This article was downloaded by: [88.8.89.

195]
On: 24 October 2014, At: 12:44
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,
UK
Behavioral Sleep Medicine
Publication details, including instructions for
authors and subscription information:
http://www.tandfonline.com/loi/hbsm20
Precipitating Factors of
Insomnia
Celyne H. Bastien , Annie Vallieres & Charles M.
Morin
Published online: 07 Jun 2010.
To cite this article: Celyne H. Bastien , Annie Vallieres & Charles M. Morin (2004)
Precipitating Factors of Insomnia, Behavioral Sleep Medicine, 2:1, 50-62, DOI:
10.1207/s15402010bsm0201_5
To link to this article: http://dx.doi.org/10.1207/s15402010bsm0201_5
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the
information (the Content) contained in the publications on our platform.
However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness,
or suitability for any purpose of the Content. Any opinions and views
expressed in this publication are the opinions and views of the authors, and
are not the views of or endorsed by Taylor & Francis. The accuracy of the
Content should not be relied upon and should be independently verified with
primary sources of information. Taylor and Francis shall not be liable for any
losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or
indirectly in connection with, in relation to or arising out of the use of the
Content.
This article may be used for research, teaching, and private study purposes.
Any substantial or systematic reproduction, redistribution, reselling, loan,
sub-licensing, systematic supply, or distribution in any form to anyone is
expressly forbidden. Terms & Conditions of access and use can be found at
http://www.tandfonline.com/page/terms-and-conditions
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

Precipitating Factors of Insomnia
Clyne H. Bastien, Annie Vallires, and Charles M. Morin
cole de psychologie and Centre dtude des troubles du sommeil
Universit Laval
Qubec, Canada
Insomnia is a prevalent health complaint whose onset is precipitated by a variety of
factors. There is an important need to identify and describe these factors to improve
our understanding of risk factors and the natural history of insomnia. This article is
aimed at identifying and describing the types of precipitating factors related to the
onset of insomnia. A total of 345 patients evaluated for insomnia at a sleep-disorders
clinic completed a sleep survey and underwent a semistructured clinical interview.
As part of the evaluation, the specific precipitating events related to the onset of in-
somnia were identified. Subsequently, these factors were categorized (workschool,
family, physical or psychological health, or indeterminate), and their affective va-
lence (negative, positive, or indeterminate) was coded. The most common precipitat-
ing factors of insomnia were related to family, health, and workschool events.
Sixty-five percent of precipitating events had a negative valence. These events dif-
fered with the age of onset of insomnia but not with the gender of participants. These
findings are useful to identify potential risk factors for insomnia and improve our un-
derstanding of the natural history of insomnia.
Epidemiological surveys estimate that 9%to 15%of adults complain of chronic in-
somnia, whereas 27% complain of occasional insomnia (Ford & Kamerow, 1989;
Gallup Organization, 1991; Mellinger, Balter, &Uhlenhuth, 1985). Prevalence es-
timates are higher among women, older adults, and among patients with medical
and psychological disorders (Bixler, Kales, &Soldatos, 1979). Three types of con-
tributing factors have been linked to insomnia: predisposing, precipitating, and
perpetuating factors, each of them playing a different role at different points in the
course of insomnia (Spielman & Glovinsky, 1991). For instance, several psycho-
logical (Borkovec, 1982), physiological (Spielman &Glovinsky, 1991), and famil-
BEHAVIORAL SLEEP MEDICINE, 2(1), 5062
Copyright 2004, Lawrence Erlbaum Associates, Inc.
Requests for reprints should be sent to Clyne H. Bastien, cole de Psychologie, Universit Laval,
Ste-Foy, Qubec, Canada G1K 7P4. E-mail: celyne.bastien@psy.ulaval.ca
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

