnia and depression diagnoses. Also, CBT-I was associated with less functional impairment, shorter sleep onset latency and wake after sleep onset but both treatments had equal improvements of sleep quality, early morning awakenings and total sleep time. Group CBT-I is an efficient form of insomnia-treatment for people with insomnia comorbid with depressive symptomatology. The mixed results regarding depression outcomes warrants replication and further studies into treatment mechanisms.

  • 15. Norell-Clarke, Annika
    et al.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Örebro University, Sweden.
    Tillfors, Maria
    Harvey, Allison G.
    Linton, Steven J.
    Cognitive processes and their association with persistence and remission of insomnia: Findings from a longitudinal study in the general population2014In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 54, p. 38-48Article in journal (Refereed)
    Abstract [en]

    Aim: Insomnia is a common health problem that affects about 10% of the population. The purpose of this investigation was to examine the association between cognitive processes and the persistence and remission from insomnia in the general population. Methods: In a longitudinal design, 2333 participants completed a survey on night time and daytime symptoms, and cognitive processes. Follow-up surveys were sent out six months and 18 months after the first assessment. Participants were categorised as having persistent insomnia, being in remission from insomnia or being a normal sleeper. Results: Cognitive processes distinguished between people with persistent insomnia and normal sleepers. Specifically, worry, dysfunctional beliefs, somatic arousal, selective attention and monitoring, and safety behaviours increased the likelihood of reporting persistent insomnia rather than normal sleep. For people with insomnia, more worry about sleep at baseline predicted persistent insomnia but not remission later on. Lower selective attention and monitoring, and use of safety behaviours over time increased the likelihood of remission from insomnia. In general, these results remained, when psychiatric symptoms and medical complaints were added to the models. Conclusions: The findings support that certain cognitive processes may be associated with persistence and remission of insomnia. Clinical implications are discussed.

  • 16. Norell-Clarke, Annika
    et al.
    Tillfors, Maria
    Wilmenius, Lina
    Jansson Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Holländare, Fredrik
    Engström, Ingemar
    Insomnia severity mediates between cognitive behavioural therapy for insomnia and depression in a sample with insomnia and depression: New possibilities for treatments of comorbid patients2016In: EABCT 2016 Abstract Book: Total Awareness, 2016, p. 544-544Conference paper (Refereed)
    Abstract [en]

    Clinical trials have shown that cognitive behavioural therapy for insomnia (CBT-I) may have an effect on both insomnia and depression in comorbid samples, but there is a gap in the knowledge on why CBT-I has an impact on depression. Neuropsychological theories suggest that disturbed sleep may work as a transdiagnostic process that maintains psychopathology. The aim was to test whether CBT-I impacts depressive symptoms through improved sleep, in a sample with insomnia comorbid with major depression and subthreshold depressive symptoms. 64 participants were recruited through advertisements and randomised to receive either CBT-I or an active control (relaxation training: RT) in groups during four bi-weekly sessions. Insomnia (ISI) and depressive severity (BDI-II) were measured pre-, mid- and post-treatment. Mediational analyses were conducted. Insomnia and depressive severity lowered over the course of treatments. CBT-I was superior in reducing insomnia. The main treatment outcomes have been published elsewhere (Norell-Clarke et al, 2015). The relationship between CBT-I and post-treatment depressive severity was mediated by mid-treatment insomnia severity, which indicates that the effect of CBT-I on depression goes through improved sleep (b = -4.87, BCa CI = -9.21, -1.97). The results were maintained when pre-treatment insomnia and depressive severity were controlled for (b = -3.36, BCa CI = -8.86, -0.45). Testing for reciprocity, we found that mid-treatment depressive severity did not mediate between CBT-I and post-treatment insomnia severity. The results support the perpetuating role of insomnia in depression. This may have implications for other psychiatric patient groups with comorbid insomnia. Also, the results indicate that CBT for comorbid patient groups may need to target sleep specifically.

