Abstract
Background:
Cancer survivors are prone to insomnia due to the physical and psychological sequelae of cancer and treatment. Individuals with insomnia may present symptoms of hyperarousal. Cancer survivors with insomnia and trait hyperarousal may require different clinical treatments than patients with insomnia without trait hyperarousal. To our knowledge, no study has examined these factors previously. This study examined the relation between insomnia and trait hyperarousal in cancer survivors.
Methods:
The sample included 160 individuals with previous cancer diagnoses who met DSM-5 criteria for Insomnia Disorder. Measures were collected with cross-sectional batteries of questionnaires, including the Insomnia Severity Index (ISI) and Hyperarousal Scale (HAS). This study is based on baseline data collected in a randomized clinical trial comparing CBT-I to acupuncture for cancer survivors with insomnia (Garland, Gehrman, Barg, Xie, & Mao, 2016).
Results:
Hyperarousal was positively associated with insomnia (ISI total score) in bivariate correlations (r = .350, p < .01) and linear regressions (F = 22.06, p < .001). In bivariate correlations, hyperarousal was related to perceptions about the consequences of disturbed sleep rather than reported sleep patterns. For example, hyperarousal was positively related to reported satisfaction (r = .159, p < .05) and worry about sleep (r = .415, p < .01), but not to falling asleep, staying asleep, or awakening too early. In regressions, younger age, insomnia duration, and worry about sleep were uniquely associated with hyperarousal when adjusting for insomnia (B = 0.200, B = 0.177, B = −0.182, p < .05).
Conclusions:
Hyperarousal is associated with psychological appraisal of insomnia rather than reported sleep pattern. Younger age and longer duration of insomnia are associated with trait hyperarousal. These findings suggest targeting trait hyperarousal with amplified psychological treatment may lead to more personalized, effective treatment for insomnia.
Keywords: insomnia, hyperarousal, cancer, sleep
Introduction
Cancer survivors have higher rates of insomnia relative to the general population, with a large portion, 30% to 60%, reporting insomnia disorder [1–4]. Insomnia disorder, henceforth called insomnia, is defined by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, as difficulties falling asleep, staying asleep, and/or early awakening, for greater than 3 months, that causes impairment in daily life [5]. While the reasons for these increased rates of insomnia among cancer survivors are not completely understood, it is likely due cancer diagnoses and treatment sequelae serving as precipitating factors to the insomnia process. Specifically, cancer survivors experience to a combination of underlying inflammatory processes [6–8], the physical effects of treatment (e.g., postsurgical pain, overall fatigue, nausea, nocturnal hot flashes, increased bathroom use, and steroid-induced agitation [3, 6, 9, 10]), and the psychological impact of the cancer diagnosis and treatment (e.g., increased worry, anxiety and depression) [2, 11, 12]. Insomnia can have significant deleterious consequences for cancer survivors: it can worsen already significant psychological distress and poor quality of life [13], exacerbate disease outcomes and may even place cancer patients at higher risk for recurrence or secondary cancers [14].
Some individuals with insomnia also report hyperarousal: increased physical and cognitive arousal characterized by sleeping issues, difficulties concentrating, irritability, anger, and panic [15]. It is not known whether the hyperarousal is a consequence of insomnia or rather a trait characteristic that preceded the insomnia. Hyperarousal in the context of insomnia is defined by lack of expected sleepiness [16], and can be defined as both a trait-like pattern or state-like hyperarousal that is present just before sleep [17]. This paper will focus on trait hyperarousal, which encompasses both cognitive and physical hyperarousal, though focuses on cognitive hyperarousal [16].
