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Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine logoLink to Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine
. 2024 Mar 1;20(3):433–443. doi: 10.5664/jcsm.10910

Perfectionism, perceived stress, and presleep arousal in insomnia: effects on sleep in a daily life study

Anna Küskens 1,✉, Johannes Stricker 1, Luca Stefan Hertrampf 1, Reinhard Pietrowsky 1, Annika Gieselmann 1
PMCID: PMC11019203  PMID: 37942932

Abstract

Study Objectives:

Perfectionism is considered a predisposing and maintaining factor for insomnia disorder. However, previous studies were predominantly based on retrospective self-reports of sleep and have yielded mixed results. Here, we investigated associations between perfectionism, daily stress levels, pre-sleep arousal, and actigraphic and sleep diary-derived sleep in insomnia using an experience sampling design.

Methods:

Individuals with insomnia (n = 63) reported their trait perfectionism levels and completed assessments on seven consecutive days. Momentary stress levels were reported on mobile phones at three semirandom time points each day. Presleep arousal levels were rated each morning for the previous night. Sleep onset latency, total sleep time, wake after sleep onset, and sleep efficiency were assessed prospectively using actigraphic watches and sleep diaries.

Results:

Perfectionism dimensions and daily stress levels did not predict self-reported or actigraphic sleep parameters. Higher levels of somatic and cognitive presleep arousal were robustly associated with indicators of poorer same-night sleep. The concern over mistakes and doubts dimension of perfectionism interacted with cognitive presleep arousal in predicting self-reported sleep parameters. In the presence of higher presleep arousal, participants with high concern over mistakes and doubts experienced shorter self-reported total sleep time and lower sleep efficiency (both Ps < .01) than on days with lower cognitive arousal.

Conclusions:

Taken together, our results did not indicate an impact of heightened perfectionism levels on sleep in individuals with insomnia, based on prospective sleep assessments. However, our findings provide further evidence for the role of somatic and cognitive presleep arousal, potentially interacting with perfectionism, in the perpetuation of insomnia symptoms.

Citation:

Küskens A, Stricker J, Hertrampf LS, Pietrowsky R, Gieselmann A. Perfectionism, perceived stress, and presleep arousal in insomnia: effects on sleep in a daily life study. J Clin Sleep Med. 2024;20(3):433–443

Keywords: insomnia, personality, sleep quality, stress, arousal, perfectionism

BRIEF SUMMARY

Current Knowledge/Study Rationale: Previous studies on associations between perfectionism and insomnia have yielded inconsistent findings, and they predominantly relied on global measures of self-reported sleep. Moreover, the roles of perceived stress during the day and arousal before sleep have not yet been addressed in this context. Here we investigated associations between trait perfectionism, daily stress, presleep arousal, and actigraphic and sleep diary-derived sleep in individuals with insomnia.

Study Impact: Based on prospective sleep assessments, the current analysis did not support a direct impact of perfectionism levels on sleep in individuals with insomnia. However, the findings emphasize the role of within-person presleep arousal in the maintenance of insomnia symptoms.

INTRODUCTION

Perfectionism is a multidimensional personality trait that is described as a risk and maintenance factor for insomnia.1,2 To date, various measures of perfectionism exist. A large body of research suggests that most of these measures align along two broader dimensions: perfectionistic concerns (centered around worries over imperfections) and perfectionistic strivings (centered around exceedingly high standards for oneself).3 Among the most frequently used perfectionism scales is Frost et al’s Multidimensional Perfectionism Scale.4 This scale differentiates concern over mistakes and doubts (a perfectionistic concerns indicator), personal standards (a perfectionistic strivings indicator), and further antecedents or correlates of perfectionism.3 Recently, a meta-analysis highlighted that differentiating perfectionism dimensions is important when investigating associations with poor sleep.5

Perfectionism and insomnia symptoms

Many studies have investigated links between perfectionism and insomnia, a sleep disorder characterized by difficulties falling asleep, difficulties maintaining sleep, and/or early morning awakening.6–8 Etiologic theories of insomnia explain the perfectionism–sleep link. The 3P model of insomnia9 postulates that predisposing (eg, genetic predispositions), precipitating (eg, stressful conditions), and perpetuating factors (eg, dysfunctional coping strategies) interact in the development and maintenance of insomnia. Personality traits, such as perfectionism, are considered factors that predispose individuals to insomnia. Over time, predisposing factors interact with stressful events as precipitating factors, subsequently triggering poor sleep. Perfectionists might be more vulnerable to reacting to stressors with dysfunctional coping strategies, ie, irregular sleep patterns.7 In this sense, perfectionism might fuel the progression from acute to chronic insomnia as a perpetuating factor.2,7

The cognitive model of insomnia10 highlights the role of cognitive processes such as worry, rumination, and dysfunctional beliefs about sleep in chronic insomnia. Individuals with high perfectionism are likely particularly vulnerable to these cognitions. Indeed, recent studies demonstrated that perfectionism, particularly perfectionistic concerns, is associated with dysfunctional sleep-related cognitions11 and counterfactual thoughts and emotions at bedtime.12 In sum, perfectionism appears to play a role in the development and maintenance of insomnia through processes involving dysfunctional cognitions, arousal, and poor sleep.

