Attempts to control unwanted thoughts in the night: development of the thought control questionnaire-insomnia revised (TCQI-R)

The attempted control of intrusive, uncontrollable thoughts has been implicated in the maintenance of a range of psychological disorders. The current paper describes the refinement of the Thought Control Questionnaire Insomnia (TCQI; Behav. Cogn. Psychoth. 29 (2001)) through its administration to a sample (n=385) including good sleepers and individuals with insomnia. Several items with poor psychometric properties were discarded, resulting in a 35-item revised TCQI. Factor analysis revealed six factors; aggressive suppression, cognitive distraction, reappraisal, social avoidance, behavioural distraction, and worry. The attempted management of unwanted thoughts was compared across individuals with insomnia and good sleepers, and the impact of these strategies on sleep quality, anxiety and depression was investigated. With the exception of cognitive distraction, individuals with insomnia, relative to good sleepers, more frequently used every thought control strategy. The strategies of aggressive suppression and worry, in particular, appeared to be unhelpful, with the use of these strategies predicting sleep impairment, anxiety and depression. The strategy of cognitive distraction appeared to be helpful, with the use of this strategy predicting better sleep quality.     

Aggressive fantasies, thought control strategies, and their connection to aggressive behaviour

The present study examined the relations between aggressive fantasies, thought control strategies and aggressive behaviour in a sample of non-clinical female participants (N = 72). First, the nature and prevalence of aggressive fantasies and thought control strategies were examined. Then, the relation between these constructs and aggressive behaviour was studied by means of correlations and regression analysis. Results indicated that aggressive fantasies were a common experience in these non-clinical participants, and that suppression, distraction and cognitive reappraisal were prevalent strategies to control aggressive intrusive thoughts. Most importantly, it was found that thought suppression and aggressive fantasies were positively correlated with aggressive behaviour. A regression analysis underlined the link between thought suppression and aggressive behaviour, but the relation between aggressive fantasies and aggressive behaviour was no longer significant. Further, some indications were found for distraction being an adaptive strategy for controlling aggressive intrusive thoughts.     

The impact of pre-sleep arousal state and strategy to control unwanted thoughts on sleep quality

Objective: It has been questioned whether elevated pre-sleep cognitive arousal contributes to poor sleep or whether it is the use of maladaptive thought control strategies, used to manage this cognitive arousal, that are responsible. The study aimed to examine how these factors – cognitive arousal (with and without anxiety) and maladaptive thought control strategies contribute to perceived sleep quality (SQ). Design: 129 “healthy adults” (46 males, 83 females) were exposed to picture-stimuli eliciting either anxious cognitive arousal or non-anxious cognitive arousal at bedtime. The groups were then randomly split and briefed to use either a cognitive distraction or cognitive suppression thought control strategy or no instructions were given (controls). Subjective SQ was measured immediately on waking. Results: Induced anxious cognitive arousal was associated with lower SQ compared to non-anxious cognitive arousal. Analyses revealed a significant interaction between arousal and the strategies used to control unwanted thoughts on SQ. When experiencing anxious cognitive arousal, the strategy of distraction was associated with poorer sleep outcomes. Conclusion: The findings suggest that the efficacy of differing thought control strategies vary depending upon whether cognitive arousal elicits anxiety or not. With that in mind, clinical implications in terms of augmenting the treatment of insomnia are discussed.     

Distinguishing rumination from worry in clinical insomnia

Research has found that repetitive thought processes, such as worry and rumination, play an important role in several disorders; however, these cognitive processes have not yet been examined in insomnia. This study explores rumination and worry in insomnia by examining: 1) whether those high and low on rumination and worry differ on subjective sleep measures, and 2) whether rumination and worry are distinct processes in insomnia. Participants (N = 242) were diagnosed with an insomnia disorder by sleep experts. Participants completed measures of worry and rumination and maintained a 2-week daily sleep log. Results of a multivariate analysis of variance found no main effect of worry; although high and low ruminators differed on several sleep log indices, including sleep efficiency, wakefulness after sleep onset and sleep quality. Factor analysis supported the idea that rumination and worry are separate constructs. Whereas previous research has focused on worry in insomnia, these findings suggest that rumination is important for understanding sleep disturbance. Further, although rumination and worry are both repetitive thought processes, these results indicate that they are distinct processes within insomnia and should be treated as such. The results are discussed with respect to treatment implications for Cognitive Behavioural Therapy for Insomnia.     

