The Contribution of Transdiagnostic Vulnerability Factors in Patients with Chronic Insomnia

doi:10.21203/rs.3.rs-2241964/v1

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The Contribution of Transdiagnostic Vulnerability Factors in Patients with Chronic Insomnia

https://doi.org/10.21203/rs.3.rs-2241964/v1

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Various transdiagnostic factors have been associated with insomnia severity. The current study aimed to predict insomnia severity based on a group of transdiagnostic factors including neuroticism, emotion regulation, perfectionism, psychological inflexibility, anxiety sensitivity, and repetitive negative thinking after controlling for depression/anxiety symptoms and demographic characteristics. Two hundred patients with chronic insomnia disorder were recruited from a sleep disorder clinic. Participants completed the Insomnia Severity Index (ISI), Clinical Perfectionism Questionnaire (CPQ), Acceptance and Action Questionnaire-II (AAQ-II), Anxiety Sensitivity Index-3 (ASI-3), Repetitive Thinking Questionnaire (RTQ-10), Big Five Inventory (BFI-10), Emotion Regulation Questionnaire (ERQ), and Depression Anxiety Stress Scale (DASS-21). After controlling for the confounding variables (depression/anxiety symptoms and demographic characteristics), hierarchical multiple linear regression suggested a significant predictive model for insomnia severity that included factors of neuroticism (BFI), cognitive reappraisal (ERQ), personal standards (CPQ), evaluative concerns (CPQ), physical concerns (ASI), cognitive concerns (ASI), and repetitive negative thinking (RTQ). The findings support the role of transdiagnostic factors, especially physical concerns, repetitive negative thinking, and neuroticism in chronic insomnia. Future research using longitudinal designs is required to verify the causal status of transdiagnostic variables.

Insomnia

Transdiagnostic factors

Anxiety

Depression

Perfectionism

Emotion regulation

Repetitive thinking

Education level and age were the most significant demographic predictors of insomnia severity.
Physical concerns dimension of the anxiety sensitivity was the strongest transdiagnostic predictor of insomnia severity.
Depression along with other transdiagnostic factors remained as one of the best predictors of insomnia severity.

Insomnia refers to the dissatisfaction with sleep quality or quantity, leading to clinically significant distress or impairments in significant areas of functioning [1]. High rates of comorbidity between chronic insomnia and other medical and psychiatric disorders have been found [2, 3]. Two disorders that commonly occur along with insomnia disorder are anxiety and depression. A prospective study on the general population found that insomnia was closely linked with depression and anxiety [4]. The positive association of insomnia with depression and anxiety was replicated in a large body of evidence [e.g., 5, 6–9]. As such, the effect of sociodemographic characteristics on insomnia severity has been documented in various studies. For instance, lower education level was shown to be a risk factor for psychological and social stressors and as a result, leads to insomnia [10–12]. Insomnia was also found to be more common in women and older adults [e.g., 11, 13]. From these evidence, one may conclude that the role of psychological transdiagnostic factors on insomnia severity might be affected or confounded by the individual’s level of depression/anxiety symptoms and demographic characteristics.

In recent years, research and treatment has focused more on the transdiagnostic approach [14]. Despite the “disorder-focused” approach that focuses exclusively on a single disorder to understand its etiology and develop its interventional protocol [15], transdiagnostic approach concentrates on factors that are common among comorbid disorders [16]. The common transdiagnostic factors that their association with insomnia were well documented include emotion dysregulation [17], neuroticism [18], psychological inflexibility [19], perfectionism [20], anxiety sensitivity [21], and repetitive negative thinking [22].

Maladaptive emotion regulation strategies have been identified as underlying mechanisms in insomnia [23]. People identified as poor sleepers, in comparison to good sleepers, have greater difficulties accepting and recognizing their own emotions, engaging in goal-directed behaviors, and controlling their impulses when experiencing negative emotions [24]. In a sample of individuals with insomnia, A Galbiati, E Giora, S Sarasso, M Zucconi and L Ferini-Strambi [25] found that increased anxiety was associated with increased insomnia severity only in those with maladaptive emotion regulation. Patients with insomnia seem to lack the capacity to regulate emotion, which may in turn lead to further psychopathology [26, 27].