Individuals who report trait hyperarousal tend to report worse insomnia [16]. This may be in part because trait hyperarousal seems to affect beliefs about insomnia (and therefore report of severity of insomnia) moreso than insomnia itself [15, 16]. For example, previous research has observed a discrepancy between a patient’s subjective report of sleep issues (e.g., sleep diaries) and objective sleep measured (i.e., polysomnography), and some argue that cognitive processes such as trait hyperarousal may contribute to the perception of insomnia [15]. Further, not only do people with insomnia and trait hyperarousal report typical hyperarousal symptoms (e.g., My mind is always going), but they also report other symptoms of emotion dysregulation and disorganization. These symptoms converge on cognitive constructs such as rumination and personality constructs such as procrastination and neuroticism [16]. Also, trait hyperarousal in the context of insomnia is linked to an increased likelihood of a patient using prescription sleep aids [18]. As such, there may be personality differences between individuals with insomnia and hyperarousal compared to those without this trait characteristic. However, research also shows that people with trait hyperarousal tend to have cortical electrical responses that are greater than the stimulus input themselves [16]. This research suggests that there may be a neurobiological difference in this group, or that those with trait hyperarousal and more perceived distress about insomnia may evidence more neurobiological distress than those with insomnia without hyperarousal. Additionally, as there are increased rates of distress and trauma in cancer survivors [19–21], there may be a greater prevalence of trait hyperarousal; more research is needed.
As such, it is important to continue to examine the relationship between insomnia and insomnia with trait hyperarousal, especially in vulnerable groups, such as cancer survivors. First, examining whether those with insomnia and trait hyperarousal report worse insomnia based on self-report than is found on behavioral measures, as treatment might differ for those with behavioral insomnia symptoms and those with perceived insomnia, or distorted beliefs about insomnia. Insomnia and trait hyperarousal have never been examined in cancer survivors. As such, it is not known whether the previous research in the general population about trait hyperarousal in insomnia would be replicated in this group. Second, examining those with insomnia and trait hyperarousal in relation to distress about insomnia is important, because elevated distress is worthy of amplified treatment, especially among people with a cancer diagnosis. Third, age, socioeconomic status, education, race/ethnicity, cancer stage and cancer treatment may all be related to relevant treatment factors such as treatment feasibility, acceptability, duration, and focus [22], and could lend itself to identification of patients with insomnia at risk of trait hyperarousal as well.
This study aims to describe the relationship between trait hyperarousal and insomnia symptoms in cancer survivors diagnosed with insomnia. Insomnia symptoms are captured via daily sleep diaries and a perceived insomnia severity scale including report of distress about insomnia symptoms and report of interference of insomnia symptoms on daily life. This study also aims to identify sociodemographic factors associated with the presence of trait hyperarousal in insomnia. Specific aims and hypotheses are as follows:
To evaluate the relationship between hyperarousal and insomnia in cancer survivors. In accordance with previous research, it is hypothesized that greater trait hyperarousal will be related to more severe reported insomnia in cancer survivors.
To evaluate the relationship between hyperarousal and specific components of insomnia (i.e., sleep diary reported difficulties with sleep onset and/or maintenance and perceptions of insomnia such as perceived interference with quality of life). In accordance with some, but not all, previous literature, it is hypothesized that trait hyperarousal will be related to greater reports of perceptions of insomnia rather than diary reports of sleep continuity disturbance.
As an exploratory aim, sociodemographic factors associated with trait hyperarousal in cancer survivors that may impact treatment and treatment outcomes were explored.
Method
Participants
Participants were 160 cancer survivors who met inclusion criteria for the parent study [1]. Inclusion criteria included being English-speaking, being over the age of 18, being a cancer survivor, and meeting criteria for an insomnia diagnosis according to the Diagnostic and Statistical Manual of Mental disorders (DSM-5) as determined by clinical interview. Exclusion criteria included the presence of another sleep disorder not adequately treated, previous experience with Cognitive Behavior Therapy for Insomnia (CBT-I) or acupuncture for insomnia, and the presence of another psychological disorder not in remission or adequately treated.
Procedures
Participants were recruited from two major cancer centers and their diverse community partners in the Northeastern United States for the larger study, a randomized clinical trial comparing CBT-I to acupuncture for cancer survivors with insomnia [1]. The data presented in the paper are from the pre-intervention battery of questionnaires and the sleep diaries. See the methods paper for more detailed methodological information about the larger study [1].