How to control a white bear? Individual differences involved in self-perceived and actual thought-suppression ability

Thought suppression is generally considered a maladaptive mental control strategy, leading to increased intrusions. In the experimental psychopathology literature, thought suppression is assigned a central role in anxiety and depression, disorders characterised by a high level of negative intrusive thoughts. We examined predictors of self-perceived and actual thought suppression ability in an undergraduate sample. It was found that self-perceived suppression ability was predicted by anxiety and depression scores, attentional control, and distraction strategies. Immediate and rebound effects of actual suppression were predicted by depression scores. Interestingly, higher levels of attentional control and distraction were related to more successful thought suppression on the questionnaires, yet were related to increased intrusions during suppression.     

Attempting suppression of traumatic memories over extended periods in acute stress disorder

This study investigated the influence of attempted suppression and thought control strategies on traumatic memories. Survivors of civilian trauma with acute stress disorder (ASD; n = 20) and without ASD (n = 20) monitored their trauma-related thoughts for three 24-h periods. In period 1, participants were instructed to think about anything. In period 2, participants were administered suppression or nonsuppression instructions relating to thoughts of the trauma. In period 3, participants were again instructed to think about anything. The results revealed no evidence for an increase in trauma-related thoughts following suppression instructions. Punishment and worry thought control strategies correlated significantly with both anxiety and suppression ratings. Frequency of intrusions was associated with a distraction cognitive strategy. These findings point to the importance of traumatised individuals' cognitive strategies in mediating the management and occurrence of posttraumatic intrusions.     

Understanding the relationship between posttraumatic stress disorder and trauma cognitions: The impact of thought control strategies

Several models of PTSD suggest that dysfunctional beliefs play an important role in the maintenance of PTSD. This study examined whether thought control strategies intermediated in the relationship between PTSD and dysfunctional cognitions. It was hypothesized that PTSD would be positively associated with dysfunctional cognitions and that negative thought control strategies (worry and self-punishment) would partially account for this relationship. These maladaptive strategies were predicted to be associated with increased levels of PTSD and more trauma-related beliefs. Additionally, it was predicted that positive thought control strategies (social control and reappraisal) would be associated with decreased levels of PTSD and fewer trauma-related beliefs. Finally, because the literature supports distraction as both an adaptive and a maladaptive thought control strategy, no a priori hypothesis was made. Results support worry and self-punishment as maladaptive intervening variables in the association between PTSD and dysfunctional cognitions, resulting in greater levels of PTSD and trauma cognitions. Social control and distraction emerged as adaptive strategies, resulting in lower levels of PTSD and trauma cognitions, while reappraisal showed no relationship with PTSD severity. Although the results are cross-sectional, continued focus on the effects of thought control strategies as meditational maintenance variables over time appears warranted.     

Thought control strategies in obsessive-compulsive disorder: a replication and extension

Previous research suggests that individuals with OCD use maladaptive strategies to control their unpleasant thoughts (Behav Res Ther (1977) 35, 775). These include worry and self-punishment strategies. In the present study we replicated and extended the previous findings by comparing thought control strategies used by patients with OCD to strategies used by anxious and non-anxious control participants. We also examined changes in thought control strategies for OCD patients who underwent cognitive-behavioral therapy. Compared to controls, OCD patients reported more frequent use of worry and punishment strategies, and less frequent use of distraction. Following successful treatment, OCD patients evidenced increased use of distraction and decreased use of punishment. Findings are discussed in terms of the cognitive model of OCD.     