Another transdiagnostic factor implicated in insomnia is neuroticism, also known as negative affectivity [28]. Neuroticism, as one of the fundamental personality traits, refers to the tendency to experience negative affects, so that people with high neuroticism can hardly maintain their calmness when they are emotionally aroused [29]. A study on general population indicated that a greater level of neuroticism in young adults is longitudinally related to the onset of insomnia [30]. CG Gurtman, R McNicol and JA McGillivray [31] showed that the intensity of insomnia increases with the increase in neuroticism.

Psychological inflexibility can also play a role in the onset and maintenance of insomnia [19]. Psychological inflexibility is characterized as “the rigid dominance of psychological reactions over chosen values and contingencies in guiding action” [32]. T Kato [33] found that psychological inflexibility was a significant contributing factor on insomnia severity, beyond the effect of neuroticism, and could mediate the relation between neuroticism and insomnia severity.

Perfectionism is another transdiagnostic factor associated with insomnia disorder. Maladaptive or clinical perfectionism is characterized by unrealistic “personal standards” or perfectionistic standards, and evaluative concerns. In other words, maladaptive perfectionism refers to the fear of making mistakes, perceiving unrealistic expectations by others, the fear of negative evaluation and rejection by society associated with not being perfect, and a perceived difference between performance and personal standards [34]. Individuals with chronic insomnia are likely to show more maladaptive perfectionism than healthy controls [35]. In addition, greater levels of perfectionism was found to have a positive link with insomnia severity in university students [36].

Another important transdiagnostic factor associated with insomnia is anxiety sensitivity, which refers to the trait-like fear of feelings and sensations related to anxiety [37]. A higher level of anxiety sensitivity has been associated with longer sleep onset latency (i.e., longer time taken to fall asleep) [38]. The physical concerns dimension of anxiety sensitivity, which refers to the belief that any bodily sensation due to emotional arousal can lead to physical diseases, was shown to have a moderating role in the relationship of sleep anticipatory anxiety with sleep onset latency [39]. The cognitive concerns dimension of anxiety sensitivity, defined as the belief that physical symptoms of anxiety lead to serious psychological disorders, was associated with daytime impairments such as fatigue, in people with chronic insomnia [40]. In addition, interventions targeting anxiety sensitivity can result in significant reductions in insomnia symptoms, even after controlling for concurrent reductions in depression and anxiety [41].

Repetitive negative thinking is another important transdiagnostic factor, present across various disorders, including insomnia [22, 42, 43]. Repetitive negative thinking refers to the process in which cognitive representation of one or multiple psychological stressors becomes chronically or repetitively activated [44]. Rumination and worry are the two best-known aspects of repetitive thought [45], that have significant associations with polysomnographic indices of disrupted sleep [25], and sleep disturbances, both in healthy people [46], and in insomnia patients [47].

There is clear evidence to support the relationships between the transdiagnostic factors and chronic insomnia [18, 19, 21]; however, the extent to which each of these factors can affect insomnia remains unclear. Assessing such transdiagnostic factors together may be helpful to analyze the contribution of each of these factors on chronic insomnia. Hence, the current study aimed to examine the six candidate transdiagnostic factors that are understood to play an important role in insomnia, based on established research findings. The study’s primary aim was to assess the predictive roles of demographic characteristics and depression/anxiety symptoms on insomnia severity, separately. The secondary aim was to examine the predictive role of transdiagnostic factors on insomnia, after controlling for the confounding effects of demographic characteristics and depression/anxiety symptoms.

Participants

Two hundred patients with chronic insomnia disorder were recruited from sleep disorders clinic of Rasoul Akram Hospital in Tehran. Inclusion criteria included: a) a minimum age of 18 years, b) fluency in Persian language, and c) meeting the diagnostic criteria for chronic insomnia disorder based on the Diagnostic and Statistical Manual, Fifth Edition [DSM-5; 1]. The exclusion criteria were having: a) severe mental disorders (e.g., bipolar disorder and psychosis), b) brain injury, c) substance abuse, d) other sleep disorders (e.g., sleep apnea and restless legs syndrome), and e) a rotating shift work within the last year Structured Clinical Interview for DSM-5 Axis I Disorders (SCID-5) were used to determine the presence of insomnia. In the case of a suspicion of an occult sleep disorder, individuals underwent polysomnography.