Prior research on the perfectionism–sleep link has yielded inconsistent findings (for a review, see Stricker et al13), with most studies indicating that perfectionistic concerns are closely linked to self-reports of poor sleep.11,12,14 However, other studies reported nonsignificant associations of perfectionistic concerns indicators with sleep, eg, based on sleep diary data.8,15 Compared to perfectionistic concerns, the association between perfectionistic strivings and self-reported sleep appeared weaker, with studies reporting positive,14 negative (eg, Richardson and Gradisar16), or nonsignificant associations (eg, Akram et al11; Schmidt et al12). Regarding associations of perfectionism dimensions with objectively measured sleep, one study using polysomnography found links between both perfectionism dimensions with indicators of poor sleep.17 In contrast, a recent study reported positive relations between perfectionism dimensions and polysomnography-derived sleep measures in individuals with insomnia.18

Due to the inconsistency of findings on the association between perfectionism dimensions and poor sleep, some methodological issues need to be addressed. Notably, previous studies predominantly used global measures of self-reported sleep, such as the Insomnia Severity Index19 or the Pittsburgh Sleep Quality Index.20 Both questionnaires cover the impact and strain caused by poor sleep over a period of two or four weeks, respectively, which makes these measures prone to retrospective biases. Specifically, when individuals evaluate their perceived sleep quality over a period of several nights, recall errors and cognitive biases might lead to inaccuracies in the estimations. For this reason, we used measures that are less subject to retrospective biases in the current study, combining prospective assessments of sleep diaries with actigraphic sleep parameters. Additionally, the inconsistency in findings indicates that third variables might moderate the link between perfectionism dimensions and poor sleep.

Perceived stress and arousal as moderators of the perfectionism-sleep link

It is essential to understand the factors influencing the relationship between perfectionism and poor sleep. Prior research indicates that perfectionistic individuals are particularly sensitive to stress (for an overview, see Dunkley et al21) and tend to experience increased arousal (eg, Besser et al22). Perfectionism interacted with perceived stress in predicting symptoms of depression23 and disordered eating behavior.24 Similarly, perceived stress and elevated presleep arousal have been proposed as factors that might amplify the relationship between perfectionism and insomnia.2,7,8 That is, individuals with high perfectionism levels would experience poorer sleep on days with heightened stress and elevated presleep arousal compared to days with lower stress levels. Indeed, in a prior study using polysomnography in a sample of sleep laboratory patients, associations between perfectionism and poor sleep were more pronounced on the first night in the sleep laboratory, which might be attributed to participants’ acute stress in the unfamiliar setting.17 In a different study,16 the tendency to react with poor sleep when confronted with stressful events (ie, stress-related sleep reactivity) explained the relationship between perfectionism and insomnia symptoms. The idea that the presence vs absence of acute stress moderates the perfectionism–sleep association is in line with the 3P model of insomnia but has so far only been empirically investigated in cross-sectional studies.

Taken together, it seems plausible that individuals high in perfectionism are prone to react with poor sleep in the context of heightened stress. However, it remains unclear whether stress levels during the day or arousal right before bedtime are relevant in this context. In the current study, we chose a clinical sample of individuals with insomnia to investigate the role of these variables in the maintenance of insomnia. Due to the mixed evidence from previous research, we took an exploratory approach to examine the potential moderating role of daily stress levels and presleep arousal in the perfectionism–sleep link.

The present study

Recent research indicates associations between perfectionism dimensions, perceived stress, arousal, and sleep, yet the interplay between those factors has not yet been addressed in a natural environment. Therefore, this study sought to examine these associations using an experience sampling method study design (ESM). In ESM studies, relevant variables are recorded in real-time during the participant’s daily lives, with the advantage of reducing recall bias while also elevating ecological validity.

Hypotheses

We hypothesized that (1) higher levels in perfectionism dimensions would predict poorer sleep (evaluated by actigraphic and self-reported sleep parameters: sleep onset latency (SOL), total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO)) over a period of seven days. We further hypothesized that higher stress levels during the day (2a) and presleep arousal (2b) would predict poorer sleep the following night. Based on the considerations outlined previously, we additionally tested for potential moderating effects of daily stress levels (3a) and presleep arousal (3b) on the link between perfectionism dimensions and poor sleep.