Measures
Independent variable: Trait Hyperarousal
The Hyperarousal Scale (HAS) consists of 26 self-reported behaviors commonly exhibited in individuals with trait hyperarousal and insomnia and has been validated against objective measures of EEG arousal [16]. Items include: My mind is always going. Some thoughts return too often. I am well-organized. I get tearful easily. Items are rated on a four-point Likert scale ranging from ‘0-not at all’ to ‘3-extremely.’ The HAS has been used in patients with insomnia as primary or other disorder [e.g., 23], patients in menopause [e.g., 24], including large international samples [25]. Reliability for this sample was α = .80.
Dependent variable: Insomnia
Insomnia Severity Index (ISI): The ISI has 7-items designed to specifically assess the severity of insomnia symptoms, the impact on daytime functioning, and the amount of associated distress [26]. Items include rating Difficulty falling asleep, Difficulty staying asleep, Problems waking up too early, and satisfaction with current sleep, how noticeable your sleep problems might appear to others, distress about sleep problems, and interference with daily functioning. Items are scored on a five-point scale ranging from 0 to 4, with higher scores representing more severe insomnia symptoms. The validated cutoff scores are 0–6 (no clinically significant sleep difficulties), 7–14 (mild insomnia) and 15+ (presence of clinically significant insomnia) [26]. The ISI has demonstrated internal consistency, reliability, construct validity, specificity and sensitivity in a representative sample of 1,670 people diagnosed with cancer [27]. Reliability for this sample was α = .74.
Covariates: Demographics
Covariates measured include age, gender, ethnicity, marital status, education, income, cancer type, time since diagnosis, type of cancer treatment, and self-reported duration of insomnia in years.
Sleep diary
Participants completed the Consensus Sleep Diary [28]. Sleep onset duration, number of awakenings, duration of time spent awake at night, early morning awakening, time in bed, and sleep efficiency was calculated by taking an average of 7 nights. These variables were used as behavioral indicators of insomnia symptoms. This measure also asks about perceived sleep quality on a Likert scale from 0, very good, to 5, very poor, and asked for daily sleep medication use.
Data Analysis
First, the data were examined for normality and descriptive statistics were run. For Aim 1, to evaluate the relationship between hyperarousal and insomnia in cancer survivors, bivariate correlations and linear regressions were used between scale scores for the HAS and ISI. Confidence intervals were reported for all correlation coefficients [29]. For Aim 2, to evaluate the relationship between hyperarousal and specific components of insomnia (i.e., onset and maintenance of insomnia), bivariate correlations and a linear regression were used between the HAS and specific components (i.e., items) of the ISI and then for sleep diary components. For Aim 3, to identify factors associated with hyperarousal in cancer survivors with insomnia, the relationships between HAS score, insomnia (ISI total score and ISI items) and covariates were examined with bivariate correlations and then with linear regressions. Specifically, in linear regressions, first model regressed possible covariates onto HAS score, then included the ISI in a second step. A second model regressed possible covariates onto HAS score, then included the ISI items in a second step.
Results
Data examination and descriptive statistics about sample
Participants were 59.5% female and 70.2% White. Participants had been diagnosed with a variety of cancers, including breast (31.2%), prostate (22.5%), hematologic (4.4%), head/neck (6.9%) colon/rectal (6.2%), gynecologic (4.4%), more than one type of cancer (6.2%) and other cancers (14.4%; e.g., skin, other gastrointestinal, other genitourinary). Treatment of participants’ cancer were varied and included surgery (71.9%), chemotherapy (48.1%), radiation, (49.4%), and hormonal therapies (23.1%). About half of participants reported being 2–5 years since cancer diagnosis, and had insomnia, on average, for 6.1 years (interquartile range 3.6–10.9; see Table 1). Variables of interest, including hyperarousal (HAS) and insomnia (ISI), were normally distributed (i.e., skewness and kurtosis below 2 [30]). HAS mean score was 38.65 (SD = 9.50) and ISI mean score was 18.02 (SD = 4.26).
Table 1.