The majority of participants were 18–45-year-old females (90.8%; Mean _age = 29.67, SD = 12.41). Regarding marital status, 62.2% were single, 33.6% were married, and 4.2% were divorced/widowed. Regarding education level, 10.1% had completed elementary school, 12.9 had a diploma, 60.8% had a bachelor’s degree, and 16.1% had a master’s and/or PhD degree.

Measures

The Structured Clinical Interview for DSM-5 Axis I Disorders (SCID-5). The SCID-5 [48] is a standardized diagnostic interview for classifying mental disorders according to DSM-5 criteria. The Persian version of the SCID-5 had adequate test–retest reliability, ranging from .60 to .79, and the Kappa reliability was between .57 and .72 [49].

Insomnia Severity Index (ISI). This is a seven-item self-report index developed by CH Bastien, A Vallières and CM Morin [50] to assess insomnia severity and its three empirically derived subscales of impact, intensity, and satisfaction during the past two weeks. Items are scored on a 0–4 scale, with the total ISI ranging from 0 to 28. A score of 0–7 demonstrates “no clinically significant insomnia”; 8–14 shows “subthreshold insomnia”; 15–21 demonstrates “moderate clinical insomnia”; and 22–28 shows “severe clinical insomnia”. The Cronbach’s alpha of the Persian version of the ISI in patients with insomnia has been reported as .82 [51], and was .71 in this study.

Depression Anxiety Stress Scale (DASS-21). This 21-item scale [52] is a short version of the DASS-42 [53]; it was developed to measure the severity of depression, anxiety, and stress symptoms during the previous week, with 7 items for each subscale. Answers are scored on a four-point Likert scale, ranging from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time). In the Iranian population, the test–retest coefficients have been reported as .85 for stress, .77 for depression, and .89 for anxiety, with respective internal consistency values of .90, .91, and .84 [54]. In this study, the Cronbach’s alpha for depression, anxiety, and stress subscales were .80, .75, and .77, respectively.

Emotion Regulation Questionnaire (ERQ). The ERQ was designed by JJ Gross and OP John [55] to evaluate two emotion regulation strategies, namely expressive suppression (four items) and cognitive reappraisal (six items). Answers are based on a seven-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). In the Iranian population, the internal consistency for cognitive reappraisal and suppression has been reported as .76 and .72, respectively [56]. In the present study, Cronbach’s alphas were .77 for expressive suppression and .84 for cognitive reappraisal.

Big Five Inventory (BFI-10). This 10-item inventory was developed by B Rammstedt and OP John [57] to measure 5 major personality traits: extroversion, agreeableness, conscientiousness, neuroticism, and openness, with 2 items for each subscale. It is measured on a seven-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The Persian version of the BFI-10 has appropriate test–retest reliability (r = .84) and acceptable internal consistency [58]. The Cronbach’s alpha of .45 was obtained for BFI-10 in this study.

Acceptance and Action Questionnaire- II (AAQ-II). This seven-item questionnaire [32] was designed to assess psychological inflexibility or rigid reactions, such as avoiding or suppressing undesirable thoughts and feelings, or evaluating feelings negatively. Answers are based on a seven-point Likert scale ranging from 1 (never true) to 7 (always true), where higher scores indicate less psychological flexibility. Split-half coefficients and Cronbach’s alpha values of the Persian version of the AAQ-II ranged between .71 and .89 in different samples [59]. Cronbach’s alpha for the AAQ-II was .63 in this study.

Clinical Perfectionism Questionnaire (CPQ). CPQ [34] is a 12-item questionnaire developed to measure clinical perfectionism, by determining the extent to which the people’s lives are affected by perfectionism. This questionnaire has two subscales: personal standards and evaluative concerns. Scoring is based on four-point Likert scales, ranging from 1 (not at all) to 4 (all the time). In an Iranian sample, the Omega reliability of CPQ was between .73 and .86 for men and women [60]. We found satisfactory internal consistency for the CPQ total score (α = .57), personal standards (α = .62), and evaluative concerns (α = .60).