Attentional interference by threat and post-traumatic stress disorder: The role of thought control strategies

Attentional interference by threat is associated with PTSD, but the mechanisms of this relationship remain unclear. Attentional interference might be related to increased use of maladaptive thought control strategies, such as suppressing unwanted thoughts (thought suppression) or replacing threatening thoughts with everyday concerns (worry), which increase PTSD risk. Conversely, attentional interference might be associated with reduced use of adaptive strategies, such as talking about threatening thoughts (social control), which decrease PTSD risk. This study tested if thought control strategies mediate the relationship between attentional interference and PTSD. Sixty-one male Vietnam-era veterans completed measures of PTSD symptoms and thought control strategies. Participants also completed a Visual Search Task measuring attentional interference, which required participants to identify a target letter string among a group of threat or neutral words. Attentional interference by threat was related to PTSD symptoms, and mediation analyses revealed significant indirect effects of attentional interference through thought suppression and worry. Attentional interference was related to re-experiencing and avoidance, but not hyperarousal, symptom clusters. Thought suppression was a unique mediator for re-experiencing, whereas thought suppression and worry both mediated the relationship with avoidance. These results offer evidence for maladaptive thought control strategies as a mechanism linking attentional biases for threat to PTSD.     

Strategies for the Control of Unwanted Thoughts in Adolescents: The Adolescent Thought Control Questionnaire (TCQ-A)

A paucity of research on thought suppression exists among adolescents. The present study describes the preliminary psychometrics of the Adolescent Thought Control Questionnaire (TCQ-A) and its relationships with internalizing symptomatology in adolescents. Adolescents between 12 and 18 years of age completed the TCQ-A and other self-report instruments. Principal components analysis yielded five-factors theoretically derived from an adult measure: distraction, social, re-appraisal, worry, and punishment control strategies. The five-factor structure was well fitted to the data in a confirmatory factor analysis. Adequate evidence of reliability was obtained; however, internal consistency of the punishment factor was not adequate in the sample. The TCQ-A evidenced convergent and divergent validity with internalizing and externalizing symptomatology respectively. Future research applications of the TCQ-A, suggestions for further analyses, and refinement of the instrument are also discussed.     

The thought control questionnaire: A measure of individual differences in the control of unwanted thoughts

Previous research has suggested that unpleasant and unwanted thoughts are a frequent experience in both normal and clinical populations. This paper describes the development and validation of a questionnaire that assesses strategies for controlling such thoughts. Analyses of the Thought Control Questionnaire (TCQ) demonstrated five replicable factors: Distraction; Social Control; Worry; Punishment and Reappraisal. Significant associations were found between the punishment and worry subscales of the TCQ and various measures of emotional vulnerability and perceptions of impaired control over cognition. The implications of these findings are discussed in relation to the literature on thought suppression, worry and mental self-regulation.     

How to suppress obsessive thoughts

Thought suppression (i.e. consciously trying to avoid certain thoughts from entering consciousness) has been argued to be an inadequate strategy in case of unwanted intrusions. That is, thought suppression seems to result in more rather than less intrusions. Although this experimental finding has been explained in terms of failing attempts to distract oneself from the target thought, the White Bear Suppression Inventory (WBSI; a scale that measures chronic thought suppression tendencies) does not address the means by which respondents try to suppress unwanted thoughts. To examine which strategies of mental control people use to suppress unwanted thoughts, obsessive-compulsive disorder patients (N=47) completed the WBSI, the Thought Control Questionnaire, and two measures of psychopathology. Results suggest that the crucial mechanism in thought suppression may not be distraction, but self-punishment.     

