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Changes in dysfunctional beliefs about sleep after cognitive behavioral therapy for insomnia: A systematic literature review and meta-analysis
Open accessAbstract
Cognitive behavioral therapy for insomnia (CBT-I) is the preferred treatment for chronic insomnia and sleep-related cognitions are one target of treatment. There has been little systematic investigation of how sleep-related cognitions are being assessed in CBT-I trials and no meta-analysis of the impact of CBT-I on dysfunctional beliefs about sleep, a core cognitive component of treatment. Academic Search Complete, Medline, CINAHL and PsychInfo from 1990 to 2018 were searched to identify randomized controlled trials of CBT-I in adults (≥18 years) reporting some measure of sleep-related cognitions. Sixteen randomized controlled trials were identified comparing 1134 CBT-I and 830 control subjects. The Dysfunctional Beliefs and Attitudes about Sleep Scale was utilized almost exclusively to assess sleep-related cognitions in these trials. Hedge's g at 95% confidence interval (CI) was calculated to assess CBT-I effect size at post-treatment compared to controls. CBT-I significantly reduced dysfunctional beliefs about sleep (g = -0.90, 95% CI -1.19, -0.62) at post-treatment. Three trials contributed data to estimate effect size for long-term effects (g = -1.04, 95% CI -2.07, -0.02) with follow up time ranging from 3 to 18 mo. We concluded that cognitive behavioral therapy for insomnia has moderate to large effects on dysfunctional beliefs about sleep.
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“a meta-analysis by Thakral et al. (2020) found dysfunctional beliefs and attitudes about sleep improve after a period of CBT-I in adults, with a large effect reported.”
From Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis (2022) · cites this paper as Thakral et al., 2020
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“This reflects a similar meta-analysis investigating the effects of CBT-I on dysfunctional beliefs and attitudes about sleep, where a large effect was found (Thakral et al., 2020).”
From Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis (2022) · cites this paper as Thakral et al., 2020
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“A 2020 meta-analysis of 16 RCTs found a large effect of CBT-I in reducing dysfunctional beliefs about sleep at post-treatment, with effect maintained at follow-up from 3 to 18 months (Thakral et al., 2020).”
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ResultMechanisms of cognitive behavioural therapy for insomnia
Altena, E., Ellis, J. G., Camart, N., Guichard, K., & Bastien, C. (2023) · Journal of Sleep Research · doi:10.1111/jsr.13860 · Cited by 60
“…with insomnia, changes in beliefs and attitudes about sleep as well as locus of control have been shown to be key aspects linked to effective CBT-I, and to diminished insomnia complaints as well as improvements in objective sleep (Chow et al., 2018; Edinger et al., 2001a; Thakral et al., 2020).”
BackgroundThe significance of cognitive-behavioral therapy on suicide: An umbrella review
Wu, H., Liu, L., Qian, Y., Jin, X., Yu, H., Du, L., Fu, X., Zhu, B., & Chen, H. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.08.067 · Cited by 57
Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis
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“This reflects a similar meta-analysis investigating the effects of CBT-I on dysfunctional beliefs and attitudes about sleep, where a large effect was found (Thakral et al., 2020).”
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“…literature to outline specific strategies for fostering more adaptive beliefs about solitude (e.g., cognitive reappraisal, mindfulness) and discuss the potential benefits and challenges of implementing such interventions in different contexts (e.g., schools, workplaces, retirement communities).”
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“In this framework, changes in dysfunctional beliefs or arousal have been considered mediators of CBT-I insomnia treatment response (Thakral et al., 2020).”
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“Digital interventions effectively reduced dysfunctional beliefs and attitudes about sleep, consistent with findings reported by Thakral et al [59], who indicated the effectiveness of CBT-i in helping individuals develop healthier sleep-related beliefs and attitudes.”
Bedtime procrastination mediates the relation between anxiety and sleep problems
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“Several studies have shown a reduction in dysfunctional beliefs about sleep, with a concomitant reduction in the severity of insomnia (Lance et al., 2019; Thakral et al., 2020).”
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“This study indicated the effectiveness of CBT in reducing maladaptive cognitions in patients with ADHD, in line with those patients with depression [56], insomnia [57], and agoraphobia [58].”
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Does psychological capital mediate the impact of dysfunctional sleep beliefs on well-being?
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Recent Advances in Diagnosis and Treatment of Insomnia Disorder
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Leitlinie „Insomnie bei Erwachsenen“ – Update 2025 (AWMF-Registernummer 063-003)
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“While applying digital CBT-I using digital therapeutic application to patients with insomnia, brief measure tools are needed to assess insomnia-related symptoms or psychological problems such as depression, anxiety, insomnia severity, and dysfunctional beliefs about sleep.”
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“CBT-I can significantly improve sleep efficiency, reduce the time to fall asleep and the number of nocturnal awakenings 40,41 .”
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“26,27 In this study, however, we observed that change in insomnia severity was significantly associated with change in sleep-related cognitions.”
