Elsevier

Sleep Medicine Reviews

Volume 17, Issue 1, February 2013, Pages 55-64
Sleep Medicine Reviews

Theoretical Review
Interpersonal factors in insomnia: A model for integrating bed partners into cognitive behavioral therapy for insomnia

https://doi.org/10.1016/j.smrv.2012.02.003Get rights and content

Summary

Sleep has largely been conceptualized as an individual phenomenon, despite the fact that most adults share their bed with a partner at some time in their life. Only recently have researchers begun to examine the dyadic nature of sleep, and there is growing evidence that bed partners can play a role in the onset and maintenance of insomnia. Additionally, emerging evidence suggests that bed partners can be powerful agents of social control in terms of promoting adaptive health and sleep-related behaviors, and shared social rhythms between partners can help foster an environment that is conducive to good sleep. As such, the aim of the present article is to review the social context of the sleep environment and how best to include bed partners in insomnia treatment. Based on a synthesis of relevant literatures, a model for integrating bed partners into cognitive behavior therapy for insomnia (CBT-I) is presented and directions for future research are discussed.

Introduction

Insomnia is one of the most prevalent psychological health problems facing adults.1 Although most adults share their bed with a partner at some time in their lives, a review of the literature reveals that sleep has largely been conceptualized and investigated as an individual phenomenon. In fact, a survey of some of the most commonly used assessment tools in insomnia research revealed that none of the standard assessment measures take into account the dyadic nature of the sleep environment for adults.2 Similarly, to date there have been no psychosocial interventions developed for insomnia that take into account interpersonal factors related to sleep. Meanwhile, most individuals describe sleep as a social experience that can lead to complicated and challenging issues for bed partners, and can play a central role in the relationship functioning of couples.3 A previous review highlighted the evidence for a bidirectional association between relationship functioning and insomnia among co-sleeping dyads, and proposed mechanisms by which bed partners may help maintain insomnia.4 The goal of the current review is to extend beyond this foundational work, by articulating the manner in which: 1) relationship issues can be conceptualized in cognitive behavioral treatments for insomnia, and 2) partners may be integrated into such therapies to maximize their effectiveness.

A survey of over 1500 adults in the United States revealed that 61% of individuals slept with a partner on most nights, and that individuals who took longer than 30 min to fall asleep were significantly more likely to report relationship problems due to their own or their partner's sleep disorder.5 Furthermore, 30% of individuals who were married or cohabitating slept in a separate bed or bedroom as a result of their own or their partner's sleep problem. Although most conceptualizations of insomnia do not explicitly discuss the role that bed partners may play in the onset and maintenance of chronic insomnia, research has shown that there may be some objective costs to co-sleeping. Specifically, research suggests that the sleep architecture of dyads improves when they sleep alone versus together.7 However, despite these changes in sleep architecture, participants subjectively reported that their sleep was worse when they were alone. Similarly, although the majority of couples endorse a general preference for sleeping with their partner rather than sleeping alone, actigraph estimates suggest that sleep quality is worse when sleeping together.8 In fact, research suggests that approximately one-third of nocturnal awakenings are concordant between bed partners, even though couples do not seem to be consciously aware of this.1, 9 Furthermore, women appear to be more reactive to the movement of another individual in their bed than men, which may account for the higher prevalence of sleep disorders in women.10 Sharing a bed with a partner appears to have significant implications for sleep, making this information useful to the development of an accurate case conceptualization in terms of hypothesized predisposing, precipitating, and perpetuating factors of insomnia.

Section snippets

Cognitive behavioral conceptualization of insomnia

Spielman and colleagues'11 model of insomnia suggests that acute insomnia develops as a result of an interaction between an individual's trait vulnerability to sleep difficulties (i.e., predisposing factors) and specific precipitating circumstances that introduce stress into the system (e.g., life event, abrupt change in sleep schedule). For some individuals, the acute insomnia episode is temporary and their sleep normalizes shortly after the stressor subsides. However, for a subset of

Predisposing factors in insomnia

With regard to predisposing factors, research suggests that being a woman,21 sensitivity to light,22 and the inclination to worry23 are associated with insomnia. Furthermore, research has shown that poor sleepers tend to have anxious and perfectionistic personality styles24, 25 and cope with stressful life events by either internalizing or somaticizing their reactions.26