METHODS

Participants

Participants were recruited using online announcements and flyers on the university campus. Persons interested in participating first underwent an online screening survey in which the following inclusion criteria were assessed: (1) the presence of insomnia symptoms according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for insomnia disorder25 and research criteria for insomnia disorder,26 (2) an Insomnia Severity Index score ≥ 10,27 and (3) age above 18 years. Exclusion criteria were (1) the presence of a different sleep disorder (SLEEP-50 questionnaire),28 (2) current shift work, (3) use of sleep-altering medication, (4) abuse of alcohol (> 3 glasses/d for at least 21 days/m) or drug use, and (5) current medical condition that might disrupt sleep. Comorbid mental disorders were tolerated as long as the sleep complaints developed independently.

A total of 157 prospective participants completed the online screening. In a semistructured interview, these participants were then contacted via telephone to check the eligibility criteria. Seventy-six participants fulfilled all criteria, were available for appointments, and were subsequently invited into the laboratory. Nine participants dropped out before the first appointment. Of the 67 participants who completed the study, 4 participants were excluded from analyses due to incomplete sleep diary data (n = 2; more than two days missing), malfunctioning of the actigraphic watch (n = 1), and sleep disruptions by the participant’s child (n = 1).

The final sample consisted of 63 participants (42 female, 21 male) with a mean age of 32.38 years (range: 18–65, standard deviation (SD) = 12.94). Table 1 displays the detailed sample characteristics. Most participants were university students (60.32%), and few reported current psychiatric comorbidity (3.17%). One participant stated that they were taking a herbal sleeping pill but was still admitted to the study. None of the participants received psychological sleep treatment at the time of the data collection. Participants received a compensation of 30 EUR or study credit. Additionally, participants were offered optional information on insomnia symptoms and treatment options after the completion of the study.

Table 1.

Descriptive statistics.

Mean (SD) or n (%) nobservations ICC
Sample Characteristics
Age 32.38 (12.94) – –
Female, n (%) 42 (66.67) – –
Working, n (%) 18 (28.57) – –
Student, n (%) 38 (60.32) – –
Comorbid mental disorders, n (%) 2 (3.17) – –
Insomnia Severity Index 15.92 (3.85) – –
Study Variables
Perfectionism
 Concern over mistakes and doubts 32.89 (10.79); range 15-54 63 –
 Personal standards 22.22 (4.90); range 12-33 63 –
Actigraphic sleep
 Sleep onset latency (min) 22.11 (33.01) 439 0.29
 Total sleep time (min) 423.18 (80.51) 439 0.24
 Wake after sleep onset (min) 71.78 (36.54) 439 0.33
 Sleep efficiency (%) 80.69 (9.01) 439 0.49
Self-reported sleep
 Sleep onset latency (min) 40.73 (43.26) 438 0.36
 Total sleep time (min) 422.42 (97.18) 433 0.21
 Wake after sleep onset (min) 31.20 (50.38) 437 0.21
 Sleep efficiency (%) 80.27 (13.01) 433 0.30
 Time in bed (min) 530.72 (109.59) 437 –
Daily measures
 Mean stress level (VAS) 27.54 (18.62) 378 0.42
 Somatic arousal 9.81 (2.89) 377 0.71
 Cognitive arousal 13.37 (6.53) 377 0.74
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n = 63. Sleep parameters are reported based on seven nights; daily stress and arousal measures are reported for six days of matched assessments. ICC = intraclass correlations (proportion of variance explained by the between-person level), VAS = visual analog scale.

Procedure

All procedures were approved by the ethical committee of the Heinrich Heine University Düsseldorf prior to data collection. Additionally, the study was conducted in line with the Declaration of Helsinki. Informed consent was obtained from all participants prior to participation. After an initial online survey, participants underwent a semistructured telephone interview based on the Structured Interview for Sleep Disorders.29 Inclusion was determined according to the criteria described previously. Eligible participants were invited to the first briefing session at the laboratory, completed trait questionnaires, and received verbal and written instructions for the week of assessments. Participants were instructed to refrain from midday sleep and abstain from alcohol for the duration of the study. All participants were equipped with study smartphones, actigraphic watches, and sleep diaries in a pen-and-paper version. Actigraphs were worn continuously for seven days, starting from the briefing session. The ESM period began the next day and comprised seven consecutive days of assessments in the participants’ natural environment. Participants visited the laboratory for a second appointment, returned the devices and sleep diaries, were debriefed, and received their compensation. Figure 1 displays an overview of the study procedure.

Figure 1. Timeline of the study procedure.

Figure 1

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After an initial online screening, participants underwent a semistructured telephone interview. On the first appointment, participants completed the FMPS and were introduced to the study procedure. They then underwent a week of assessments in their home environment where they wore actigraphs continuously, completed a sleep diary and the Pre-Sleep Arousal Scale (PSAS) for the preceding sleep period each morning, and entered their stress levels into a smartphone app on three semirandom occasions during the day. After the seven-day period, the study was completed with an appointment at the laboratory.