Anxiety Sensitivity Index-3 (ASI-3). This 18-item Index [61] measures three dimensions of anxiety, namely physical (α = .84), cognitive (α = .77), and social concerns (α = .84), with 6 items per subscale. Participants are asked to rate their concerns regarding the potential negative consequences of anxiety-related experiences, using five-point Likert scales ranging from 0 (very little) to 4 (very much). The internal consistency of the ASI-3 in the Iranian population was previously reported as .90 [62]. In this study, these values were .84, .77, and .84 for physical, cognitive, and social concerns, respectively.

Repetitive Thinking Questionnaire (RTQ-10). The RTQ-10 [63] is a unidimensional scale for measuring repetitive thinking. The RTQ-10 is rated on a 5-point scale, where 1 represents “not at all true”, 3 indicates “somewhat true”, and 5 reflects “very true”. The Persian version of the RTQ-10 was reported as having high internal consistency [α = .77; 64]. The RTQ-10 also had adequate internal consistency (α = .89) in the present study.

Procedure

The sample consisted of individuals who were seeking treatment at the sleep disorders clinic of Rasoul Akram hospitals in Tehran. Individuals who volunteered for the study were first asked to fill written informed consent forms. They were informed that their participation in the study was completely voluntary. In addition, they were assured about the confidentiality and that their data would only be used for research purposes. Then, they underwent a structured clinical interview by a sleep clinician to verify inclusion criteria. Patients with the probability of an occult sleep disorder, underwent PSG to screen the physiological parameters related to a wide range of sleep disturbances (exclusion criterion “d”). Those who were not excluded during this phase, were asked to complete the following questionnaires: ISI, DASS-21, ERQ, BFI-10, CPQ, AAQ-II, ASI, and RTQ-10. This study was approved by the ethics committee at the Iran University of Medical Sciences (approval code = IR.IUMS.REC.1397.1346).

Statistical Strategies

The data screening included consistency checks and descriptive and graphical analysis checks. We decided whether to remove or keep outliers using the comparison between the mean and the 5% trimmed mean (p > .05). The substantive main study findings were not affected by the outliers’ presence or absence. Hence, the data of all participants were preserved and the original data were analyzed [65, 66]. For data entry and statistical analyses, SPSS version 28 software was used. The Pearson correlation coefficient was used to indicate the relationship between variables. Hierarchical multiple linear regression was subsequently employed to indicate the predictive power of the included variables. Correlations were interpreted as having small (.10), medium (.30), large (.50), or very large (.70) effect sizes [67].

Correlation of Insomnia Severity with Demographic and Transdiagnostic Factors

As shown in Table 1, ISI total score had a significant positive correlation with age (r = .14, p < .05), depression (DASS-21) (r = .58, p < .01), anxiety (DASS-21) (r = .76, p < .01), cognitive reappraisal (ERQ) (r = .73, p < .01), expressive suppression (ERQ) (r = .75, p < .01), neuroticism (BFI) (r = .70, p < .01), AAQ total score (r = .80, p < .01), CPQ total score (r = .13, p < .05), personal standards (CPQ) (r = .86, p < .01), evaluative concerns (CPQ) (r = .86, p < .01), physical concerns (ASI) (r = .47, p < .01), cognitive concerns (ASI) (r = .61, p < .01), social concerns (ASI) (r = .63, p < .01), and RTQ total score (r = .80, p < .01). In addition, total ISI score had a significant negative correlation with education level (r = − .21, p < .01).