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“, 2014), they deviate from the wider literature (Thakral et al., 2020).”
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“Prior studies demonstrate that cognitive-behavioral interventions aimed at correcting DBAS effectively improve sleep quality [30–32].”
Impact of Adherence to Digital Cognitive Behavioral Therapy for Insomnia Effectiveness
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“29,33 In contrast to the results of other studies, we did not find significant between-group differences in ISI scores from baseline to post intervention.”
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“Speci fi cally, while both interventions likely addressed AT through CBT components (Nicolai, 2014; Thakral, Von Korff, McCurry, Morin, & Vitiello, 2020) and anxiety to some extent, the addition of MBI in the combined group may have offered a more comprehensive strategy for managing anxiety.”
Roland, A., Windal, M., Briganti, G., Kornreich, C., & Maîresse, O. (2023) · Nature and Science of Sleep · doi:10.2147/nss.s432944 · Cited by 5
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“Both sleep and non-sleep symptoms, quality of life, and dysfunctional beliefs about sleep can be helped with CBTI (Manber et al., 2016; Thakral et al., 2020).”
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Matricciani, L., Paquet, C., Dumuid, D., Lushington, K., & Olds, T. (2022) · The Science of Diabetes Self-Management and Care · doi:10.1177/26350106221137896 · Cited by 7
Effects of schedule exercise therapy on chronic insomnia
Liao, Y., Huang, F., Ni, X., Ke, H.-Y., Tian, Y., Yu, M., Jin, G., & Chen, G. (2022) · Medicine · doi:10.1097/md.0000000000030792 · Cited by 7
“[14,15] Since Spielman first proposed the concept of behavioral treatment for insomnia,[16] an increasing number of studies have examined its mechanism of action and clinical applications.[17-21] Clinical research has demonstrated that CBT-I can be a safe and effective treatment option for patients with CID with vario…”
BackgroundAdjunctive smart ring monitoring during digital cognitive behavioral therapy for insomnia
Moon, D. U., Lee, Y., Lütt, A., Lee, S., & Lee, E. M. (2025) · Scientific Reports · doi:10.1038/s41598-025-24312-0 · Cited by 4
“Cognitive factors, such as heightened sleep-related worry and selective monitoring, may lead to exaggerated perceptions of sleep deficits 69,70 .”
Identifying the association of hyperarousal and insomnia symptoms: A network perspective
Zhu, K., & Xue, S. (2025) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2025.06.017 · Cited by 4
Chan, K. L., Pau, N. H. Y., Poon, S. F. O., Lam, B. L. H., Lam, C. B., & Chan, K. K. S. (2025) · Applied Psychology Health and Well-Being · doi:10.1111/aphw.70047 · Cited by 5
“This finding aligns with previous research demonstrating that CBT-I can address misconceptions about the causes and consequences of insomnia, unrealistic sleep expectations, and faulty beliefs about sleep control and practices (Furukawa et al., 2024; Thakral et al., 2020).”
Wang, B., Wang, Z., Zhang, X., Ji, Y., Shuai, Y., Shen, Y., Shen, Z., & Chen, W. (2025) · Sleep And Breathing · doi:10.1007/s11325-025-03283-6 · Cited by 5
“Providing accurate sleep information or cognitive restructuring strategies may prevent short-term sleep issues from escalating into long-term problems, particularly during high-stress events like the COVID-19 pandemic [28, 53].”
Gao, Z., Gao, Z., Chen, Z., Ma, J., Zhao, Y., Zhang, L., & Guo, L. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05580-y · Cited by 4
“The false cognition of sleep in cancer patients creates a serious psychological burden in cancer patients, triggering anxiety, worry, and ultimately non-adaptive behaviors [29, 30].”
BackgroundVeteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study
Kaitz, J. E., Robinson, S. A., Petrakis, B. A., Reilly, E. D., Chamberlin, E. S., Wiener, R. S., & Quigley, K. S. (2022) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-022-00287-x · Cited by 4
Assessing the Sleep-wake Pattern in Cancer Patients for Predicting a Short Sleep Onset Latency
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“Cognitive-behavioral therapy for insomnia (CBT-I) improves insomnia by targeting perpetuating factors, such as dysfunctional beliefs [7], and is an effective treatment for insomnia secondary to cancer [8].”
BackgroundThe Network of Dysfunctional Beliefs About Sleep: A Structural Re-Analysis of the DBAS-16
Carmo, M., Morin, C. M., Hasan, R., Toscanini, A. C., & Rafihi‐Ferreira, R. E. (2026) · Behavioral Sleep Medicine · doi:10.1080/15402002.2026.2711286 · Cited by 3
Self-citationInvestigating the Effectiveness of CBT-i Coach, a Free, Publicly Available mHealth App for Insomnia
Dolezal, M. L., Wielgosz, J., Miller, K. E., Taylor, K. L., Owen, J. E., & Kuhn, E. R. (2024) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-024-00459-x · Cited by 3
“…restriction (Maurer et al., 2021; Miller et al., 2014), stimulus control (Jansson-Fröjmark et al., 2024), relaxation (Lichstein et al., 2011), sleep hygiene/psychoeducation (Chung et al., 2018; van Straten et al., 2018), and cognitive restructuring (Thakral et al., 2020) all improve sleep outcomes.”