Demographic and clinical characteristics the participants
| N | Percent | |
|---|---|---|
| Age (Mean, SD) | 61.5 (11.7) | |
| Gender | ||
| -Male | 69 | 43.1 |
| -Female | 91 | 56.9 |
| Race | ||
| -White | 111 | 70.2 |
| -Non-white | 47 | 29.8 |
| Ethnicity | ||
| -Hispanic | 8 | 5.0 |
| -Non-Hispanic | 151 | 95.0 |
| Education | ||
| -High school or less | 18 | 11.2 |
| -College or above | 142 | 88.8 |
| Marital Status | ||
| -Married/Living w/Partner | 81 | 50.6 |
| -Single/Divorced/Separated/Widowed | 79 | 49.4 |
| Income | ||
| -<$20,000 | 20 | 12.9 |
| -$20,000–$34,999 | 22 | 14.2 |
| -$35,000–$64,999 | 30 | 19.4 |
| -$>=$65,000 | 83 | 53.6 |
| Cancer Type | ||
| -Breast | 50 | 31.2 |
| -Prostate | 36 | 22.5 |
| -Colon/Rectal | 10 | 6.2 |
| -Head/Neck | 11 | 6.9 |
| -Hematologic | 13 | 8.1 |
| -Gynecological | 7 | 4.4 |
| -Other Cancer* | 23 | 14.4 |
| -More than one cancer | 10 | 6.2 |
| Cancer Treatments ** | ||
| -Surgery | 115 | 71.9 |
| -Chemotherapy | 77 | 48.1 |
| -Radiation | 79 | 49.4 |
| -Hormonal | 37 | 23.1 |
| Years since Cancer Diagnosis | ||
| -Median, IQR | 4.6 (0.8–22.9) | |
| Years since Cancer Diagnosis | ||
| - <=2 Years | 20 | 12.7 |
| - 2–5 Years | 73 | 46.2 |
| - 5–10 Years | 42 | 26.6 |
| - >10 Years | 23 | 14.6 |
| Years since Insomnia | ||
| -Median, IQR | 6.1 (3.6–10.9) | |
Note.
Other Cancer includes: Skin, Lung, Other Gastrointestinal, Other Genitourinary, etc.
Subjects can have more than 1 type of cancer treatments
Aim 1: Evaluate the relationship between trait hyperarousal and insomnia in cancer survivors
Hyperarousal was positively and significantly associated with insomnia (ISI total score) in bivariate correlations (r = .350, 95% CI [0.311, 0.425], p < .01) and linear regressions (F = 22.06, p < .001, R2 = 0.10).
Aim 2: Evaluate the relationship between trait hyperarousal and components of insomnia
In bivariate correlations, hyperarousal was related to perceptions about the consequences of disturbed sleep rather than perception of nocturnal sleep patterns. Hyperarousal was positively and statistically significantly related to reported satisfaction (r = .159, 95% CI [0.132, 0.186], p < .05), interference (r = .331, 95% CI [0.321, 0.339], p < .01), perception of others’ recognition of insomnia’s quality of life interference (r = .252, 95% CI [0.242, 0.291], p < .01), and worry about sleep (r = .415, 95% CI [0.401, 0.429], p < .01), but not to falling asleep, staying asleep, or awakening too early. In linear regressions, these relationship patterns held.
As hyperarousal was related to perceived sleep issues (e.g., worry about sleep) and not actual sleep issues (e.g., difficulty falling asleep), sleep diary data was used to replicate and confirm these findings. In correlations between hyperarousal (HAS) and sleep diary indices, hyperarousal was not related to any specific insomnia complaint (i.e., sleep onset, number of awakenings, duration of nighttime awakening, early morning awakening, time in bed, or sleep efficiency). Hyperarousal was, however, related to poor perceived sleep quality (r = −.209, p < .05; i.e., subjective sleep rating from poor to good on 0–5 Likert scale) and use of sleep medication (r = .168, p < .05; See Table 4). As such, hyperarousal appears to continue to relate to perception of sleep issues more so than actual insomnia symptoms.