Measures

Screening questionnaires

The online screening comprised demographic characteristics and the eligibility criteria mentioned previously. The presence of insomnia symptoms was assessed with the Insomnia Severity Index (ISI).19 The 7-item self-report instrument captures current sleep complaints, their intensity, and their impact during the last month. A cut-off score of ≥ 10 was used to identify individuals with insomnia.27 Additionally, other sleep disorders were ruled out using a German translation of the SLEEP-50 questionnaire.28 Cut-off scores were used for the following sleep disorders: sleep apnea, narcolepsy, restless legs or periodic limb movement disorder, circadian rhythm sleep disorder, sleepwalking, and nightmares. Neither screening questionnaires was included in the statistical analyses.

Multidimensional perfectionism

Perfectionism was captured with the German version30 of the Frost Multidimensional Perfectionism Scale (FMPS).4 This 35-item, Likert-type scale questionnaire was completed during the briefing session. Participants rated their agreement with each item (eg, “I set higher goals than most people”; “If I fail partly, it is as bad as being a complete failure”) on a scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The German FMPS comprises four subscales: personal standards, concern over mistakes and doubts, parental expectations and criticism, and organization.31 The subscales parental expectations and criticism as well as organization are correlates rather than components of perfectionism (eg, Stoeber3). These subscales were, therefore, not included in the current analyses. Scores range from 13 to 65 for concern over mistakes and doubts and from 7 to 35 for personal standards. The German FMPS has displayed satisfactory reliability and validity.31 In the present study, Cronbach’s alpha was .92 for concern over mistakes and doubts and .78 for personal standards.

Daily stress ratings

The present study used an app-based ESM design, a method in which individuals are surveyed at the current moment during their daily lives. For the assessment, the movisensXS-app (versions 1.5.0 through 1.5.19, movisens GmbH, Karlsruhe, Germany) was installed on study smartphones (Nokia 4.2). Participants were prompted by an alarm to answer a brief questionnaire on three semirandom occasions a day over seven days, spaced at least 1 hour apart. The app allowed participants to set individual timeframes for the sampling procedure to avoid disrupting the participants’ sleeping habits. To this end, participants entered their habitual sleeping times together with the experimenter during the briefing session. We determined momentary stress experience using one item (“At the current moment, I feel stressed”). Participants responded on a visual analog scale ranging from 0 (“not at all”) to 100 (“extremely”). Additionally, four items from the German translation of the short mood scale32 were included but are irrelevant to the current analyses. The items were presented in the same order across all assessments, each taking about 2 minutes to be completed. Daily stress levels were computed as the average score across all three assessments for the respective day.

Daily presleep arousal

We assessed cognitive and somatic presleep arousal with the German version33 of the Pre-Sleep Arousal Scale (PSAS).34 Participants completed the PSAS each morning in a pen-and-paper version. The instructions referred to the state arousal at bedtime for the preceding night. The PSAS is a 16-item questionnaire with a 5-point Likert scale ranging from 1 (“not at all”) to 5 (“extremely”). The PSAS assesses the severity of cognitive arousal (eg, “Worry about falling asleep”) and somatic arousal (eg, “A jittery, nervous feeling in your body”). The scores for both subscales are calculated separately. The German PSAS displays high reliability and validity.33 Cronbach’s alpha was acceptable for all measurement points (somatic arousal ranging from .68 to .81; cognitive arousal ranging from .90 to .94).

Actigraphy

Actigraphic sleep measures were assessed using a MotionWatch 8 (CamNtech Ltd., Cambridge, UK), a triaxial accelerometer worn on the nondominant wrist. Actigraphy provides estimated parameters of sleep continuity by measuring physical activity during the day and at night. We used the recommended recording mode for sleep analysis using a single-axis algorithm and an epoch length of 30 seconds. Data was subsequently analyzed with MotionWare Version 1.1.25 software (CamNtech Ltd.). Sleep–wake analysis was performed automatically using the MotionWare scoring algorithm with a high sensitivity threshold of 20 and an epoch length of 60 seconds. Estimated sleep parameters were exported for each sleep period. Actigraphic sleep parameters show satisfactory agreement with polysomnography in insomnia patients (eg, Sánchez-Ortuño et al35). Time in bed (TIB) for actigraphic analyses was determined by corresponding items from the daily sleep diary that were entered into the software manually for each sleep period to set the analysis window. In addition, participants were instructed to indicate their bedtime and rising times with an event marker button on the actigraph. In case of missing sleep diary entries, which occurred in n = 8 cases (0.91% of data points), event markers were then used to set time in bed. The following outcome variables were derived as indicators of actigraphic sleep quality: (a) SOL, (b) TST, (c) WASO, and (d) SE.