ial or hereditary (Bastien & Morin, 2000; Hauri & Olmstead, 1980) factors have
been hypothesized to predispose to insomnia. Other risk factors, categorized as
precipitating events, have been linked indirectly to the onset of insomnia
(Borkovec, 1982; Chilcott & Shapiro, 1996; Kales & Vgontzas, 1992; Morin,
1993). Those included psychological and physical dysfunctions, environmental,
family, and work-related factors (Morin, 1993). Maladaptive sleep habits, poor
sleep hygiene, and dysfunctional beliefs and attitudes about sleep have been asso-
ciated with the perpetuation of insomnia (Morin, 1993).
Stress may be the most common precipitant of insomnia. In a retrospective
study, 74% of poor sleepers recalled specific stressful life experiences associated
with the onset of their insomnia (Healy et al., 1981). These events were reported
more frequently during the year the sleep problembegan than in either the previous
or subsequent years. The most common precipitants of insomnia were significant
losses through separation, divorce, or the death of a loved one. In another study
(Vollrath, Wicki, & Angst, 1989) a greater frequency of negative life events
(mostly related to interpersonal relationship), diminished coping skills, and lower
self-esteem were reported among individuals with insomnia compared to normal
controls. However, when depression was partialled out, group differences were no
longer apparent. The rate of reported sleep disturbances among residents of Israel
was much higher during than before or after the Gulf War (Askenasy & Lewin,
1996). Together, these findings suggest that the onset of sleep disturbances is often
preceded by negative or stressful life events.
Two longitudinal studies investigated the relations of age, gender, and health to
the onset of insomnia in a general adult population (Katz & McHorney, 1998;
Klink, Quan, Kaltenborn, & Lebowitz, 1992). Depression, medical conditions in-
terfering with sleep (e.g., cardiopulmonary, painful musculoskeletal, and prostate
diseases), and lifestyle factors such as a high level of daytime activity were the
most likely events associated with the onset of insomnia. Similar factors were also
identified as important precipitants of insomnia among older adults, even after
controlling for covariant predisposing factors such as age and gender (Morgan &
Clarke, 1997; Roberts, Shena, &Kaplan, 1999). The study by Roberts et al. (1999)
showed that women with mood disturbances and chronic health problems were
particularly at greater risk for developing insomnia.
The impact of traffic road noise at night on the onset of insomnia was recently
evaluated in a Japanese population (Kageyama et al., 1997). It was found that liv-
ing near a road with a heavy volume of traffic represented a high risk factor to pre-
cipitate insomnia. Living with a child 6 years or younger, undergoing medical
treatment, and experiencing major life events were other potential precipitating
factors reported in that same study.
In summary, several psychological, health, lifestyle, and environmental factors
have been linked indirectly to insomnia, and only one survey has examined the re-
lation of stressful life events to the onset of insomnia. Additional research with
PRECIPITATING FACTORS OF INSOMNIA 51
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

treatment-seeking individuals is needed to document more precisely the types of
events that are temporally associated with the onset of insomnia. Such data would
yield useful information about risk factors for insomnia. The aim of this study is to
identify the types of precipitating factors associated with the onset of insomnia and
to determine if their nature varies according to age, gender, age of insomnia onset,
subtypes and severity of insomnia. It is expected that more negative than positive
events will be associated with the onset of insomnia. It is also expected that as peo-
ple grow older, health factors will increasingly be reported as precipitating factors
of insomnia.
METHOD
Participants
The participants were 345 clinical patients presenting themselves to a sleep-disor-
ders center. The participants were 192 women and 153 men with a mean age of
42.1 years (SD = 14.5, range 1782) and a mean education level of 14.5 years (SD
= 3.2). They were community residents, predominantly married (49.6%), and were
employed or at school (72.6%). Mean average insomnia duration was 10.1 years
(SD = 11.5), with a mean age of insomnia onset of 32.0 years (SD = 16.5). The
types of insomnia complaints involved sleep onset (17.9%), sleep maintenance
(18.2%), or mixed onset and maintenance difficulties (60.8%). The only criterion
for inclusion was that the primary complaint was insomnia. There were no exclu-
sion criteria for this study.
Procedure
Data were compiled from a clinical interview obtained from participants pre-
senting themselves at a sleep-disorders center with a chief complaint of insom-
nia. All participants underwent a standard assessment protocol. First, a sleep sur-
vey and the Insomnia Severity Index (ISI; Bastien, Vallires, & Morin, 2001;
Morin, 1993) were completed. The ISI includes five questions about the partici-
pants sleep difficulties estimated on Likert-type scales ranging from 0 (absent)
to 4 (extremely severe) for a maximum score of 28 (07: no clinically significant
insomnia; 814: subthreshold insomnia; 1521: clinical insomnia moderate se-
verity; 2228: clinical insomniasevere). The items evaluate the severity of sleep
onset, sleep maintenance, early morning awakening problems, satisfaction with
current sleep pattern, interference with daily functioning, noticeable impairment
attributed to the sleep problem, and level of distress caused by the sleep prob-
lem. The ISI (Bastien et al., 2001) has adequate psychometric properties (inter-
nal consistency of .74) and has been shown to be sensitive to changes in clinical
52 BASTIEN, VALLIRES, MORIN
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

