Theoretical ReviewInterpersonal factors in insomnia: A model for integrating bed partners into cognitive behavioral therapy for insomnia
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
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Cited by (45)
Partner Alliance to Enhance Efficacy and Adherence of CBT-I
2023, Sleep Medicine ClinicsCBT-I in pregnancy
2022, Adapting Cognitive Behavioral Therapy for InsomniaVulnerability and resistance to sleep disruption by a partner: A study of bed-sharing couples
2020, Sleep HealthCitation 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 HealthCitation 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.
The impact of environmental exposures on sleep
2019, Sleep and HealthAdult insecure attachment plays a role in hyperarousal and emotion dysregulation in Insomnia Disorder
2018, Psychiatry ResearchCitation 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.
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