Sleep diary

To capture the participants’ perception of sleep, self-reported sleep was assessed using sleep diaries. Upon awakening, participants rated their sleep and estimated several sleep parameters with one item each (bedtime, SOL, TST, WASO, waking, and rising times). The self-reported SE was calculated from these answers (TST/time in bed × 100). Items of the sleep diary were adapted from a self-report instrument recommended for clinical practice by the German Sleep Society.36

Statistical analyses

Statistical analyses were conducted in SPSS Statistics 27 for descriptive statistics and R for multilevel analyses (lme 4 package Version 1.1-30).37 To account for the hierarchical structure of the data, we analyzed the data on two levels: daily observations (level 1) were nested within individuals (level 2). Daily stress levels, presleep arousal, and sleep parameters were assessed at level 1, while trait perfectionism was assessed at level 2. We estimated all multilevel models with random intercepts and fixed slopes. Deviance tests revealed that allowing random slopes did not improve model fit. Therefore, we did not include random slopes in our models. Intraclass correlations were computed to determine the proportion of variance explained by the within- and between-person level.

We estimated separate models for each sleep parameter with age and sex as covariates. When testing perfectionism dimensions as predictors, we included sleep parameters for all seven nights in the analyses. When testing time-varying predictors (ie, daily stress levels, presleep arousal), we included six days of daily measures with matching same-night sleep data in the analyses. The first night of sleep assessments was excluded in these analyses, as sleep recordings began the night before the experience sampling onset.

The first set of models tested perfectionism dimensions (separate models for concern over mistakes and doubts and personal standards) as predictors of actigraphic and self-reported sleep parameters across seven nights (hypothesis 1). In the second set of models, within-person stress levels (hypothesis 2a) and presleep arousal (hypothesis 2b) predicted same-night sleep parameters based on six days of matched diary and sleep data. The third set of models evaluated our moderation hypotheses. We examined the interaction effects between perfectionism dimensions and daily stress (hypothesis 3a) or presleep arousal (hypothesis 3b) on sleep parameters. Cross-level interaction terms for stress or arousal as moderators were entered into separate models. To support the interpretation of cross-level interactions, we examined simple slopes plots for high (+1 SD) and low (−1 SD) levels of the moderator. Results with P values for all models are reported in the supplemental material (Table S1 (227.2KB, pdf) , Table S2 (227.2KB, pdf) , Table S3 (227.2KB, pdf) , Table S4 (227.2KB, pdf) , Table S5 (227.2KB, pdf) , and Table S6 (227.2KB, pdf) in the supplemental material). The level of statistical significance was set at .01 to reduce type I errors due to multiple testing.

Due to missing data in the actigraphic and self-reported sleep parameters, the number of observations varied between the models. Prior to analysis, level 2 predictors (ie, perfectionism dimensions) were grand-mean centered. Level 1 continuous variables (ie, time-varying variables) were person-mean centered.

RESULTS

Preliminary analyses

Sample characteristics and descriptive statistics for the study variables are presented in Table 1. During the experience sampling, there were n = 1323 possible observations for momentary stress levels (21 daily assessments × 63 persons). Participants missed n = 163 out of a total of n = 1323 assessments, resulting in a high response rate of 87.68%. For presleep arousal and sleep data, there were n = 441 possible observations (7 days × 63 persons). Data collection resulted in excellent response rates of 99.77% for PSAS ratings, 99.55% for actigraphic recordings, and 98.19% for complete sleep diaries. Intraclass correlations revealed that a considerable proportion of variance (26%–79%) was explained by the within-person level (ie, day-to-day fluctuations), confirming the need for a multilevel approach (see Table 1).

On average, the stress level during the day was 27.54 (SD = 18.62; visual analog scale, 0–100). For presleep arousal, participants reported an average somatic arousal score of 9.81 (SD = 2.89) and a cognitive arousal score of 13.37 (SD = 6.53). Participants slept an average of 7.05 hours (SD = 1.34) for actigraphic sleep and reported 7.04 hours (SD = 1.62) of self-reported sleep time. The average SE was 80.69% (SD = 9.01) for actigraphic sleep and 80.27% (SD = 13.01) for self-reported sleep. Thus, SE was below the level of 85%, indicating, as expected, poor sleep in our sample.38 Participants overestimated their SOL (M = 40.73, SD = 43.26) compared to actigraphic SOL (M = 22.11, SD = 33.01), while they reported lower WASO (M = 31.20, SD = 50.38) than assessed by the actigraph (M = 71.78, SD = 36.54). The average time spent in bed was 8.85 hours (SD = 1.83).

Effects of perfectionism on sleep

The results for the first set of analyses examining the effects of perfectionism dimensions on sleep parameters are presented in Table 2. No sleep parameters were significantly predicted by perfectionism dimensions (all Ps ≥ .014; nonsignificant at an alpha level of .01; see Table S1 (227.2KB, pdf) and Table S2 (227.2KB, pdf) for P values).

Table 2.

Perfectionism dimensions (FMPS) as predictors of sleep parameters.