Table 1

*Descriptive Statistics and Correlations of Insomnia Severity with Demographics Characteristics, and Transdiagnostic Vulnerability factors in Insomnia*
Variables	N/ Mean (SD)	Insomnia severity	Impact-ISI	Severity-ISI	Satisfaction-ISI
Age (years)	29.67 (12.41)	.14^*	− .04	.27^**	.09
Gender (0 = female, 1 = male)	20, 197	− .04	− .10	.02	− .04
Marital status (1 = Married, 2 = Single, 3 = Divorced/ Widow)	135, 73, 9	− .05	− .01	− .07	− .03
Education level (0 = Elementary School, 1 = Diploma, 2 = Bachelor, 3 = Master and PhD)	22,28,132,35	− .21^**	.03	.35^**	.15^*
Job status (0 = Unemployed, 1 = Employed)	112, 105	− .04	− .14^*	− .20^**	− .04
Neuroticism (BFI-10)	5.90 (2.22)	.70^**	.55^**	.57^**	.64^**
Physical concerns (ASI-3)	14.75 (5.93)	.47^**	.45^**	.27^**	.42^**
Cognitive concerns (ASI-3)	11.59 (5.73)	.61^**	.52^**	.49^**	.46^**
Social concerns (ASI-3)	12.30 (6.23)	.63^**	.49^**	.55^**	.51^**
CPQ	26.92 (4.85)	.13^*	.26^**	− .08	.20^**
Personal standards (CPQ)	18.36 (6.29)	.86^**	.73^**	.64^**	.75^**
Evaluative concerns (CPQ)	11.77 (2.96)	.86^**	.74^**	.63^**	.76^**
Cognitive reappraisal (ERQ)	24.77 (9.01)	.73^**	.59^**	.57^**	.67^**
Expressive suppression (ERQ)	18.11 (5.58)	.75^**	.62^**	.58^**	.65^**
Depression (DASS-21)	12.20 (4.72)	.58^**	.50^**	.42^**	.48^**
Anxiety (DASS-21)	14.74 (3.62)	.76^**	.67^**	.54^**	.67^**
AAQ-II	38.59 (13.88)	.80^**	.63^**	.63^**	.70^**
RTQ	32.77 (8.76)	.80^**	.65^*	.64^**	.72^**

Notes. ^* p < .05, ^** p < .01, N = Number of participants, SD = Standard deviation, ISI = Insomnia Severity Scale, BFI = Big Five Inventory, ASI-3 = Anxiety sensitivity index-3, CPQ = Clinical Perfectionism, Questionnaire, ERQ = Emotion regulation Questionnaire, DASS = Depression Anxiety Stress Scale, AAQ-II = Acceptance and Action Questionnaire-II, RTQ = Repetitive Thinking Questionnaire.

Prediction Of Insomnia Severity Based On Demographic And Transdiagnostic Factors

A hierarchical linear multiple regression model was performed to test the contribution of demographic and transdiagnostic factors in the prediction of insomnia severity. Demographic characteristics such as gender, age, education level, job status, and marital status were considered as the first block, with depression and anxiety as the second block. The third block comprised of emotion regulation strategies, neuroticism, psychological inflexibility, clinical perfectionism subscales, anxiety sensitivity dimensions, and repetitive negative thinking.

The first hierarchical regression analysis model (R² = .08), performed to assess the predictability of insomnia severity based on demographic characteristics, showed that only education level (β = .20, p < .01) was significantly able to predict insomnia severity. Gender (β = −.06, p > .05), age (β = .04, p > .05), job status (β =-.13, p > .05), and marital status (β = .01, p > .05) did not significantly predict insomnia severity. After controlling for demographic in the second model (R² = .10, R²Δ = .007), depression (β = .10, p > .05) and anxiety (β = .03, p > .05) were not significant predictors of insomnia severity. In the third model, depression was revealed as a significant predictor of insomnia severity (β = .34, p < .001). Finally, as seen in Table 2, after controlling for demographic characteristics, depression and anxiety in the third model (R² = .40, R²Δ = .30), the following transdiagnostic variables significantly predicted insomnia severity: cognitive reappraisal (ERQ) (β = .19, p < .01), neuroticism (BFI) (β = .24, p < .001), evaluative concerns (CPQ) (β = .16, p < .05), personal standards (CPQ) (β = .22, p < .01), physical concerns (ASI) (β = .34, p < .001), cognitive concerns (ASI) (β = .18, p < .05), and repetitive negative thinking (β = .33, p < .001). However, expressive suppression (ERQ) (β = .13, p > .05), psychological inflexibility (β = .07, p > .05), and social concerns (ASI) (β = − .02, p > .05) did not significantly predict insomnia severity.

