Daytime rumination as a feature of Insomnia Disorder: sleep related cognition is not merely a problem of the night

Laura Palagini, Mauro Mauri, Tommaso Banfi, Irene Mazzei, Alessia Gronchi, Enrica Bonanni, Michelangelo Maestri, Dieter Riemann, Colleen E. Carney, Liliana Dell'Osso


Night-time sleep related cognitions have been shown to play a perpetuating role in insomnia. According to the cognitive hypothesis of insomnia the day time thinking may also contribute to it. The aim was to study the possible role of daytime sleep related rumination in Insomnia Disorder (n= 55, mean age 49.7±16.7 years) Obstructive Sleep Apnea Syndrome (OSAS) (n=33, mean age 58.1±10.2 years) and healthy subjects (n=33, mean age 49.8±13.9) using a set of sleep related variables which included the Daytime Insomnia Symptom Response Scale (DISRS), the Dysfunctional Beliefs about Sleep Scale (DBAS), the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). Daytime sleep related rumination was higher in insomnia when compared to both OSAS (p<.001) and good sleepers  (p<.001).  In insomnia, elevated sleep related daytime rumination was best determined by unhelpful beliefs (coeff=0.3 p=.004) while in OSAS by insomnia symptoms (coeff=0.9, p=.02). Findings suggest that the association between insomnia-specific daytime rumination and unhelpful beliefs may be considered a cognitive feature of insomnia. In insomnia, sleep related cognition may interest the 24-hour period. This aspect should be useful, in the future, to study therapeutic strategies acting on cognitive processes to prevent and treat insomnia disorder.



chronic insomnia, daytime rumination, unhelpful sleep related beliefs, cognitive behavioral therapy

Full Text:




American Academy of Sleep Medicine. International Classification of Sleep Disorders. Third edition.(ICSD-3). Chicago: American Academy of Sleep Medicine, 2014.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth edition (DSM-5). Washington: American Psychiatric Pub., 2013.

Baglioni C., Spiegelhalder K., Lombardo C., Riemann D. Sleep and emotions: a focus on insomnia. Sleep Med Rev, 14: 227-238, 2010.

Baglioni C., Battagliese G., Feige B., Spiegelhalder K., Nissen C., Voderholzer U., et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord., 135:10-19, 2011.

Baglioni C., and Riemann D. Is chronic insomnia a precursor to major depression? Epidemiological and biological findings. Curr Psychiatry Rep., 14,511-518, 2012.

Beck A.T., Ward C.H., Mendelson M., Mock J., Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry, 4: 561-571, 1961.

Beck A.T. La Depressione. Bollati Boringhieri Editore, Torino,1978.

Bonnet M.H. and Arand D.L. Hyperarousal and insomnia: state of the science.Sleep Med Rev., 14:9-15, 2010.

Buysse D.J., Reynolds III, C.F., Monk T.H., Berman S.R., Kupfer D.J. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res., 28:193-213, 1989.

Carney,C.E. and Edinger J.D. Identifying critical beliefs about sleep in primary insomnia. Sleep,29:444-53, 2006.

Carney C., Edinger J., Meyer B., Lindman L., Istre, T. Symptom-focused rumination and sleep disturbance. Behav Sleep Med,4:228-41, 2006.

Carney C.E., Harris A.L., Moss T., Edinger J.D. Distinguishing rumination from worryin clinical insomnia. Behav Res Ther,48:540-6, 2010.

Carney C.E, Edinger J.D., Morin C.M., Manber R., Rybarczyk B., Stepanski E.J., et al. Examining maladaptive beliefs about sleep across insomnia patient groups J Psychosom Res., 68:57-65,2010.

Carney C.E., Harris A.L., Falco A., Edinger, J.D. The relation between insomnia symptoms, mood, and rumination about insomnia symptoms.J Clin Sleep Med, 9:567-75, 2013.

Conti L.Repertorio dellel scale di valutazione in psichiatria.SEE Firenze, 1999.

Cronbach L.J. Coefficient alpha and the internal structure of tests. Psychometrika.16,297–334, 1951.