Perfectionism Dimensions (FMPS)
CMD PS
Actigraphic sleep SOL 0.12 [−0.35, 0.58] −0.52 [−1.58, 0.54]
TST 0.61 [−0.32, 1.55] 0.79 [−1.35, 2.94]
WASO −0.48 [−1.02, 0.06] −1.52 [−2.73, −0.31]
SE 0.10 [−0.05, 0.25] 0.39 [0.05, 0.72]
Self-reported sleep SOL −0.07 [−0.75, 0.60] −1.25 [−2.74, 0.25]
TST −0.36 [−1.44, 0.72] −1.15 [−3.61, 1.30]
WASO 0.63 [−0.01, 1.27] 0.92 [−0.56, 2.39]
SE −0.11 [−0.30, 0.08] −0.01 [−0.44, 0.42]
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n = 63. Sleep outcomes are included across seven nights. Values are unstandardized regression coefficients [95% confidence intervals]. All analyses control for age and sex. See Table S1 (227.2KB, pdf) and Table S2 (227.2KB, pdf) for covariates and P values. CMD = concern over mistakes and doubts, FMPS = Frost Multidimensional Perfectionism Scale, PS = personal standards, SE = sleep efficiency, SOL = sleep onset latency, TST = total sleep time, WASO = wake after sleep onset.

Effects of daily stress levels and presleep arousal on same-night sleep

The results for multilevel analyses of daily stress and presleep arousal predicting same-night sleep parameters are presented in Table 3. There was no statistically significant effect of daily stress levels in predicting same-night sleep parameters (see Table S3 (227.2KB, pdf) and Table S4 (227.2KB, pdf) for P values). Regarding presleep arousal, on days when participants experienced more severe somatic arousal than usual, they had shorter actigraphic TST (b = –7.54, 95% confidence interval (CI) [–12.59, –2.49], P = .004) and lower actigraphic SE (b = –0.63, 95% CI [–1.08, –0.17], P = .007). Analyses with self-reported sleep parameters showed no significant effects of somatic arousal on self-reported sleep (all Ps ≥ .029; Table S4 (227.2KB, pdf) ).

Table 3.

Within-person daily stress and presleep arousal as predictors of sleep parameters.

Presleep Arousal Daily Stress
Somatic Arousal Cognitive Arousal Mean Stress Levels
Actigraphic sleep SOL −0.43 [−2.51, 1.64] 0.94 [−0.01, 1.89] −0.02 [−0.24, 0.21]
TST −7.54** [−12.59, −2.49] −4.55*** [−6.85, −2.25] −0.28 [−0.83, 0.28]
WASO 1.99 [−0.11, 4.09] 0.42 [−0.55, 1.39] −0.23 [−0.46, 0.00]
SE −0.63** [−1.08, −0.17] −0.40*** [−0.61, −0.19] 0.02 [−0.03, 0.07]
Self-reported sleep SOL 0.06 [−2.36, 2.48] 2.38*** [1.30, 3.46] −0.15 [−0.41, 0.12]
TST −5.33 [−11.40, 0.74] −6.46*** [−9.18, −3.73] −0.06 [−0.72, 0.59]
WASO −1.45 [−4.46, 1.55] 0.23 [−1.16, 1.61] 0.15 [−0.18, 0.48]
SE −0.85 [−1.62, −0.09] −1.01*** [−1.35, −0.67] 0.05 [−0.03, 0.13]
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n = 63. Daily assessments and same-night sleep measures across six days. Values are unstandardized regression coefficients [95% confidence intervals]; within-person effects. All analyses control for age and sex. **P < .01, ***P < .001. See Table S3 (227.2KB, pdf) and Table S4 (227.2KB, pdf) for covariates and P values. SE = sleep efficiency, SOL = sleep onset latency, TST = total sleep time, WASO = wake after sleep onset.

Daily cognitive arousal negatively predicted same-night actigraphic TST (b = –4.55, 95% CI [–6.85, –2.25], P < .001) and actigraphic SE (b = –0.40, 95% CI [–0.61, –0.19], P < .001). Regarding self–reported sleep parameters, daily cognitive arousal significantly predicted self–reported SOL (b = 2.38, 95% CI [1.30, 3.46], P < .001), TST (b = –6.46, 95% CI [–9.18, –3.73], P < .001), and SE (b = –1.01, 95% CI [–1.35, –0.67], P < .001).