Repetitive Thought and Self-Reported Sleep Disturbance

Repetitive thought has been focused upon as a transdiagnostic risk factor for depression, anxiety, and poor physical health. Among the forms of repetitive thought, rumination and worry are considered to play important roles in the onset and maintenance of insomnia. However, there have been few attempts to clarify the similarities, differences, and interaction between the functions of rumination and worry in sleep problems. Furthermore, no study has investigated the prospective relationships between these two forms of repetitive thought and sleep disturbance. In the present study, we examined the prospective associations between repetitive thought and subjective sleep quality, measured by a self-report questionnaire. A total of 208 undergraduates participated in a 2-wave longitudinal survey with an interval of 3 weeks between assessments. Hierarchical multiple regression analyses showed that baseline rumination predicted reduction in the follow-up assessment of subjective sleep quality, controlling for levels of depressive and anxious symptoms. This main effect of rumination was qualified by the levels of worry; for individuals with higher levels of worry, rumination was associated with greater reduction in subjective sleep quality. These results suggest that both rumination and worry have unique associations with sleep and that their interaction is especially important in sleep problems.     

Incorporating Principles from Acceptance and Commitment Therapy into Cognitive-Behavioral Therapy for Insomnia: A Case Example

Although traditional cognitive behavioral treatments for insomnia have demonstrated efficacy for many individuals with primary and comorbid insomnia, not all individuals benefit from treatment and some experience a subsequent relapse of insomnia. Furthermore, many individuals experience difficulty in implementing the sleep restriction and stimulus control strategies, especially over the long-term. The current article describes ways in which principles from a newer type of behavior therapy, Acceptance and Commitment Therapy (ACT), can be integrated with traditional behavioral treatment strategies for insomnia. A major goal of ACT is to increase willingness to experience unpleasant thoughts, feelings, and physical sensations, and to promote engagement in personally-valued behaviors while non-judgmentally observing these unpleasant experiences. ACT has the potential to enhance the behavioral treatment of insomnia by fostering willingness to experience short-term discomfort (e.g., fatigue) that occurs while implementing sleep restriction and stimulus control strategies. A case example is presented to illustrate how these principles from ACT can be integrated with behavioral techniques in the treatment of insomnia.     

A cognitive model of insomnia

Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.     

The clock as a focus of selective attention in those with primary insomnia: An experimental study using a modified Posner paradigm

Espie and colleagues [(2006). The attention-intention-effort pathway in the development of psychophysiological insomnia: a theoretical review. Sleep Medicine Reviews, 10, 215-245] propose a route into psychophysiological insomnia along the attention-intention-effort pathway which focuses on the inhibition of sleep-wake automaticity. A contributing factor to this is selective attention to sleep (alongside explicit intention to sleep and effort in the sleep engagement process). Following on from previous work on selective attention to sleep [Marchetti, L. M., Biello, S. M., Broomfield, N. M., MacMahon, K. M. A., & Espie, C. A. (2006). Who is pre-occupied with sleep?. A comparison of attention bias in people with psychphysiological insomnia, delayed sleep phase syndrome and good sleepers using the induced change blindness paradigm. Journal of Sleep Research, 15, 212-221; MacMahon, K., Broomfield, N., Macphee, L., & Espie, C. A. (2006). Attention bias for sleep related stimuli in primary insomnia and delayed sleep phase syndrome using the dot-probe task. Sleep, 29, 11] and considering the importance of monitoring both internal and external cues in the maintenance of insomnia, as highlighted in the cognitive model of insomnia [Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40, 869-893], a cognitive probe task was employed to investigate further the role of the clock as a focus of selective attention in those with primary insomnia.A 2 × 2 between participants design comparing reaction time of individuals with primary insomnia (n = 22) and normal sleepers (n = 22) on a modified Posner paradigm. Responses obtained from a computer task presenting times which fall within a normal sleep period were analysed.Individuals with primary insomnia demonstrated delayed disengagement to the clock (F(1,84) = 6.9, p < 0.05) which is taken as further support for previous research demonstrating that individuals with primary insomnia exhibit an attentional bias to sleep related stimuli.These results lend support to the attention-intention-effort model (Espie et al., 2006) and the cognitive model (Harvey, 2002) both of which recognise the importance of selective attention towards salient stimuli in the maintenance of insomnia. Possible clinical implications of attentional bias to sleep as a marker of psychopathology progression and treatment efficacy are discussed.     