  • 17.
    Sunnhed, Rikard
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Univ Orebro, CHAMP, Sch Law Psychol & Social Work, Örebro, Sweden.
    Are Changes in Worry Associated with Treatment Response in Cognitive Behavioral Therapy for Insomnia?2014In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 43, no 1, p. 1-11Article in journal (Refereed)
    Abstract [en]

    Aim: Little is known about why some patients respond to cognitive behavioral therapy for insomnia, whereas other patients do not. To understand differences in treatment response, there is a dire need to examine processes of change. The purpose was to investigate the long-term association between insomnia-related worry and outcomes following cognitive behavior therapy for insomnia. Methods: Sixty patients with early insomnia (3-12 months duration) received group cognitive behavioral therapy for insomnia. At pretreatment and at a 1-year follow-up, the patients completed questionnaires indexing two domains of insomnia-related worry (sleeplessness and health), insomnia severity, anxiety, and depression as well as sleep diaries. Results: Decreases in the two worry domains were associated with improvements in all of the outcomes, except for sleep onset latency (SOL), at a medium to large level. Reductions in insomnia-related worry were associated with improvements in insomnia severity, wake after sleep onset (WASO), total sleep time (TST), and depression, but not in SOL or anxiety. While reductions in worry for sleeplessness were related to improvements in insomnia severity and TST, decreases in worry for health were associated with enhancements in WASO and depression. Conclusion: The findings suggest that reductions in insomnia-related worry might be one process route in which cognitive behavioral therapy operates to improve insomnia symptomatology. The results are discussed in relation to theory, clinical implications, and future research.

  • 18.
    Sunnhed, Rikard
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Örebro University, Sweden.
    Cognitive Arousal, Unhelpful Beliefs and Maladaptive Sleep Behaviors as Mediators in Cognitive Behavior Therapy for Insomnia: A Quasi-Experimental Study2015In: Cognitive Therapy and Research, ISSN 0147-5916, E-ISSN 1573-2819, Vol. 39, no 6, p. 841-852Article in journal (Refereed)
    Abstract [en]

    The purpose with the investigation was to examine whether improvements in pre-sleep cognitive arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors mediate the outcomes in in-person CBT-I. Fifty-eight participants with insomnia were administered either cognitive behavioral therapy or belonged to a waitlist. At pre- and post-treatment, participants completed questionnaires and sleep diaries assessing cognitive arousal, unhelpful beliefs about sleep, maladaptive sleep behaviors, insomnia severity, dysfunction, and subjective sleep parameters. Outcome measures were re-administered at a 3-month follow-up. Decreases in cognitive arousal mediated the effect on dysfunction. Reductions in unhelpful beliefs mediated the treatment effect on insomnia severity and dysfunction. Decreases in bedtime variability mediated the outcome on insomnia severity, and reductions in time in bed had a mediating effect on total wake time. Neither rise time variability nor napping mediated the improvements. A reversed model, in which the outcomes were used as mediators, showed less fit with the current data, indicating that change in the psychological processes as mediators of improvement in the outcomes was the most plausible conclusion. These findings are clearly supportive of cognitive-behavioral models of insomnia by highlighting cognitive arousal, unhelpful beliefs about sleep, and maladaptive sleep behaviors as mediators in the treatment of insomnia. The results are also important for clinical work and for testing new approaches in future research.

  • 19. Tillfors, Maria
    et al.
    Toll, Christine
    Branting, Mattias
    Boersma, Katja
    Jansson-Fröjmark, Markus
    Stockholm University, Faculty of Social Sciences, Department of Psychology. Örebro University, Sweden.
    Allowing or fighting social anxiety: The role of psychological inflexibility in a non-clinical population2015In: Journal of Person-Oriented Research, ISSN 2002-0244, Vol. 1, no 3, p. 151-161Article in journal (Refereed)
    Abstract [en]

    In an acceptance-based model of what maintains social anxiety, the focus is on counterproductive attempts to control unpleasant internal experiences through avoidance of them. An example of such an avoidance strategy, especially prominent among socially anxious women, is rumination. According to this model, the road to recovery for people suffering from social anxiety is through increased acceptance of internal experiences. This process is also referred to as decreasing an individual’s ‘psychological inflexibility’. The overall aim of the current study was to examine the relationship between psychological inflexibility and social anxiety in a non-clinical population. We used cluster analysis to examine subgroups with different individual profiles of symptoms of social anxiety/avoidance and psychological inflexibility. The clusters were examined in relation to depressive symptoms, rumination, and the moderating effect of gender. The design was cross-sectional and consisted of 219 university students (101 men, 118 women; M age = 23 years). Four clusters were generated, whereof two (the Multidimensional Problem cluster and the No Problem cluster) reflected a strong positive relationship between social anxiety/avoidance and psychological inflexibility, however in different ways. Gender did not act as a mod-erator. However, people in the Multidimensional Problem cluster reported higher degree of depressive symptoms as well as higher levels of rumination compared to the other clusters. To conclude, psychological inflexibility seems to be related not only to symptoms of ill-health such as social anxiety and depressive symptoms but also to control strategies such as rumination.

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