Daily stress and presleep arousal as moderators of the perfectionism-sleep link

The results of the moderation analyses are reported in the supplemental material (Table S5 (227.2KB, pdf) for actigraphic sleep and Table S6 (227.2KB, pdf) for self-reported sleep). Concern over mistakes and doubts did not interact with daily stress levels to predict sleep parameters (all Ps ≥ .032; see Table S5 (227.2KB, pdf) and Table S6 (227.2KB, pdf) ). However, concern over mistakes and doubts interacted significantly with presleep cognitive arousal in predicting self-reported sleep parameters, namely shorter TST (b = –0.35, 95% CI [–0.59, –0.10], P = .005) and lower SE (b = –0.05, 95% CI [–0.08, –0.02], P = .001). Finally, no significant effects emerged for personal standards interacting with daily stress levels or presleep arousal in predicting sleep parameters (all Ps ≥ .051; see Table S5 (227.2KB, pdf) and Table S6 (227.2KB, pdf) ).

Simple slopes plots for significant interactions are shown in Figure 2 and Figure 3. The plots display associations between concern over mistakes and doubts and self-reported TST or SE, depending on the severity of cognitive arousal. On days with higher cognitive arousal, participants with high concern over mistakes and doubts experienced shorter self-reported TST and lower self-reported SE than on days with lower cognitive arousal.

Figure 2. Simple Slopes plot for effects of concern over mistakes and doubts perfectionism on self-reported total sleep time for high and low levels of cognitive presleep arousal.

Figure 2

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Figure 3. Simple Slopes plot for effects of concern over mistakes and doubts perfectionism on self-reported sleep efficiency for high and low levels of cognitive presleep arousal.

Figure 3

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DISCUSSION

This study investigated associations between trait perfectionism, daily stress, presleep arousal, and sleep in individuals with insomnia. To our knowledge, this is the first study using an ESM design in a clinical sample to examine the relationship between these variables. Contrary to our hypothesis, results indicated that perfectionism dimensions were not associated with objective or self-reported sleep parameters. No significant effects of stress levels during the day on subsequent sleep were observed. However, within-person somatic and cognitive presleep arousal robustly predicted poorer subsequent sleep. While higher somatic arousal predicted same-night actigraphic sleep (shorter TST, lower SE), cognitive arousal predicted actigraphic (shorter TST, lower SE) and self-reported sleep (longer SOL, shorter TST, and lower SE). Finally, our moderation analyses revealed that cognitive presleep arousal moderated the relationship between the concern over mistakes and doubts dimension of perfectionism and parameters of self-reported sleep, specifically shorter TST and lower SE. Overall, the results underline the role of heightened presleep arousal in the maintenance of insomnia.

Perfectionism dimensions predicting sleep

Our hypothesis that perfectionism dimensions are related to poor sleep across seven days was not supported. There were no effects of perfectionism on actigraphic sleep parameters or self-reported sleep. This finding contrasts with previous work linking concern over mistakes and doubts to diagnosed insomnia6–8 and self-reported poor sleep (eg, Schmidt et al12). The current data indicated that personal standards were also unrelated to sleep parameters. This finding is in line with prior studies reporting nonsignificant relations for this perfectionism dimension (eg, Akram et al11; Schmidt et al12) but contrasts with other previous work that linked personal standards to insomnia disorder.7 The current study’s methodology may account for the differing results. First, previous results are primarily based on larger samples. Although our sample size is comparable to other ESM studies, we might not have been able to detect smaller effects. Second, other studies predominantly used global self-report questionnaires on sleep. This is particularly relevant because perfectionistic tendencies might influence sleep perceptions. Perfectionists potentially show a specific response pattern in sleep questionnaires, especially when they are asked to recall their sleep quality retrospectively.2,5 Specifically, individuals high in perfectionism might evaluate their sleep more critically, overestimate sleep parameters, or be more likely to report severe insomnia complaints than individuals low in perfectionism, thus scoring higher in those questionnaires. In line with this reasoning, perfectionistic concerns and perfectionistic strivings were not significantly associated with sleep parameters derived from daily sleep diaries in previous studies.8,15 Moreover, previous findings on the associations between perfectionism and polysomnography-derived objective sleep parameters, which are not affected by the biases mentioned previously, remain inconsistent.17,18 Accordingly, the methodology in our study might have reduced self-report biases, as we used prospective assessments of actigraphic sleep parameters and sleep diary data.

Daily stress and presleep arousal predicting subsequent sleep

Daily stress levels did not predict sleep in our study. There is mixed evidence from previous studies with daily diary designs on the link between stress and sleep. Unlike our findings, some studies showed that higher within-person perceived stress or stressor occurrence had detrimental effects on same-night actigraphic sleep parameters39,40 and self-reported sleep40,41 in nonclinical samples. In contrast, other studies did not find an effect of perceived stress or stressor occurrence on subsequent electroencephalogram-determined sleep measures,42 actigraphic sleep parameters,43 or self-reported sleep.44