From an interpersonal perspective, additional predisposing variables may serve to increase one's propensity for insomnia, for

The role of bed partners in promoting good sleep

As reviewed above, partners can interfere with sleep and can play a role in the maintenance of insomnia, but bed partners may also serve to promote good sleep. Potential positive roles that partners can play in sleep are reviewed here. Individuals who are married tend to be healthier overall and live longer than single individuals, including those who have never been married, are widowed, or divorced.70 Although some research indicates a biological sex difference in the health advantages of

A model for integrating bed partners into cognitive behavioral therapy for insomnia

Although there appear to be some objective costs to sharing a bed with a partner, co-sleeping has the potential to motivate individuals to adhere to relatively consistent daytime and nighttime routines, creating a more conducive environment for sleep. Furthermore, incorporating bed partners into assessment and treatment has shown some promising results for several other sleep disorders, such as obstructive sleep apnea.87, 88 As such, incorporating bed partners into insomnia treatment may

Conclusion and future directions

Insomnia is generally conceptualized, researched, and treated as an individual phenomenon, despite the fact that the majority of adults share their bed with a partner. Only recently have researchers begun to examine the dyadic nature of sleep, and there is growing evidence that bed partners can play a significant role in the onset and maintenance of insomnia. Additionally, emerging evidence suggests that bed partners can be powerful agents of social control in terms of promoting adaptive health

References (99)

  • M.A. Lewis et al.

    Understanding health behavior change among couples: an interdependence and communal coping approach

    Soc Sci Med

    (2006)
  • D.E. Ford et al.

    Epidemiologic study of sleep disturbances and psychiatric disorders

    JAMA

    (1989)
  • D.J. Buysse et al.

    Recommendations for a standard research assessment of insomnia

    Sleep

    (2006)
  • P.C. Rosenblatt

    Two in a bed: the social system of couple bed sharing

    (2006)
  • National Sleep Foundation

    Adult sleep habits and styles sleep in America poll

    (2005)
  • NIH

    National Institutes of Health state of the science conference statement on manifestations and management of chronic insomnia in adults

    Sleep

    (2005)
  • L.J. Monroe

    Transient changes in EEG sleep patterns of married good sleepers: the effects of altering sleeping arrangement

    Psychophysiology

    (1969)
  • F.P. Pankhurst et al.

    The influence of bed partners on movement during sleep

    Sleep

    (1994)
  • R. Meadows et al.

    Exploring the interdependence of couples’ rest-wake cycles: an actigraphic study

    Chronobiol Int

    (2009)
  • J. Dittami et al.

    Sex differences in the reactions to sleeping in pairs versus sleeping alone in humans

    Sleep Biol Rhythms

    (2007)
  • M.L. Perlis et al.

    Psychophysiological insomnia: the behavioral model and a neurocognitive perspective

    J Sleep Res

    (1997)
  • R.R. Bootzin
    (1972)
  • C.M. Morin

    Insomnia: psychological assessment and management

    (1993)
  • C.M. Morin

    Cognitive-behavioral approaches to the treatment of insomnia

    J Clin Psychiatry

    (2004)
  • S.J. Wilson et al.

    British Association for psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders

    J Psychopharmacol

    (2010)
  • T. Morgenthaler et al.

    Practice parameters for the psychological and behavioral treatment of insomnia: an update

    Sleep

    (2006)
  • S. Schutte-Rodin et al.

    Clinical guideline for the evaluation and management of chronic insomnia in adults

    J Clin Sleep Med

    (2008)
  • B. Zhang et al.

    Sex differences in insomnia: a meta-analysis

    Sleep

    (2006)
  • A. Chesson et al.

    Practice parameters for the use of light therapy in the treatment of sleep disorders

    Sleep

    (1999)
  • K.L. Lichstein et al.

    Insomniacs’ perceptions of cognitive versus somatic determinants of sleep disturbance

    J Abnorm Psychol

    (1980)
  • T.D. Borkovec

    Insomnia

    J Consult Clin Psychol

    (1982)
  • J.D. Kales et al.

    Biopsychobehavioral correlates of insomnia, V: clinical characteristics and behavioral correlates

    Am J Psychiatry

    (1984)
  • P. Hauri et al.