Table 2

*Hierarchical Multiple Linear Regression Analyses for Insomnia Severity in Insomniac Sample*
Predictor variables	Regression 1 β (se)	Regression 2 β (se)	Regression 3 β (se)	Tolerance	VIF
Gender	− .06 (1.12)	− .08 (1.13)	− .04 (.97)	.89	1.12
Education level	.20^** (.43)	.19^* (.44)	.25^** (.44)	.74	1.33
Age	.04 (.03)	.05 (.38)	.17^* (.03)	.65	1.52
Job status	− .13 (.62)	.12 (.62)-	− .12 (.58)	.96	1.03
Marital status	.01 (.55)	.01 (.55)	.05 (.49)	.90	1.10
Depression (DASS-21)		.10 (.08)	.34^*** (.08)	.57	1.73
Anxiety (DASS-21)		.03 (.09)	− .10 (.09)	.56	1.78
Neuroticism (BFI-10)			.24^*** (.18)	.55	1.80
Physical concerns (ASI)			.34^*** (.06)	.44	2.27
Cognitive concerns (ASI)			.18^* (.07)	.42	2.37
Social concerns (ASI)			− .02 (.06)	.51	1.92
Personal standards (CPQ)			.22^** (.07)	.64	1.56
Evaluative concerns (CPQ)			.16^* (.12)	.63	1.56
Cognitive reappraisal (ERQ)			.19^** (.04)	.57	1.73
Expressive suppression (ERQ)			.13 (.06)	.56	1.77
AAQ-II			.07 (.04)	.34	2.88
RTQ			.33^*** (.05)	.29	3.44
R	.28	.32	.63
R²	.08	.10	.40
adj R²	.05	.06	.34
R²_Δ	.08	.007	.30
F_Δ	3.15^**	.75	9.94^***
F _model	3.15^**	2.64^**	7.02^***

Notes. ^* p < .05, ^** p < .01, ^*** p < .001, β = Standardized regression coefficient, se = Standard error, VIF = Variance inflation factor, DASS = Depression Anxiety Stress Scale, BFI = Big Five Inventory, ASI-3 = Anxiety Sensitivity Index-3, CPQ = Clinical Perfectionism Questionnaire, ERQ = Emotion Regulation Questionnaire, AAQ-II = the Acceptance and Action Questionnaire-II, RTQ = Repetitive Thinking Questionnaire. Dependent Variable = Insomnia severity, In Hierarchical regression procedure, the blocks were applied as = Block 1 = Predictors = Gender, education level, age, job status, and marital status; Block 2 = Predictors = Depression, anxiety, after adjusted for gender, education level, age, job status, marital status; Block 3 = Predictors = Neuroticism, physical concerns, cognitive concerns, social concerns, personal standards, evaluative concerns, expressive suppression, AAQ, RTQ, after adjusted for gender, education level, age, job status, marital status, depression, anxiety.

The present study sought to identify the best predictive transdiagnostic factors of chronic insomnia in a sample of patients with chronic insomnia. The results demonstrated that all of the transdiagnostic variables evaluated in the current study had moderate to high correlations with insomnia severity, with the exception of clinical perfectionism (r = .13). Demographic characteristics, depression, and anxiety symptoms accounted for 10% of the variance of the ISI, with only depression, education level, and age being the significant contributing factors for insomnia severity. Furthermore, 30% of insomnia severity variance was explained by the transdiagnostic factors (in order of highest to lowest coefficients) of: physical concerns (ASI), repetitive negative thinking (RTQ), neuroticism (BFI), personal standards (CPQ), cognitive reappraisal (ERQ), cognitive concerns (ASI), and evaluative concerns (CPQ). Overall, physical concerns (ASI) and repetitive negative thinking (RTQ) served simultaneously as the most significant contributing variables for insomnia severity.

Among demographic characteristic, education level was one of the strongest contributing factors for insomnia severity. Lower education has been considered as a sociodemographic risk factor for insomnia and lower sleep quality in previous studies [11, 12], associated with the susceptibility to psychological and social stressors in less-educated populations [10]. In addition, age, as the second demographic factor, could predict insomnia severity. Consistent with this result, previous studies have demonstrated t that older patients will develop more severe insomnia [e.g., 11].