trials of insomnia. The assessment protocol also included psychometric ques-
tionnaires (e.g., Beck Depression Inventory [BDI] and StateTrait Anxiety In-
ventory [STAI]), a medical history, and completion of a clinical evaluation (in-
vestigating any psychopathology or mental disorders according to Diagnostic
and Statistical Manual of Mental DisordersFourth Edition [DSMIV] criteria).
About half of the participants completed at least 1 week of sleep diary. The sur-
vey, questionnaires, and diaries were self-administered.
The clinical evaluation was conducted by a board-certified sleep specialist
(CM; 85% of patients) or a postdoctoral fellow in clinical psychology (15% of pa-
tients). All information pertaining to the nature, severity, onset, course, and precip-
itating circumstances of insomnia was obtained with a semistructured clinical in-
terview (Morin, 1993) aimed at circumscribing the sleep difficulties (onset, type,
development, and sleep hygiene) and based on DSMIV criteria for insomnia. As
part of this evaluation, the clinician investigated any factor or life event that pre-
ceded or was associated temporally with the onset of insomnia. The following
question was asked of the participant: To your recollection, are there any life
events that may be linked to the onset of your sleep difficulties? When there was
more than one precipitating factor associated with the onset of insomnia, the clini-
cian made a determination, after thorough consideration of the full evaluation, of
which was the most important by asking Which one of these events would you say
had more impact on your sleep? The precipitating factor was subsequently coded
by the clinician into either one of six categories: workschool, family, health,
psychopathology, other, and indeterminate. Indeterminate was coded when neither
the patient nor the clinician could identify a precipitating factor. Within each cate-
gory, specific subtypes of events were identified. For example, the health category
included events such as a medical illness, a hospitalization, pain, and menopause.
The events were subsequently coded according to their affective valence (negative
impact on life in generalperceived as a negative event by the participant; positive
impact on life in generalperceived as a positive event by the participant; or neu-
tral impact).
Statistical Analysis
First, descriptive analyses were computed for the total sample (demographic data),
as a function of the different category of precipitating events, as well as for their
subtypes and affective valence. Second, chi-square analyses were performed for
the category as a function of gender and the median age of onset of insomnia.
Finally, one-way analyses of variance (ANOVAs) were computed to evaluate
whether categories and subtypes of precipitating factors varied according to the
nature, severity, and course of insomnia. An alpha level of .05 was used to assess
significant differences.
PRECIPITATING FACTORS OF INSOMNIA 53
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

RESULTS
Data on precipitating factors were available for 327 participants. Eighteen participants
were excluded from the initial sample because of missing or ambiguous data about
precipitating factors. Of the 327 participants, 39.2% reported that the development of
their insomnia was gradual, 37.5% reported a sudden onset, and 24.3% could not de-
termine the nature of their insomnia onset. The large majority of the sample reported
that their insomnia was chronic, whereas 23.3%reported an episodic course. Mean se-
verity of sleep difficulties from the ISI was 21.7 (SD = 4.4; maximum score for the
scale being 28). The average sleep efficiency computed from the baseline diary data
was 67.7%(SD= 17.8). Mean scores on the BDI and on the STAI trait and state scales
were 14.1 (SD = 8.3), 46.0 (SD = 10.6), and 45.8 (SD = 11.7), respectively.
The frequencies and percentages for each category and subtype of precipitating
factors arepresentedinTable1. Aspecificprecipitatingevent, or combinationof cir-
cumstances, could be identified in 78.3% of the sample. No precipitant could be
identified in 21.7% of the patients. As only 34 participants reported more than one
precipitatingfactor, onlythe primaryprecipitatingevent, as determinedbythe clini-
cian, was retained for further analyses. Among the six categories of major
54 BASTIEN, VALLIRES, MORIN
TABLE 1
Categories and Subtypes of Precipitating Factors
Categories n % Subtypes % Within Category Total %
Health 75 22.9
a
Pain 38.7
a
11.1
Medical illness 37.3
a
10.7
Hospitalization 18.7
b
5.4
Menopause 5.3
b
1.5
Family 78 23.9
a
Separation 21.5 6.5
Marital problem 17.7 5.4
Family member illness 11.4 4.6
Death of a significant person 15.2 4.2
Sexual or physical abuse 13.9 3.4
Birth of child 11.4 3.4
Caregiving 7.6 2.3
Other 1.3 0.4
Workschool 56 17.1
a
Stress at workschool 61.8
a
13.4
Rotating shift 23.6
a
5.0
Employment change 12.7
b
2.7
Retirement 1.8
b
0.4
Psychopathology 38 11.6
b
Major affective disorder 80.5
a
12.6
Substance abuse 19.5
b
3.1
Other 13 2.8
b
3.9
Indeterminate 71 21.7
a