Table 4.
Bivariate Correlations of Hyperarousal and Sleep Diary Indices
| Correlations | ||
|---|---|---|
| HAS total | ||
| Sleep latency | Pearson Correlation | −.046 |
| Sig. (2-tailed) | .583 | |
| N | 145 | |
| Night wakenings | Pearson Correlation | .131 |
| Sig. (2-tailed) | .115 | |
| N | 146 | |
| Wake time after sleep onset | Pearson Correlation | −.021 |
| Sig. (2-tailed) | .799 | |
| N | 146 | |
|
Wake time after sleep onset
+ early morning awakenings |
Pearson Correlation | −.030 |
| Sig. (2-tailed) | .722 | |
| N | 146 | |
| Total sleep time | Pearson Correlation | .021 |
| Sig. (2-tailed) | .803 | |
| N | 145 | |
| Time in bed | Pearson Correlation | .019 |
| Sig. (2-tailed) | .824 | |
| N | 145 | |
| Sleep efficiency | Pearson Correlation | .001 |
| Sig. (2-tailed) | .994 | |
| N | 145 | |
| Sleep intent | Pearson Correlation | .005 |
| Sig. (2-tailed) | .951 | |
| N | 145 | |
| Sleep Quality | Pearson Correlation | −.209 |
| Sig. (2-tailed) | .011 | |
| N | 146 | |
| Early morning awakenings | Pearson Correlation | −.108 |
| Sig. (2-tailed) | .194 | |
| N | 146 | |
| Medication | Pearson Correlation | .168 |
| Sig. (2-tailed) | .043 | |
| N | 145 | |
Note.
Correlation is significant at the 0.05 level (2-tailed).
Aim 3: Explore demographic factors associated with trait hyperarousal
For Aim 3, demographic factors associated with hyperarousal and insomnia were explored to identify any independent correlates of hyperarousal above and beyond insomnia. Significant demographic factors were included as covariates to ensure that the relationship between hyperarousal and insomnia holds above and beyond these potential confounding third variables. Again, covariates included age, gender, race, ethnicity, marital status, education, cancer type, time since diagnosis, type of cancer treatment, and duration of insomnia in years.
In the first model that regressed covariates onto hyperarousal (HAS), age was the only significant correlate of hyperarousal (B = −.270, p < .01, R2 = 0.09), such that as age increased, reports of hyperarousal decreased. In the second model that regressed covariates onto insomnia total score, education was the only significant correlate of insomnia (B = −3.063, p < .01), such that increases in education were linked to decreases in reported insomnia severity.
In the first model that regressed demographic covariates onto hyperarousal (HAS) and included insomnia (ISI total score) in a second step, hyperarousal remained significantly and positively related to insomnia (B = .867, p < .001), even when taking into account sociodemographic factors. Furthermore, younger age (B = −.200, p < .01) and more reported years of insomnia (B = .177, p < .05) were independent correlates of hyperarousal (See Table 2).
Table 2.