    Persistent psychophysiologic (learned) insomnia

    Sleep

    (1986)
  • J.A. Bowlby

    secure base: parent-child attachment and healthy human development

    (1990)
  • W.M. Troxel

    It’s more than sex: exploring the dyadic nature of sleep and implications for health

    Psychosom Med

    (2010)
  • R.C. Fraley et al.

    Adult romantic attachment: theoretical developments, emerging controversies, and unanswered questions

    Rev Gen Psychol

    (2000)
  • R.E. Dahl et al.

    Considering sleep in a family context: introduction to the special issue

    J Fam Psychol

    (2007)
  • E.P. Sloan et al.

    Insecure attachment is associated with the alpha EEG anomaly during sleep

    Biopsychosocial Med

    (2007)
  • C.L. Carmichael et al.

    Attachment, sleep quality, and depressed affect

    Health Psychol

    (2005)
  • E. Scharfe et al.

    Associations between attachment representations and health behaviors in late adolescence

    J Health Psychol

    (2001)
  • W.M. Troxel et al.

    Attachment anxiety, relationship context, and sleep in women with recurrent major depression

    Psychosom Med

    (2007)
  • R.D. Cartwright et al.

    REM latency and the recovery from depression: getting over divorce

    Am J Psychiatry

    (1991)
  • L.M. Diamond et al.

    Every time you go away: changes in affect, behavior, and physiology associated with travel-related separations from romantic partners

    J Pers Soc Psychol

    (2008)
  • T.M. Buckley et al.

    On the interactions of the hypothalamic-pituitary-adrenal (HPA) axis and sleep: normal HPA axis activity and circadian rhythm, exemplary sleep disorders

    J Clin Endocrinol Metab

    (2005)
  • E.S. Healey et al.

    Onset of insomnia: role of life-stress events

    Psychosom Med

    (1981)
  • C.H. Bastien et al.

    Precipitating factors of insomnia

    Behav Sleep Med

    (2004)
  • L. Hale

    Who has time to sleep?

    J Public Health

    (2005)
  • W.M. Troxel et al.

    Marital happiness and sleep disturbances in a multi-ethnic sample of middle-aged women

    Behav Sleep Med

    (2009)
  • P. Butterworth et al.

    Concordance in the mental health of spouses: analysis of a large national household panel survey

    Psychol Med

    (2006)
  • Cited by (45)

    • CBT-I in pregnancy

      2022, Adapting Cognitive Behavioral Therapy for Insomnia
    • Vulnerability and resistance to sleep disruption by a partner: A study of bed-sharing couples

      2020, Sleep Health
      Citation Excerpt :

      The present sample had similar levels of percent transmissions received as individuals with insomnia (18.9% vs 18.7%19), and slightly lower than partners of individuals with insomnia (23.6%19). This is interesting because it has been suggested that sleep disturbance caused by a bedpartner could precipitate or maintain sleep disorders.34 Present data, combined with those published in the earlier insomnia study, suggest there may be factors in addition to frequency of wake transmissions that puts an individual at risk for clinically relevant sleep disruption.

    • A bad night's sleep on campus: an interview study of first-year university students with poor sleep quality

      2019, Sleep Health
      Citation Excerpt :

      The current study provides further support for this, suggesting that peers' tendency to socialize late at night may provide a social norm by which staying up very late becomes normalized. In other age groups, it is well recognized that sleep is affected by social context: studies have investigated the impact of sharing a bed in adults6 and sharing a room or bed in children.7 The possible ways in which other people and social norms affect sleep quality should now be further explored in adolescents.

    • Adult insecure attachment plays a role in hyperarousal and emotion dysregulation in Insomnia Disorder

      2018, Psychiatry Research
      Citation Excerpt :

      A model for integrating interpersonal factors into traditional Cognitive-Behavioral Therapy for Insomnia, CBT-I, has been already proposed (Rogojanski et al., 2013) and we should consider applying this model if subjects are non respondent or partially respondent to this traditional therapy by integrating it or using the interpersonal approach as sequential treatment.

    View all citing articles on Scopus
    a

    Tel.: + 416 979 5000x2177.

    b

    Tel.: + 416 979 5000x6209.

    The most important references are denoted by an asterisk.

    View full text