Note. Significant differences between subgroups in the same category are represented by differ-
ent letters superscripts.
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

precipitants, factors related to health, family, and workschool stress were the most
frequentlyreported,
2
(5, N=327) =67.0, p<.0001. Of all health-relatedprecipitat-
ing factors, the most frequently identified subtypes were pain and medical illness,

2
(3, N= 75) = 23.0, p < .0001, whereas hospitalization and menopause were much
less frequently reported. For those who reported family-related precipitating fac-
tors, all subtypes were equally reported,
2
(6, N = 78) = 7.1, ns. Stress in the work-
place or at school androtatingshift were the most commonsubtypes inthe workand
school category, followed bychange of employment and retirement,
2
(4, N=55) =
17.5, p<.002. Finally, evenif psychopathologywas not reportedas frequentlyas the
previous three categories, the incidence of major affective disorder was more fre-
quent than substance or alcohol abuse,
2
(1, N = 41) = 15.2, p < .0001.
The large majority of precipitating factors was judged to have a negative va-
lence (65%), whereas only 4.6%had a positive valence. Birth of a child and change
of employment were the precipitating factors most frequently identified as having
a positive valence. For 31%, it could not be determined whether the precipitating
event had a positive or negative valence.
Age of Onset of Insomnia and Gender
Table 2 presents the frequency of different precipitating factors according to age of
onset of insomnia and gender. The median age of onset of insomnia was used to
form 2 groups: onset 30 (n = 167; 78 men, 89 women) and onset > 30 (n = 169;
73 men, 96 women). There were significant differences in frequency of precipitat-
ing factors according to age of onset,
2
(5, N = 323) = 40.1, p < .0001, but not ac-
cording to gender,
2
(5, N = 327) = 8.0, ns. Health problems were more often re-
ported as a precipitating factor when the onset of insomnia was after age 30. When
the onset of insomnia was before age 30, the most frequent precipitating factors
were occupational or school-related stress. Family factors were reported equally
frequently as a precipitating event of sleep difficulties in both groups. Collectively
PRECIPITATING FACTORS OF INSOMNIA 55
TABLE 2
Type of Precipitating Factors According to Age of Onset of Insomnia and
Gender
Onset 30 Onset > 30 Women Men
Type of Factors n % n % n % n %
Health 17 10.6
b,c
60 36.8
a,d
50 24.1 26 18.6
Family 41 24.8
a
43 26.4
a
50 27.5 35 24.1
Psychopathology 20 12.5
b
21 12.9
b
24 13.2 18 12.4
Workschool 41 25.6
a,d
23 14.1
b,d
30 16.5 35 24.1
Other 8 5.0
b
3 1.8
b
7 3.8 4 2.8
Indeterminate 33 20.6
a,d
13 8.0
b,d
21 11.5 26 17.9
a,b
Significant differences within onset of insomnia groups, p < .0001.
c,d
Significant differences be-
tween onset of insomnia groups for the same type of factor, p < .001.
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

and independently of age of onset and gender, psychopathology was less fre-
quently reported as a precipitating factor of insomnia.
Diagnosis of Insomnia
Psychophysiological insomnia (n = 98; 31%) and insomnia secondary to a psychi-
atric disorder (n = 77; 24%) were the two most frequent insomnia diagnoses, fol-
lowed by insomnia associated with substance abuse (n = 36; 11%); the remaining
participants (n = 107; 34%) had other insomnia diagnoses (e.g., associated with
medical conditions, other sleep disorders).
The types of precipitating events associated with the most common insomnia
diagnoses are presented in Table 3. A family-related circumstance was more often
reported as a precipitating event when the diagnosis was psychophysiological in-
somnia. Not surprisingly, other than family, psychopathology (e.g., depression,
anxiety) was the most frequently identified precipitating factor when the diagnosis
was insomnia secondary to psychopathology. Finally, work or school-related
stress was reported as precipitating factors more often when the primary diagnosis
was insomnia associated with substance abuse.
Course and Nature of Insomnia
One-way ANOVAs were computed to evaluate whether categories and subtypes of
precipitating factors varied according to the nature, severity, and course of insom-
nia. The analyses revealed that neither categories nor subtypes of precipitating fac-
tors varied as a function of these clinical parameters (nature: p = .585; severity: p =
.516; course: p = .603). A one-way ANOVA also revealed that categories and sub-
types of precipitants did not vary as a function of sleep efficiency computed from
56 BASTIEN, VALLIRES, MORIN
TABLE 3
Types of Precipitating Factors According to Diagnosis of Insomnia
Diagnosis
Psychophysiological Psychiatric Substance Abuse
Types of Factors n % n % n %
Health 19 19.4
b
7 9.1
b
6 16.7
b
Family 31 31.6
a
23 29.9
a
7 19.4
b
Workschool 24 24.5
b
16 20.8
b
10 27.8
a
Psychopathology 11 11.2
b
22 28.6
a
4 11.1
b
Other 3 3.1
b
4 5.2
b
2 5.6
b
Indeterminate 10 10.2
b
5 6.5
b
7 19.4
b
Note. Significant differences in the same category are represented by different superscripts.
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