Stepwise Linear Regression of Demographics Regressed onto Hyperarousal, with Insomnia Scale Total
| Coefficientsa | |||||
|---|---|---|---|---|---|
| Unstandardized Coefficients | Standardized Coefficients Beta | ||||
| Model | B | Std. Error | Beta | t | Sig. |
| 1 (Constant) | 40.405 | 9.856 | 4.100 | .000 | |
| age | −.221 | .070 | −.270 | −3.170 | .002 |
| gender | 2.869 | 1.593 | .148 | 1.801 | .074 |
| ethnicity | 5.002 | 3.918 | .103 | 1.277 | .204 |
| race | −1.752 | 1.755 | −.085 | −.998 | .320 |
| marital status | −.192 | 1.541 | −.010 | −.125 | .901 |
| cancer type | −.265 | .328 | −.068 | −.810 | .420 |
| education | −2.823 | 2.542 | −.091 | −1.111 | .269 |
| years since insomnia | .145 | .090 | .139 | 1.616 | .108 |
| years since cancer diagnosis | .119 | .928 | 011 | .129 | .898 |
| 2 (Constant) | 18.614 | 10.122 | 1.839 | .068 | |
| age | −.200 | .065 | −.245 | −3.092 | .002 |
| gender | 2.429 | 1.477 | .125 | 1.645 | .102 |
| ethnicity | 6.296 | 3.634 | .129 | 1.732 | .085 |
| race | −2.327 | 1.628 | −.112 | −1.429 | .155 |
| marital status | .145 | 1.427 | .008 | .102 | .919 |
| cancer type | −.280 | .303 | −.071 | −.923 | .357 |
| education | −.168 | 2.412 | −.005 | −.069 | .945 |
| years since insomnia | .177 | .084 | .169 | 2.118 | .036 |
| years since cancer diagnosis | .303 | .859 | .028 | .352 | .725 |
| Insomnia Severity Index (ISI) | .867 | .175 | .381 | 4.958 | .000 |
Dependent Variable: Hyperarousal Scale (HAS)
In the second model that regressed covariates onto hyperarousal (HAS) and then included the ISI items in a second step, worry about insomnia was related to hyperarousal (B = 2.918, p < .01, R2 = 0.32), and report that others can perceive insomnia’s interference with one’s quality of life was related to less hyperarousal (B = −.182, p < .01). These relationships were uniquely correlated with hyperarousal when all other ISI and sociodemographic factors were included. Overall, younger age, more years since insomnia, and worry about sleep were uniquely associated with hyperarousal when controlling for other insomnia symptoms.
Discussion
This study examined the relationship between trait hyperarousal and insomnia in cancer survivors. Trait hyperarousal mean score was 38.65 (SD = 9.50), indicating the level of hyperarousal slightly higher than those reported in individuals with insomnia but no cancer (Pavlova et al., 2001), and ISI mean score was 18.02 (SD = 4.26), indicating an average of clinical insomnia with moderate severity. For Aim 1, trait hyperarousal was positively and statistically significantly associated with greater insomnia severity with a weak to moderate effect size, consistent with our hypothesis and previous literature (i.e., Pavlova, 2001).
For Aim 2, Trait hyperarousal was related to reported dissatisfaction with sleep pattern, interference of insomnia on functioning, impact of insomnia on quality of life, and worry about sleep problems with weak to moderate effect sizes, but not the actual time spent falling asleep, staying asleep, or awakening too early. This is aligned with hypotheses in previous literature that were not empirically tested (e.g., Riemann et al., 2010). It could be that trait hyperarousal affects the perception of sleep via increased worry or distress; those who report hyperarousal may be more likely to report sleep issues because they perceive their quality of life or quality of sleep to be poor. It is also possible that hyperarousal leads to a decreased ability to cope with insomnia or sleep difficulties due to comorbid syndromes or symptoms associated with hyperarousal (e.g., if the participant has stress or ruminates, their insomnia may feel more overwhelming).
For Aim 3, younger age, duration of insomnia, and worry about sleep were uniquely associated with hyperarousal when controlling for insomnia severity. We did not find a significant effect of race or ethnicity, gender. or sociodemographic factors on the relationship between hyperarousal and insomnia symptoms. Previously, Jean-Louis and colleagues found that the prevalence of insomnia symptoms varies among different ethnicities and concluded that ethnicity explained 20% of the variance in the insomnia variable, sociodemographic factors explained 5% of the variance, risk markers explained 5%, medical factors 20%, and coping styles 1% [31]. Moreover, income and employment status were found to relate to individuals’ sleep patterns such that adults in disadvantaged socioeconomic positions exhibited more insomnia symptoms. These findings seemed to be largely driven by education. Similarly, Rocha, Guerra, and Lima-Costa studied the factors associated with insomnia among adults in Brazil and found that “insomnia was independently associated with less education in both sexes” [32]. They also found that the “prevalence of insomnia among women was higher than that of men, and among females, the prevalence increased with age.” Lallukka and colleagues suggest targeting low-income families and people who are unemployed or retired due to disability for insomnia interventions [22]. A study by Paine, Gander, Harris, and Reid further supported the idea that unemployment and socioeconomic deprivation are strongly associated to all insomnia symptoms [33]. Our research suggests that hyperarousal, when present, may be a stronger predictor of insomnia than other characteristics.