Depression emerged as one of the strongest predictors of insomnia severity in this study. In fact, it has been demonstrated that depression is usually accompanied by somatic symptoms and poor sleep, which, in turn, may exacerbate insomnia severity [68]. In line with our result, EO Bixler, AN Vgontzas, HM Lin, A Vela-Bueno and A Kales [69] showed that depression, followed by female gender, was the strongest variable predictive of insomnia in a sample of general population. Additionally in our study, anxiety was positively correlated with ISI; however, unexpectedly, it was not a significant predictor of insomnia severity, which is in contrast to previous evidence [70–72]. This difference may stem from different characteristics of the samples. For example, our study only included patients diagnosed with insomnia, while the abovementioned studies were on general population, patients with cancer, and military personnel. Hence, potential differences in the level of anxiety and insomnia in these different groups might be the cause of this discrepancy. Nonetheless, further examinations are needed to explore the nature of the link between these two variables in the presence of transdiagnostic variables.

Both cognitive reappraisal (ERQ) and expressive suppression (ERQ) indicated significant correlations with insomnia severity, which is consistent with previous findings [73, 74]. However, only cognitive reappraisal (ERQ) was a significant predictor of insomnia severity, which emphasizes the exclusive effect of emotion regulation strategies on insomnia severity. One possible explanation might be that although cognitive reappraisal during the day can regulate emotions via problem solving and negative affect management, it may play a negative role at bedtime by increasing sleep onset latency and reducing sleep quality [75].

Neuroticism was shown to be another significant transdiagnostic factor for predicting insomnia severity; this is in line with previous findings [see 76, 77]. High levels of neuroticism reflects negative emotions, guilt, moodiness, and poor active control in a person, leading to pre-sleep cognitive distortions, such as worrying, and active thinking at bedtime, which can be associated with over-excitation and hypersensitivity [31]. This lack of capability to stop or manage thoughts at night can lead to insomnia [78].

Psychological inflexibility indicated a high significant correlation with insomnia severity (r = .80), which is consistent with previous studies [79, 80]; however, it had no predictive role in our study. When a person engages in “experiential avoidance,” they may actively avoid experiencing symptoms or cognitions related to their sleep problems. This active avoidance may increase pre-sleep arousal and, as a result, lead to a delay in falling asleep [81]. Nevertheless, our study indicates that in the presence of other transdiagnostic factors which may be better predictors of insomnia severity, psychological inflexibility could not significantly predict insomnia.

This study, in line with previous studies [82, 83], found a significant but weak association between perfectionism and insomnia severity. Also, its two components of personal standards and evaluative concerns could significantly predict insomnia severity. Maladaptive perfectionism may lead to heightened insomnia through its association with excessive arousal [84] and chronic fatigue [85], which are thought to be amplifying factors for insomnia [86, 87]. Furthermore, perfectionists with chronic insomnia unrealistically expect to have excellent quality sleep and become extremely anxious or frustrated with any sleep deprivation. This may cause them to experience negative emotions, leaving them emotionally aroused, which can interfere with their sleep [88].

The present findings suggest that two anxiety sensitivity dimensions – namely physical and cognitive concerns – could predict insomnia severity, with physical concerns (ASI) being the strongest predictive factor among all the present transdiagnostic variables. This association is consistent with previous studies [89, 90]. According to AG Harvey [78]’s cognitive model, people with elevated anxiety sensitivity are more alert to the physical and cognitive signs and symptoms associated with poor sleep and are more likely to discover these signs and symptoms. As a result, they catastrophize these cues as predictors of insufficient sleep, an inability to fall asleep, or low levels of daily performance, which in turn, heighten a person’s arousal and increase the likelihood of sleep disturbance. In contrast to physical and cognitive concerns, social concerns failed to predict insomnia severity. In general, the previous findings on the sub-dimension of social concerns are scarce, perhaps because the body of research has concentrated only on physical and cognitive concerns [e.g., 39].