the sleep diary. However, a one-way ANOVA yielded a significant effect for cate-
gory as a function of the frequency of use of sleep medications, F(5, 261) = 2.93, p
= .014. Post hoc comparisons, using the Tukey honestly significant difference test,
revealed that participants reporting a health-related precipitating factor were tak-
ing medications more frequently (M = 1.49, SD = 1.54) than participants identify-
ing a workschool-related precipitant (M= .69, SD= 1.16; p = .025). Frequency of
medication intake for sleep difficulties was similar in the other four categories of
precipitating factors.
DISCUSSION
This study shows that problems related to health, family relationships, and work or
school are the most common precipitating factors associated with the onset of in-
somnia. The nature of these events vary with the age of onset and specific insomnia
diagnosis, but not with the gender of the participant or with the nature, course, or
severity of the sleep difficulties. When a precipitating factor is identified, it is gen-
erally perceived as a negative event.
Pain and general medical illness accounted for 22% of all health-related fac-
tors associated with the onset of insomnia. These results are consistent with pre-
vious findings reporting health as an important precipitating factor of insomnia
(Katz & McHorney, 1998; Klink et al., 1992; Morgan & Clarke, 1997; Roberts
et al., 1999). Although it is unclear whether health problems per se or worries
about health trigger insomnia, individuals with health problems are likely to be
at greater risk for chronic insomnia. Menopause and hospitalization were not
identified as precipitating factors of insomnia as often as one might have pre-
dicted. Only four of the 96 women older than 50 years reported menopause as
the major precipitating factor of their sleep difficulties. However, it is also plau-
sible that postmenopausal women who attribute their sleep difficulties to hor-
monal factors consult their primary care physicians for hormonal therapy rather
than a sleep clinic. Given the relatively infrequent occurrence of hospitalization,
although remaining stressful, its impact on the onset of insomnia remains un-
clear, at least in terms of its affect on sleep quality. Nonetheless, it is possible
that the chance of developing persistent insomnia increases with the time spent
in the hospital or with certain consequences associated with hospital stay or
other medication intake (i.e., recovering from surgery, prescribed medication for
health problems).
Every subtype of factors in the family category was equally linked to the onset
of insomnia. Our results corroborate only partially previous data suggesting that
marital difficulties, divorce, or separation were among the most common factors
associated with the onset of insomnia (Morin, 1993). Furthermore, dysfunctional
PRECIPITATING FACTORS OF INSOMNIA 57
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

