Sleep-related metacognitions and cognitive behavioral therapy for insomnia

Participants

A total of 92 patients with chronic insomnia disorder diagnosed according to the third edition of the International Classification of Sleep Disorders (ICSD‑3; mean age = 49.4; standard deviation [SD] = 12.01) participated in group therapy for chronic insomnia. Demographic information, comorbidities, and use of sleep medication are displayed in Table 1. Antidepressant medication in the patient group without affective comorbidity was used as sleep-promoting medication. A subgroup analysis was performed for those 69 insomnia patients without any psychiatric or sleep-related comorbidity (mean age [M] = 50.20, SD = 12.16). There was a significant age difference (total sample: t(90) = −2.65, p = 0.010; subsample without comorbidities: t(67) = −2.68, p = 0.009), with women (total sample: M = 51.31, SD = 11.72, N = 68; subsample without comorbidities: M = 52.26, SD = 11.45, N = 53) being older than men (total sample: M = 44.00, SD = 11.37, N = 24; subsample without comorbidities: M = 43.38, SD = 12.29, N = 16).

Therapy

CBT‑I was conducted according to [17]. It consisted of seven 90-minute group sessions. The first four sessions were held on a weekly basis, the fifth and sixths session each after 2 weeks. The last session after 8 weeks of therapy is here referred to as “post visit.” A seventh follow-up visit was offered 3 months after the post visit (here referred to as “follow-up visit”). A licensed specialist in psychiatry and psychotherapy, certified in sleep medicine and with a diploma in metacognitive therapy (MCT) from the MCT Institute, conducted the group sessions. The therapy consisted of the development of a disease model, sleep restriction monitored by sleep diaries, psychoeducation about sleep-related topics, restructuring of dysfunctional sleep-related beliefs, relaxation techniques, and exchange of experiences during therapy between the group members.

For 40 out of 92 patients with insomnia receiving treatment from 2019 onwards, CBT‑I integrated elements MCT. Approximately 25% of the total therapy time was allocated to metacognitive interventions. The allocated time was obtained by omission of restructuring of dysfunctional sleep-related beliefs and reducing time spent on psychoeducation about sleep architecture and relaxation techniques from the original program. Sleep-related cognitions and metacognitions were collected by the group members, and a metacognitive case formulation inspired by the generalized anxiety disorder case formulation from Wells was developed with the group [31]. The metacognitive interventions in subsequent therapy sessions referred to this case formulation. It contained sleep-related cognitions like “If I don’t sleep now, I won’t be able to be active tomorrow,” sleep-related metacognitions like “Thinking in bed means I won’t get to sleep,” and the cognitive, emotional, behavioral, and physiological reactions to them. The technique of “detached mindfulness” was introduced. Behavioral experiments and exercises were used to show how to let go of thoughts without giving them further attention. Metaphors were introduced to facilitate its use. Another technique is postponing worrying and rumination. The purpose of this technique is to reduce dysfunctional thought processes and show that thought processes are controllable, i.e., to challenge the negative metacognitive belief of uncontrollability of excessive thinking [31]. The goal of another technique, the “attention training technique,” is to focus attention outward, away from dysfunctional thought processes [31].

Questionnaires

The Insomnia Severity Index (ISI) [2, 14, 15] consists of seven items covering the nature and severity of insomniac complaints, both at nighttime and during the daytime, during the previous 2 weeks on a five-point Likert scale ranging from 0 to 4, with 4 indicating a very severe problem. A sum score is calculated reaching values between 0 and 28, with higher values representing more insomnia symptoms: a score of 0–7 indicates no clinically significant insomnia, 8–14 subthreshold insomnia, 15–21 clinical insomnia (moderate severity), and 22–28 clinical insomnia (severe) [2, 15]. The German version was used [4]. In the current study the reliability coefficients (Cronbach’s alpha) for the three measurement points were 0.711 (pretest), 0.798 (posttest), and 0.809 (follow-up).