The study findings indicated that repetitive negative thinking had a strong correlation with insomnia severity. It was also a significant predictor of insomnia severity, which is consistent with previous studies [24, 25]. According to AG Harvey [78]’s cognitive model of insomnia, excessive worry and rumination (two components of repetitive negative thinking) about sleep, as well as long-term unresolved problems experienced during the day and night, result in attentional bias to sleep-related negative information, which trigger psychological arousal, and subsequently delay falling asleep.

Study Limitations And Future Directions For Research

Although our study provides new insights into the transdiagnostic factors that can predict insomnia severity, several limitations should be noted when drawing conclusions from our data. First, self-report measures are exposed to bias, owing to common method variance [CMV; 79]. Other methods, including actigraphy or daily sleep diaries, are suggested as alternatives, as well as conducting longitudinal studies to limit the effect of potential CMV biases [see 91]. Second, examining a clinical sample limits the generalizability to other samples. Thus, the findings must be interpreted cautiously. Future studies should examine our results in different samples (e.g., college students). Third, the majority of study participants were women. Although insomnia is more common in women than in men [13], we suggest that future studies consider equal number of men and women in their sample. This may increase the generalizability of their results to both male and female patients with insomnia and also provide the opportunity to explore the potential gender differences. Forth, low Cronbach’s alpha estimates for AAQ-II, CPQ, and BFI-10 may raise doubt about the reliability of these questionnaires. Therefore, the finding related to these constructs must be interpreted cautiously. Finally, the cross-sectional design used in this study prevents any causal conclusion. Research with longitudinal design is needed to further establish the role of transdiagnostic factors in insomnia severity over time.

Our findings underlined the importance of transdiagnostic factors of (in descending order) physical concerns (ASI), repetitive negative thinking (RTQ), neuroticism (BFI), personal standards (CPQ), cognitive reappraisal (ERQ), cognitive concerns (ASI), and evaluative concerns (CPQ) in predicting insomnia severity. The transdiagnostic factors of physical concerns (ASI) and repetitive negative thinking (RTQ) accounted for the most significant degree of variance in predicting insomnia severity, after controlling for demographic characteristics, depression, and anxiety symptoms. Longitudinal research on the role of transdiagnostic variables on insomnia severity is warranted. Such study design adds to our results and help designing an empirical framework to develop more accurate scientific and practical interventions for treating sleep disorders.

Ethics approval and consent to participate

This study was approved by the ethics committee at the Iran University of Medical Sciences (approval code = IR.IUMS.REC.1397.1346) and participants have filled written informed consent forms. It should be noted that all methods were performed based on the relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available in the supplementary file.

Competing interests

The authors of the present study declare no financial and non-financial competing interests.

Funding

This research was supported by grant number 97-4-23-13-762 from School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, received by Dr. Mojtaba Habibi Asgarabad. Dr. Habibi Asgarabad’s time on this research was funded by the Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway.

Authors' contributions

All authors on this paper met the four criteria for authorship as identified by the International Committee of Medical Journal Editors (ICMJE); all authors have contributed to the conception and design of the study, drafted or have been involved in revising this manuscript, reviewed the final version of this manuscript before submission, and agreed to be accountable for all aspects of the work. Specifically, the specific contributions of each author are as follows:

conceptualization, design, and methodology: MHA and HD; data collection: PSY; formal analysis: MHA, PSY, and RA; funding acquisition: MHA; investigation and project administration: MHA, HD, and FH; supervision: MHA; writing the original draft: HD, PSY, and RA; writing/ revising: HD, FH, PSY, RA, and MHA

Acknowledgements

The authors gratefully thank the patients who kindly participated in this research.

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No competing interests reported.

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The Contribution of Transdiagnostic Vulnerability Factors in Patients with Chronic Insomnia

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Abstract

Highlights

Introduction

Method

Participants

Measures

Procedure

Statistical Strategies

Results

Correlation of Insomnia Severity with Demographic and Transdiagnostic Factors

Prediction Of Insomnia Severity Based On Demographic And Transdiagnostic Factors

Discussion

Study Limitations And Future Directions For Research

Conclusions, And Clinical Applications

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References

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