relationships within the family seem to be a common precipitating factor across all
insomnia diagnoses.
In the workschool category, several sources of stress were identified as precip-
itating insomnia. Those included conflicts with a supervisor, interpersonal rela-
tionship difficulties, workload, and financial strain. These results concur with ear-
lier findings (Ribet & Derriennic, 1999) that occupational stress is frequently
associated with sleep disturbances. On the other hand, other infrequent life events
such as change of employment or retirement were the least frequent precipitators
of insomnia. This is not surprising given that 63%of our participants were working
or studying, and only 1.5% were retired; furthermore, the mean age of our sample
was 42 years. It is likely that retirement might have been associated more fre-
quently with the onset of sleep disturbances in a sample of older adults.
Psychopathology accounted for only 12% of all reported precipitating factors
of insomnia. This finding is surprising because more than one third of our sample
received a primary diagnosis of insomnia associated with psychopathology or sub-
stance abuse. Although it is well recognized that psychopathology is an important
risk factor for insomnia, recent evidence also suggests that chronic and untreated
sleep disturbances may be a risk factor for psychopathology (major depression,
anxiety; Breslau, Roth, Rosenthal, & Andreski, 1996; Foley, Monjan, Izmirlian,
Hays, &Blazer, 1999; Ford &Kamerow, 1989; Morin, Stone, McDonald, &Jones,
1994). Our results preclude this distinction and simply reflect the clinicians and
patients perception of the most important factor precipitating insomnia. It remains
unclear whether these results reflect an underestimation of the influence of psy-
chological dysfunctions on insomnia or that psychopathology developed as a
by-product of another stressful life event (e.g., occupational or family stress) and
was not directly associated with the onset of insomnia.
Consistent with previous findings (Morgan & Clarke, 1997; Roberts et al.,
1999), age of onset of insomnia was related to the subtypes of precipitating factors.
For example, precipitants related to work or school were more common when the
onset of insomnia was earlier in life, whereas health factors were more often asso-
ciated with an insomnia onset later in life. The proportion of participants who
could not identify a precipitating factor was relatively high. The earlier the insom-
nia onset, the more difficult it was to identify a precipitating factor. In that regard,
two explanations might be offered. First, insomnia was reported to have developed
gradually for a large subset of the sample (n = 115; 39.2%), making it more diffi-
cult to associate its onset with a specific precipitating event. Second, it is possible
that as the interval of time between the onset of insomnia and the clinical interview
lengthens, the more likely participants were to have recall problems or some mem-
ory bias surrounding the event that precipitated their sleep difficulties.
The interpretation of these findings is, however, tinted by some limitations.
First, there were no interrater reliability checks of the affective valence, the
subtyping of insomnia and psychopathology diagnosis between clinicians. Al-
58 BASTIEN, VALLIRES, MORIN
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

though clinicians were experienced and followed good clinical guidelines for diag-
nosis, it is possible that diagnosis differed from one clinician to the other. Second,
it is possible that some memory biases fromclients were present. Those who report
a long duration of insomnia might be more prone to have such bias than those
whose insomnia was more recent. Furthermore, when many factors are reported to
have contributed concurrently to the onset of insomnia, the imperativeness of hav-
ing to choose the most influential factor might make participants uncomfortable,
and results might be blurred by such bias. However, this again might also be a true
reflection of insomnia. Although one major factor may be identified as related to
its onset, insomnia is multidimensional in nature. More than one factor can often
contribute to the onset, development, and maintenance of persistent insomnia, and
those factors might not be easily dissociated at times.
These findings still generate very informative results regarding potential risk
factors associated with primary and secondary diagnoses of insomnia, the identifi-
cation of which is certainly a valuable step in treatment outcome, especially for
planning and preventing relapses. Possible links observed between precipitating
and perpetuating factors concur with etiological models of insomnia (Morin, 1993;
Spielman, 1986) and have an impact on the elements chosen for the prevention and
treatment of insomnia. If one knows what has triggered insomnia the first time, one
might be able to prevent relapse afterward by working on those precipitating fac-
tors and related events.
According to Spielman (1986), if some factors are also linked to the mainte-
nance of insomnia (e.g., cognitive arousal, worry), the same factors might also pre-
cipitate it. As such, Waters, Adams, Binks, & Varnado (1993), reported that nega-
tive emotions, attention factors, and stress responsiveness are predictors of
increases in sleep onset and maintenance difficulties. On the other hand, Watts,
Coyle, &East (1994) also showed that worrying does interact with sleep. More re-
cently, Hall, Buysse, Reynolds, Kupfer, & Baum (1996) reported that insomnia
can be precipitated by stress-related intrusive thoughts. These data thus suggest
that worrying over different life events might be a precipitant of insomnia. Our
data appear to support these observations. Most identified contextual and temporal
factors appear to be stress factors that can potentially generate worry. For example,
health is a general worry as one grows older. If you are anxious by nature, predis-
posed to worrying (and thus predisposed to develop insomnia), a health problem
can lead to substantial worry that will, in turn, translate into insomnia.
Recently, Espie (2002) proposed an integrated model of insomnia mainly sug-
gesting a bidirectionality between sleep protectors, which have a defensive func-
tion against external and internal stimuli able to disrupt or disturb sleep, and sleep
itself. The protectors are reinforcing sleep and vice versa. Insomnia would result in
an inhibition problem in at least one protector. If one protector is deficient, then
sleep becomes deficient, and this might lead to insomnia. The precipitating factors,
such as health, family, and workschool categories might lead to the first inhibition
PRECIPITATING FACTORS OF INSOMNIA 59
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