Clinical implications
Insomnia on its own, versus insomnia with trait hyperarousal, may present different clinical challenges and/or require different clinical treatments [34]. This study provides a description of the trait hyperarousal experienced by some cancer survivors, associated with perceived sleep issues in cancer patients and an increased likelihood of medication use, also aligned with previous literature in a non-clinical sample [18]. It may provide support for additional clinical attention to and treatment of trait hyperarousal in cancer survivors in order to decrease report of insomnia, perception of interference of insomnia in daily life, and worry and quality of life disruptions, all of which these cancer survivors are already experiencing related to their disease.
Trait hyperarousal appears to be related more to perception of sleep disturbance, worry about sleep disturbance, and interference of sleep with daily life, than sleep continutity characteristics. Should patients with trait hyperarousal present with insomnia symptoms that meet criteria for insomnia disorder, they might require supplemental treatment to address the worries, report of interference of insomnia with quality of life, and desire for medication above and beyond Cognitive behavioral therapy for insomnia (CBT-I). Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard treatment for insomnia [35], and has been shown to work well for those with cancer [36]. Of course, the cognitive component of CBT-I addresses thoughts and worries about sleep, but this might need to be emphasized more and/or included earlier in those with trait hyperarousal compared to individuals with insomnia and low trait arousal. Perhaps those with insomnia who screen high on trait hyperarousal should also have a heavier emphasis on dearousal strategies (e.g., relaxation exercises, winding down time, worry time, challenging unhelpful thoughts). Relaxation strategies have been shown to have benefit for physiologic and cognitive hyperarousal [37]. Further, those with trait hyperarousal may require additional psychoeducation related to sleep medication, as this research indicates that they are more likely to use sleep medication. CBT-I has been shown to work better than medication for insomnia. Avoiding additional medication for cancer patients may be especially helpful in order to reduce possible drug-drug interactions and medicine-related side effects in addition to the physiological side effects already being experienced as the result of cancer and cancer treatment.
Trait hyperarousal could partially explain the phenomenon by which sleep diaries show increases in sleep efficiency and sleep duration but reported sleep quality shows stable poor perception of sleep quality during CBT-I treatment. It is important psychologically for patients to perceive that they are feeling better and sleeping better and more, especially for an already-distressed group of cancer patients. Burgeoning literature on insomnia identity points to the conviction that one has insomnia, and that this sleep complaint can be measured independently of sleep [38]. Trait hyperarousal and insomnia identity may be related, through cognitive or personality variables. More research about insomnia identity, insomnia identity in cancer survivors, and insomnia identity as it relates to trait hyperarousal, is needed.
Little is known about whether adaptations to CBT-I may be necessary for those cancer patients with state hyperarousal or posttraumatic stress symptoms as well; more research is needed.
Limitations and future research
There are four main limitations to this study. First, the data used for this study was cross-sectional. As such, temporality and directionality assumptions cannot be made. More longitudinal research is needed. Second, data was self-report; in future studies, sleep studies and more objective measures can be collected. Third, correlations demonstrated weak to moderate sizes and more research is needed to replicate these effects. Fourth, participants resided in the metropolitan Northeastern United States and were English speaking; despite having a larger than typical representation from non-white groups, minority groups were still under-represented. As such, this research may not be generalizable to cancer patients in other areas of the country or the world or to more diverse populations. A recent meta-analysis indicated that other patient characteristics do not effect the efficacy of CBT-I (i.e., similar for patients with or without comorbid disease, younger or older patients, using or not using sleep medication) [39]. However, a recent systematic review pointed out that inconsistency in adherence findings among the studies may be explained in part by diverse sample characteristics (e.g., education, socioeconomic status), varied CBT-I components, and lack of a standardized definition and measurement of adherence [40], indicating that those with lower education and socioeconomic status may benefit from additional treatment adherence; accommodations to systemic barriers that would prevent treatment initiation and adherence must be paid attention to, and the role of socioeconomic status, education, and race should be studied. Research with more diverse populations is warranted.
