Moderators and mediators of the relationship between stress and insomnia: stressor chronicity, cognitive intrusion, and coping.

STUDY OBJECTIVES: To assess moderators, such as stressor chronicity, and mediators, including stress response in the form of cognitive intrusion and coping behavior, of the prospective association between naturalistic stress and incident insomnia. DESIGN: Longitudinal. SETTING: Epidemiological. PARTICIPANTS: A community-based sample of good sleepers (n = 2,892) with no lifetime history of insomnia. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Participants reported the number of stressful events they had encountered at baseline, as well as the perceived severity and chronicity of each event. Similarly, volitional stress responses such as coping, as well as more involuntary responses such as cognitive intrusion were assayed for each stressor. Follow-up assessment 1 y hence revealed an insomnia incidence rate of 9.1%. Stress exposure was a significant predictor of insomnia onset, such that the odds of developing insomnia increased by 19% for every additional stressor. Chronicity significantly moderated this relationship, such that the likelihood of developing insomnia as a result of stress exposure increased as a function of chronicity. Cognitive intrusion significantly mediated the association between stress exposure and insomnia. Finally, three specific coping behaviors also acted as mediators: behavioral disengagement, distraction, and substance use. CONCLUSIONS: Most studies characterize the relationship between stress exposure and insomnia as a simple dose-response phenomenon. However, our data suggest that certain stressor characteristics significantly moderate this association. Stress response in the form of cognitive intrusion and specific maladaptive coping behaviors mediate the effects of stress exposure. These findings highlight the need for a multidimensional approach to stress assessment in future research and clinical practice. CITATION: Pillai V, Roth T, Mullins HM, Drake CL. Moderators and mediators of the relationship between stress and insomnia: stressor chronicity, cognitive intrusion, and coping.