deficiency of a protector, creating the first night of insomnia. The inability of other
protectors to compensate for the deficiency create a loss of sleep automaticity and,
consequently, persistent insomnia. The identified factors in this study might also
trigger an inhibition deficiency in more than one sleep protector, thus increasing
furthermore the risk of developing persistent insomnia.
Hyperarousal, which has been suggested as a predisposing factor of insomnia,
is also a central constituent in Perlis, Giles, Mendelson, Bootzin, &Wyatts (1997)
neurocognitive model of insomnia. Hyperarousal, defined as high cortical activity,
becomes increasingly associated with stimuli usually associated with sleep (e.g.,
going to bed). Hyperarousal is the inability to inhibit intrusive stimuli, both inter-
nal (cognitive, physical) and external (environmental). By integrating both models
(Espie, 2002; Perlis et al., 1997), hyperarousal (as defined by Perlis et al., 1997)
would be the result of a deficiency in the de-arousal sleep protector (as defined by
Espie, 2002). Adeficient ability in the inhibition system may be present before the
onset of insomnia but remain sufficiently active to maintain good sleep until af-
ter being fully triggered by one or more stressors, or precipitating factors. The pre-
cipitating factors identified in this study had a certain impact on sleep probably via
the cognitive and physiological arousal they produced while being interpreted as
stressors to the individual. Although individuals who participated in this study
were not overly anxious (STAI mean scores), they still showed a reasonable anxi-
ety base. A longitudinal protocol studying the preinsomnia moment, with good
sleepers and other individuals followed on a number of years, might be able to tar-
get those individuals more at risk to develop later chronic insomnia.
In summary, these findings suggest that several types of factors contribute to the
onset of insomnia and that the nature of those precipitating events may vary with
the age of onset. Each identified category may be integrated to the conceptualiza-
tion models of insomnia as precipitating factors. It is possible that some
precipitants are chronic in nature and come to play a role in perpetuating sleep dif-
ficulties over time. These maintaining factors could lead to inadequate stress-cop-
ing strategies, maladaptive sleep habits, and dysfunctional beliefs and attitudes
about sleep (Foley et al., 1999; Healy et al., 1981; Morin et al., 1994; Ribet &
Derriennic, 1999). Although these data do not inform us about the process under-
lying a negative event associated with the development of chronic insomnia, they
are useful to identify potential risk factors for insomnia. Because retrospective data
are always subject to bias, it will be important in future research to conduct pro-
spective and longitudinal analyses of risk factors for insomnia. Furthermore, these
data were obtained in a clinical sample of participants seeking help for their sleep
difficulties, and no comparison group is available. Considering that the incidence
of insomnia is about 3.5% in young adults (Spielman, 1986) and 5% in older peo-
ple (Waters et al., 1993), it would be interesting to conduct a longitudinal study
aimed at evaluating the premorbid factors associated with the development of
chronic insomnia.
60 BASTIEN, VALLIRES, MORIN
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