Curcio G., Tempesta D., Scarlata S., Marzano C., Moroni,F., Rossini P.M., et al. Validity of the Italian version of the Pittsburgh Sleep Quality Index (PSQI).Neurol Sci., 34: 511-9, 2013.

Devoto A. and Violani, C. Curare l'insonnia senza farmaci. Metodi di valutazione e intervento cognitivo-¬comportamentale. Carrocci Faber Editors Roma, 2009.

Fernandez-Mendoza J., Vela-Bueno A., Vgontzas A.N., Ramos-Platón M.J., Olavarrieta-Bernardino S., Bixler E.O., et al. Cognitive emotional hyperarousal as a premorbid characteristic of individuals vulnerable to insomnia. Psychosom Med., 72:397-403, 2010.

Fernandez-Mendoza J. and Vgontzas A.N. Insomnia and its impact on physical and mental health.Curr Psychiatry Rep.,15: 418, 2013

Harvey A.G.A cognitive model of insomnia. Behav Res Ther., 40: 869–893,2002.

Harvey A. G. Insomnia, psychiatric disorders, and the transdiagnostic perspective.Curr. Dir. Psychol. Sci.,17:299–303, 2008.

Harvey C.J., Gehrman P., Espie C. A. Who is predisposed to insomnia: a review of familial aggregation, stress-reactivity, personality and coping style.Sleep Med Rev., 18:237-47,2014.

Jansson-Fröjmark M. and Lindblom K.A. Bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population.J Psychosom Res.,64:443-9, 2008.

Knutson K.L. Does inadequate sleep play a role in vulnerability to obesity? Am J Hum Biol., 24:361-371, 2012.

Kucharczyk E.R., Morgan K.,Hall A.P. The occupational impact of sleep quality and insomnia symptoms Sleep Med Rev,16: 547–559, 2012.

Léger D.and Bayon V. Societal costs of insomnia. Sleep Med Rev,14:79–389,2010.

Lichstein K.L., Durrence H.H., Taylor, D.J., Bush A.J., Riedel B.W. Quantitative criteria for insomnia. Behav Res Ther,41:427–445,2003.

MAPI Research Institute eds. Italian version of the Insomnia Severity Index. Lyon: MAPI Research Institute, 2008

Morin C. M. Insomnia: Psychological Assessment and Management. New York: Guilford Press, 1993.

Morin C.M. and Espie, C.A. Insomnia: A Clinical Guide to Assessment and Treatment. New York: Kluwer Academic/Plenum Publishers, 2003.

Morin C.M,Vallières A., Ivers, H. Dysfunctional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16).Sleep,30:1547-54,2007.

NCSS Kaysville, Utah, USA.2008

Palagini L., Bruno R.M., Gemignani A., Baglioni C., Ghiadoni L., Riemann, D. Sleep loss and hypertension: a systematic review. Curr Pharm Des., 19: 2409-19,2013.

Riemann D., Spiegelhalder K., Feige B., Voderholzer U., Berger,M., Perlis M., et al.The hyperarousal model of insomnia: a review of the concept and its evidence. Sleep Med Rev., 14:19-31, 2010.

Riemann D., Baglioni C., Spiegelhalder, K. Lack of sleep and insomnia. Impact on somatic and mental health. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz, 54:1296-1302,2011.

Riemann D., Nissen C., Palagini L., Otte A., Perlis,M.L.,Spiegelhalder K. The neurobiology, investigation, and treatment of chronic insomnia. Lancet Neurol, 14:547-558,2015.

Roth T. and Roehrs T. Insomnia: epidemiology, characteristics, and consequences. Clin. Cornerstone, 5: 5-15, 2003.

Yaffe K., Falvey C.M., Hoang, T. Connections between sleep and cognition in older adults. Lancet Neurol,10:1017–1028, 2014.

Zung W.W. K. A rating instrument for anxiety disorders. Psychosomatics, 12:371-379, 1971.

Watkins E. Appraisals and strategies associated with rumination and worry. Pers Indiv Differ,37:679-94, 2004.

Watkins E., Moulds M.,Mackintosh, B. Comparisons between rumination and worry in a non-clinical population. Behav Res Ther,43:1577-85, 2005.



  • There are currently no refbacks.