In contrast to daily stress levels, presleep arousal was robustly linked to same-night actigraphic and self-reported sleep. Accordingly, individuals with insomnia have poorer sleep on days when they experience more presleep arousal than usual. This finding is in line with the hyperarousal model of insomnia,45,46 suggesting that bidirectional relations between arousal and sleep exacerbate sleep disturbances over time. Thus, a vulnerability to arousal is not only viewed as a predisposing factor in insomnia disorder but is also a well-established factor in its maintenance (eg, Morin et al47). Our results are consistent with previous daily diary studies linking presleep arousal to subsequent self-reported poor sleep48,49 and longer actigraphic SOL50 in nonclinical samples. There were more overall effects of cognitive arousal than of somatic arousal on sleep. Thus, in our sample of individuals with insomnia, cognitive activation was more disruptive to subsequent sleep than physical symptoms of activation on a daily level. Interestingly, somatic arousal was linked to actigraphic poor sleep but not self-reported sleep measures. One possible explanation for this finding is that somatic arousal encompasses heightened muscle tension and activity, which could be interpreted as wakefulness in actigraphic recordings.

Overall, our findings suggest that days with more severe presleep arousal interfere most with sleep, compared to daily stress levels and perfectionistic dispositions. Thus, processes that occur immediately before bedtime seem to be more relevant for one’s night sleep than daily fluctuations of stress.

Daily stress and arousal as moderators

Moderation analyses revealed that cognitive presleep arousal, but not stress levels, moderated the perfectionism–sleep link. More specifically, there were interactions between the concern over mistakes and doubts dimension of perfectionism and cognitive presleep arousal in predicting shorter self-reported TST and lower SE. Individuals with high concern over mistakes and doubts levels were more vulnerable to experiencing shorter sleep duration when high presleep cognitive arousal occurred. It seems plausible that the concern over mistakes and doubts subscale, rather than the personal standards subscale, interacts with cognitive arousal, as the impact of evaluations and worries associated with concern over mistakes and doubts on sleep would depend on the presence of sleep-interfering cognitive activation at bedtime. Moreover, we did not find this moderation effect for actigraphic sleep measures. One explanation for this pattern of results might be that self-reported sleep and actigraphic sleep measures capture different aspects of sleep. Thus, the interaction between concern over mistakes and doubts perfectionism and higher cognitive activation before sleep would be linked to the perception and evaluation of one’s sleep rather than to sleep–wake patterns as assessed by actigraphy.

Interventions that target dysfunctional thought processes at bedtime may reduce the vulnerability to insomnia symptoms. Based on our results, therapists might explore and modify perfectionistic cognitions in the presleep state for insomnia patients who report high levels of concern over mistakes and doubts perfectionism. However, these implications need to be viewed as preliminary.

Limitations and strengths

Several limitations of this study need to be considered. First, we included only persons with insomnia in our sample. On the one hand, this is a strength of this study as we observed the processes of interest in the affected population. On the other hand, this inclusion criterion might have reduced the observed variance in sleep measures and stress levels. Relatedly, the observed range in perfectionism levels may have been reduced, as higher perfectionism levels have been shown in insomnia compared to good sleepers.6–8 Second, we captured objective and self-reported sleep parameters but relied on self-report for assessing stress levels and presleep arousal. Future studies may benefit from assessments of physiological stress markers. Third, arousal before sleep and self-reported sleep measures were assessed at the same time in the morning for the previous night, so that the timing of self-reports may have aggravated common method bias. Fourth, we did not estimate bidirectional effects as the sample size did not allow more complex statistical models. There is some evidence for bidirectional associations of daily stress and arousal with sleep.40 Thus, future large-scale ESM studies should incorporate bidirectional pathways linking stress, presleep arousal, and sleep to clarify the temporal dynamics between those variables.

Despite these limitations, the present study expands upon previous research by investigating the relationship between perfectionism and insomnia symptoms in a naturalistic setting. Our study design provided high ecological validity, as sleep was evaluated in the participant’s home. Moreover, we combined actigraphic and sleep diary-derived sleep parameters to reduce reporting bias.

CONCLUSIONS

Based on prospective sleep assessments, our results do not support a direct impact of perfectionism on actigraphic and self-reported sleep in individuals with insomnia. However, we found strong support for the role of within-person presleep arousal in the chronicity of insomnia. While somatic arousal was associated with same-night actigraphic sleep parameters, cognitive arousal appears to negatively impact both same-night actigraphic sleep parameters and self-reported sleep. Given our findings from the moderation analyses, the effect of perfectionistic concerns on poor sleep might be triggered in the context of high cognitive arousal. Together, our findings emphasize the impact of within-person processes just before bedtime in the maintenance of insomnia symptoms.

DISCLOSURE STATEMENT

All authors have seen and approved the final version of the manuscript. This study was funded in part by the German Sleep Society (DGSM). The authors report no conflicts of interest.

ABBREVIATIONS

CI

confidence interval

ESM

experience sampling method

PSAS

Pre-Sleep Arousal Scale

SE

sleep efficiency

SOL

sleep onset latency

TST

total sleep time

WASO

wake after sleep onset

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