ACKNOWLEDGMENT
Preparation of this article was supported in part by the National Institute of Mental
Health Grant #MH55469 and the Fonds de la Recherche en Sant du Qubec.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th
ed.). Washington, DC: Author.
Askenasy, J. J., & Lewin, I. (1996). The impact of missile warfare on self-reported sleep quality. Sleep,
19, 4751.
Bastien, C. H., & Morin, C. M. (2000). Familial incidence of insomnia. Journal of Sleep Research, 9,
4954.
Bastien, C. H., Vallires, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an
outcome measure for insomnia research. Sleep Medicine, 2, 297307.
Bixler, E. O., Kales, A., & Soldatos, C. R. (1979). Sleep disorders encountered in medical practice: A
national survey of physicians. Journal of Behavioral Medicine, 6(13), 1721.
Borkovec, T. D. (1982). Insomnia. Journal of Cross-Cultural Psychology, 50, 880895.
Breslau, N., Roth, T., Rosenthal, L., &Andreski, P. (1996). Sleep disturbance and psychiatric disorders:
A longitudinal epidemiological study of young adults. Biological Psychiatry, 39, 411418.
Chilcott, L. A., & Shapiro, C. M. (1996). The socioeconomic impact of insomnia: An overview.
PharmacoEconomics, 10(Suppl. 1), 114.
Espie, C. A. (2002). Insomnia: Conceptual issues in the development, persistence, and treatment of
sleep disorder in adults. Annual Review of Psychology, 53, 215243.
Foley, D. J., Monjan, A. A., Izmirlian, G., Hays, J. C., & Blazer, D. G. (1999). Incidence and remission
of insomnia among elderly adults in a biracial cohort. Sleep, 22, S373S378.
Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric dis-
orders: An opportunity for prevention? Journal of the American Medical Association, 262,
14791484.
Gallup Organization (1991). Sleep in America. Princeton, NJ: Author.
Hall, M., Buysse, D. J., Reynolds, C. F., Kupfer, D. J., & Baum, A. (1996). Stress related intrusive
thoughts disrupt sleep onset and continuity. Sleep Research, 25, 163.
Hauri, P. J., & Olmstead, E. M. (1980). Childhood-onset insomnia. Sleep, 3, 5965.
Healy, E. S., Kales, A., Monroe, L. J., Bixler, E. O., Chamberlin, K., &Soldatos, C. R. (1981). Onset of
insomnia: Role of life-stress events. Psychosomatic Medicine, 43, 439451.
Kageyama, T., Kabuto, M., Nitta, H., Kurokawa, Y., Taira, K., &Suzuki, S. (1997). A population study
on risk factors for insomnia among adult Japanese women: A possible effect of road traffic volume.
Sleep, 20, 963971.
Kales, A., & Vgontzas, A. N. (1992). Predisposition to and development and persistence of chronic in-
somnia: Importance of psychobehavioral factors. Archives of Internal Medicine, 152, 15701572.
Katz, D. A., &McHorney, C. A. (1998). Clinical correlates of insomnia in patients with chronic illness.
Archives of Internal Medicine, 158, 10991107.
Klink, M. E., Quan, S. F., Kaltenborn, W. T., & Lebowitz, M. D. (1992). Risk factors associated with
complaints of insomnia in a general adult population. Archives of Internal Medicine, 152,
16341637.
Mellinger, G. D., Balter, M. B., &Uhlenhuth, E. H. (1985). Insomnia and its treatment: Prevalence and
correlates. Archives of General Psychiatry, 42, 225232.
PRECIPITATING FACTORS OF INSOMNIA 61
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4

Morgan, K., &Clarke, D. (1997). Risk factors for late-life insomnia in a representative general practice
sample. British Journal of General Practice, 47, 166169.
Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford.
Morin, C. M., Stone, J., McDonald, K., & Jones, S. (1994). Psychological management of insomnia: A
clinical replication series with 100 insomnia patients. Journal of Behavior Therapy, 25, 291309.
Perlis, M. L., Giles, D. E., Mendelson, W. B., Bootzin, R. R., & Wyatt, J. K. (1997).
Psychophysiological insomnia: The behavioral model and a neurocognitive perspective. Journal of
Sleep Research, 6, 179188.
Ribet, C., &Derriennic, F. (1999). Age, working conditions, and sleep disorders: Alongitudinal analy-
sis in the French cohort E.S.T.E.V. Sleep, 22, 491504.
Roberts, R. E., Shena, S. J., & Kaplan, G. A. (1999). Prospective data on sleep complaints and associ-
ated risk factors in an older cohort. Psychosomatic Medicine, 61, 188196.
Spielman, A. (1986). Assessment of insomnia. Clinical Psychology Review, 6, 1125.
Spielman, A. J., &Glovinsky, P. B. (1991). The varied nature of insomnia. In P. Hauri (Ed.), Case stud-
ies in insomnia (pp. 115). New York: Plenum.
Waters, W. F., Adams, S. G., Jr., Binks, P., &Varnado, P. (1993). Attention, stress and negative emotion
in persistent sleep-onset and sleep-maintenance insomnia. Sleep, 16, 128136.
Watts, F. N., Coyle, K., & East, M. P. (1994). The contribution of worry to insomnia. British Journal of
Clinical Psychology, 33, 211220.
Vollrath, M., Wicki, W., &Angst, J. (1989). The Zurich Study: Insomnia: Association with depression,
anxiety, somatic syndromes, and course of insomnia. European Archives of Psychiatry &Neurologi-
cal Sciences, 239, 113124.
62 BASTIEN, VALLIRES, MORIN
D
o
w
n
l
o
a
d
e
d

b
y

[
8
8
.
8
.
8
9
.
1
9
5
]

a
t

1
2
:
4
4

2
4

O
c
t
o
b
e
r

2
0
1
4