Conclusions
Overall, trait hyperarousal is more highly associated with distress about insomnia and reports of interference of insomnia for quality of life rather than specific difficulties with sleep onset and maintenance. Age was the only socioeconomic factor and duration of insomnia was the only clinical factor uniquely related to hyperarousal. Implications for clinical practice include careful assessment of insomnia symptoms in those with trait hyperarousal and amplified cognitive or arousal reduction techniques in traditional CBT-I. More intervention research is needed to suggest ways to tailor interventions for insomnia to the individual patient.
Supplementary Material
Table 3.
Stepwise Linear Regression of Demographics Regressed onto Hyperarousal, with ISI Items
| Coefficientsa | |||||
|---|---|---|---|---|---|
| Unstandardized Coefficients | Standardized Coefficients Beta | ||||
| Model | B | Std. Error | Beta | t | Sig. |
| 1 (Constant) | 26.136 | 4.061 | 6.435 | .000 | |
| Difficulty falling asleep | .730 | .662 | .083 | 1.102 | .272 |
| Difficulty staying asleep | −.475 | 1.000 | −.041 | −.475 | .635 |
| Waking early | .197 | .760 | .022 | .259 | .796 |
| Satisfaction with sleep | −.736 | 1.161 | −.054 | −.634 | .527 |
| Interfere with life | 1.795 | 1.045 | .172 | 1.718 | .088 |
| Quality of life | −.068 | .793 | −.008 | −.086 | .931 |
| Worried about sleep | 3.653 | .987 | .359 | 3.702 | .000 |
| 2 (Constant) | 20.956 | 10.137 | 2.067 | .041 | |
| Difficulty falling asleep | 1.229 | .698 | .141 | 1.760 | .081 |
| Difficulty staying asleep | −.414 | .978 | −.036 | −.423 | .673 |
| Waking early | .389 | .744 | .044 | .523 | .602 |
| Satisfaction with sleep | −1.182 | 1.141 | −.087 | −1.036 | .302 |
| Interfere with life | 1.701 | 1.023 | .163 | 1.662 | .099 |
| Quality of life | .537 | .804 | .066 | .667 | .506 |
| Worried about sleep | 2.918 | .994 | .287 | 2.935 | .004 |
| Age | −.182 | .064 | −.222 | −2.820 | .006 |
| Gender | 2.360 | 1.538 | .122 | 1.534 | .127 |
| Ethnicity | 6.622 | 3.610 | .136 | 1.834 | .069 |
| Race | −2.802 | 1.669 | −.135 | −1.679 | .096 |
| Marital status | .021 | 1.436 | .001 | .015 | .988 |
| Cancer type | −.280 | .302 | −.071 | −.925 | .357 |
| Education | −.038 | 2.421 | −.001 | −.016 | .988 |
| Years since insomnia | .148 | .084 | .141 | 1.756 | .081 |
| Years since cancer diagnosis | .457 | .861 | .042 | .531 | .596 |
Dependent Variable: Hyperarousal Scale (HAS) total
Acknowledgements:
Research reported in this paper was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (CER-1403-14292). Research reported in this paper was also funded in part through a cancer center support grant from the National Cancer Institute of the National Institutes of Health awarded to Memorial Sloan Kettering Cancer Center under award number P30 CA008748: This grant supports the Behavioral Research Methods Core Facility, which was used for completing this study. Dr. Riley was supported by a training grant from the NCI under award number T32 CA009461. Thank you to Elana Fox and Maia Buschmann at the Graduate School of Applied and Professional Psychology. Thank you to our study coordinators and participants.
Footnotes
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Conflict of Interest: The authors declare that they have no conflict of interest.
Informed consent: Informed consent was obtained from all individual participants included in the study.
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Welfare of animals: This article does not contain any studies with animals performed by any of the authors.
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