Examining the Relationship Between Worry and Sleep: A Daily Process Approach

There is growing evidence suggesting that worry and sleep are intimately linked. However, the relationship between these two phenomena over the course of a day remains largely unstudied. It is possible that (a) worry predicts sleep disturbance that night, (b) sleep disturbance predicts worry the following day, or (c) there is a bidirectional relationship between worry and sleep disturbance. The present study examined the daily relationship between worry (both during the day and immediately prior to sleep onset) and sleep in 50 high trait worriers who were randomly assigned to one of two interventions aimed at reducing worry as part of a larger study. A daily process approach was utilized wherein participants completed daily reports of sleep and worry during a 7-day baseline period followed by a 14-day intervention period. Results of repeated measures multilevel modeling analyses indicated that worry experienced on a particular day predicted increased sleep disturbance that night during both the baseline and intervention weeks. However, there was no evidence of a bidirectional relationship as sleep characteristics did not predict worry the following day. Additionally, the type of intervention that participants engaged in did not affect the daily relationship between worry and sleep. Results of the present study are consistent with the cognitive model of insomnia (Harvey, 2002) and highlight the importance of addressing and treating worry among individuals with high trait worry and sleep disturbance.     

Better control with less effort: The advantage of using focused-breathing strategy over focused-distraction strategy on thought suppression

It has been suggested that unwanted thoughts usually intrude during mind wandering due to a shortage of mental resources. However, strategies for suppressing such thoughts have never been examined from a mind wandering perspective. Here, we compare the effectiveness of two types of attention distraction strategies that either redirect users’ attention to their own breathing (focused-breathing strategy, FBS) or to a mental image (focused-distraction strategy, FDS) as related to working memory capacities. Eighty-two undergraduates were randomly assigned into a FBS or FDS group. They completed a concentration task and a thought suppression task, in which mind wandering and thought intrusions were each measured. Our results support the hypothesis that mind wandering is positively correlated to thought intrusions and shows that FBS is more effective than FDS in reducing mind wandering and thought intrusions. Moreover, in contrast to FDS, the effect of FBS is independent of users’ mental resources.     

Dysfunctional meaning of posttraumatic intrusions in chronic PTSD

The paper suggests that the negative idiosyncratic meaning of posttraumatic intrusions (e.g., 'I am going crazy') and cognitive strategies intended to control the intrusions play a major role in maintaining posttraumatic stress disorder. Two studies of 159 and 138 motor vehicle accidents survivors showed that the dysfunctional meaning of intrusions explained a proportion of the variance of the intrusion-related distress, strategies used to end the intrusions, and PTSD severity that was not explained by intrusion frequency, accident severity, or by general catastrophic thoughts when anxious. Rumination, thought suppression, and distraction when having intrusions showed substantial correlations with PTSD severity, as did avoidance of reminders of the accident. The results have implications for the treatment of chronic PTSD.     

Psychometric properties of an insomnia-specific measure of worry: the Anxiety and Preoccupation about Sleep Questionnaire

The aim of this study was to examine the psychometric properties of the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), with a focus on factorial validity and internal consistency as well as discriminative, convergent, and association with sleep parameters and daytime impairment. Among a randomly selected sample from the general population (N = 5,000), 2,333 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1800 participants who did not fulfill criteria for another sleep disorder than insomnia. A two-factor solution, accounting for 70.7% of the variance, was extracted from the 10 APSQ items. One six-item factor determined worries about the consequences of poor sleep (α = .91); the second factor, with four items, assessed worries about the uncontrollability of sleep (α = .86). The two factors were significantly intercorrelated (ρ = .65) and significantly associated with the total APSQ (ρs = .97 and .76, respectively). The APSQ and the two subscales showed discriminant validity between three sleep status groups (normal sleep, poor sleep, and insomnia disorder; R(2) = .33-.41). The APSQ and the subscales demonstrated convergent validity with measures on cognitive arousal, sleep-related beliefs, anxiety, and depression. They also were significantly correlated with sleep parameters and daytime impairment. The findings suggest that the APSQ is a psychometrically sound instrument for assessing worry in insomnia.