The Metacognitions Questionnaire—Insomnia was originally created by Waine et al. [30] and includes 60 questions about sleep-related metacognitions [30]. Each question is answered on a four-point Likert scale from “do not agree” (1) to “agree very much” (4). A sum score of all items is calculated, with higher values representing more maladaptive sleep-related metacognitions [30]. A short form of the questionnaire, the MCQ-I 20, was developed by Schredl [24]. Three certified MCT therapists independently agreed on 20 translated items that unambiguously captured sleep-related metacognitions, e.g., “Before I fall asleep, I must get things sorted in my mind.” The MCQ-I 20 showed high internal consistency (rtt = 0.906) and high test–retest reliability (r = 0.916). The sum scores were previously shown to be higher for patients diagnosed with insomnia disorder as well as for those with nightmare disorder and depression disorder [24]. In the current study, the reliability coefficients (Cronbach’s alpha) for the two measurement points were 0.885 (pretest) and 0.818 (posttest).

Two questions related to the uncontrollability of excessive thinking were presented at the beginning and after the intervention. These questions were adapted from the CAS module “cognitive attentional syndrome” published in [31]. The questions used were 1) “Nocturnal chains of thoughts are uncontrollable” and 2) “Thought circles happen automatically.” Participants rated their level of conviction in these statements on a scale of 0 to 100, with 0 representing “I don’t believe in this belief at all” and 100 representing “I am absolutely convinced that this belief is true.”

Procedures

The CBT‑I program was offered to patients who underwent clinical diagnostics in the sleep laboratory of the Central Institute of Mental Health Mannheim, Germany, and who had received a diagnosis of chronic insomnia disorder. Each group consisted of 4 to 9 patients. The therapy was carried out between March 2015 and November 2020, whereby 52 patients received standard CBT‑I therapy and 40 patients received CBT‑I with integrated metacognitive elements.

Patients completed paper–pencil self-assessment questionnaires at the beginning of the therapy (pre), after 8 weeks (post), and after 20 weeks (follow-up visit; Fig. 1). If the patients were not able to join a meeting, they were asked to send the completed questionnaires. Not all participants completed the ISI at all timepoints. Some completed it only at the pre visit (total sample n = 11; sample without comorbidities n = 6), at the pre and post visits (total sample n = 23; sample without comorbidities n = 20), at the pre and follow-up visits (total sample n = 22; sample without comorbidities n = 19), and some completed the ISI at pre, post, and follow-up visits (total sample n = 21; sample without comorbidities n = 13). The effect of metacognitive interventions was evaluated by presenting two questions related to the uncontrollability of excessive thinking at the beginning and after the intervention (only in the CBT-I + MCE group).

Fig. 1figure 1

Visits over time and completed questionnaires. Therapy duration was 8 weeks followed by a 3-month follow-up phase. Questionnaires were completed before the start of the therapy (Pre), after the therapy (Post), and at the end of follow-up (Follow-up). The Insomnia Severity Index (ISI) was completed at all timepoints and the short version Metacognitions Questionnaire—Insomnia (MCQ‑I 20) was completed at pre and post visits. Not all participants completed the questionnaires at all timepoints

The Ethics Committee II of the Medical Faculty Mannheim/University Heidelberg approved the retrospective analysis of the clinical data.

Statistical analysis

Data analysis was performed using the SPSS statistical software package, version 27 (IBM Corp., Armonk, NY, USA). Paired t-tests were used to test differences in mean scores comparing the pre, post, and follow-up timepoints. For the ISI, Bonferroni adjustment for multiple comparisons was performed. Cohen’s d was calculated between the three timepoints [3].

Associations between patient-reported psychometric measures (ISI, MCQ-I 20) and the demographic data (age, gender, comorbidities) at the pre visit were calculated using the Pearson correlation coefficient.

Mixed linear models were used to assess interactions of demographics or the pretreatment MCQ-I 20 score and therapy effectiveness based on the ISI scores over time (ISI score as dependent variable and time as the fixed factor, i.e., pre, post, follow-up). Demographic data (age, gender, comorbidities) and the pretreatment MCQ-I 20 score were set as covariates. The random factor was the subjects ID. We ran multiple linear models with one covariate in each model. For the treatment comparison of the CBT‑I (CBT-I) with the CBT‑I with integrated metacognitive elements (CBT-I+MCE), mixed linear models were calculated.

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