Nielson, S. A., Boyle, J. T., Dautovich, N. D., & Dzierzewski, J. M. (2024) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2024.102032 · Cited by 6
Relationship between Psychological Capital and Sleep Quality in Intensive Care Unit Nurses
Sajedi, S., Jafarjalal, E., & Haghani, S. (2022) · Journal of Client-centered Nursing Care · doi:10.32598/jccnc.8.2.418.1 · Cited by 3
Cognitive Behavior Therapy Effects in Patients with Insomnia: A Literature Review
Kurnianto, S., Abidin, Z., & Puspitasari, H. D. (2022) · Fundamental and Management Nursing Journal · doi:10.20473/fmnj.v5i1.38908
Tang, T., Zhang, N., Qu, L., Zhang, J., Yang, D., Shen, S., Du, B., Du, X., Liu, N., & Cui, L. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-109402 · Cited by 2
Zhu, H., Wen, Q., Zhang, F., Li, S., Wang, X., & Li, J. (2025) · Sleep Medicine · doi:10.1016/j.sleep.2025.108678 · Cited by 2
Islam, M. Z., Rafi, M. F. A., Podder, P., Siddika, A., Kabir, M., Khan, E. M., Islam, A. K. M. N., & Mukta, S. H. (2025) · Data and Information Management · doi:10.1016/j.dim.2025.100104 · Cited by 2
Park, K., Lee, S., Lee, Y., Moon, D. U., & Lee, E. M. (2025) · Journal of Medical Internet Research · doi:10.2196/70722 · Cited by 3
“The treatment effects of the WELT-I intervention align with findings from recent meta-analyses, supporting the efficacy of digital CBT-I [51-53].”
You, S., Xie, Y., Wang, X., Tang, S., & Wu, D. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1744418
“For individuals with high scores on dysfunctional sleep beliefs and attitudes, integrating core modules of CBT-I, such as cognitive restructuring, stimulus control, and sleep restriction, can be used for intervention, with a focus on strengthening cognitive reappraisal components (65).”
Yang, S., Zhang, Z., & Lei, X. (2026) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2026.01.029 · Cited by 1
Ossipova, I., Pössel, P., & Fernandez-Botrán, R. (2025) · Research in Nursing & Health · doi:10.1002/nur.70019 · Cited by 1
Factors Linking Interoception and Sleep Across the Adult Lifespan
Seo, A., Nishiyama, R., Lee, K., & Duarte, A. (2025) · Psychophysiology · doi:10.1111/psyp.70120 · Cited by 1
“…have emphasized this arousal before sleep as a target for insomnia interventions (Harvey 2002), shaping one of the core principles of cognitive-behavioral therapy for insomnia (CBT-I; Cincotta et al. 2011; Ong et al. 2018; Sunnhed and Jansson-Fröjmark 2015; as reviewed in Thakral et al. 2020).”
Roh, Y., Yoon, A. S., & Oh, H. (2026) · JMIR Formative Research · doi:10.2196/79242 · Cited by 1
“CBT-I targets maladaptive beliefs about sleep and conditioned arousal, and prior studies have shown that cognitive changes achieved through CBT-I are relatively stable after treatment completion [17].”
Isaksson, S., Henriksson, V., Salim, O., Bäccman, C., & Norell, A. (2025) · Sleep Medicine · doi:10.1016/j.sleep.2025.106595 · Cited by 1
Sleep misperception in women with myofascial temporomandibular disorder
Chan, C. C., Dubrovsky, B., Bouchard, M., Tartter, V. C., & Raphael, K. G. (2024) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.11330 · Cited by 1
“40 Future investigations could focus on the effect of cognitive behavioral therapy for insomnia on self-reported sleep and pain experience in patients with TMD and insomnia, with and without the misperception component.”
Psychological repercussions of COVID-19 on health care workers, Sudan
Salman, F. H., Elmahdi, Z. Z. M., & Elnour, S. M. B. (2023) · International Journal of Social Psychiatry · doi:10.1177/00207640231199406 · Cited by 1
“…(Killgore et al., 2020), anxiety was evaluated using the Generalised Anxiety Disorder 7-item (GAD-7) scale (Lechner et al., 2020), and insomnia was assessed using the validated version of the Insomnia Severity Index (Thakral et al., 2020), both of which are validated measuring techniques.”
MethodAmani, O., Mazaheri, M. A., Malekzadeh, M., & Zarani, F. (2023) · Biological Rhythm Research · doi:10.1080/09291016.2023.2242063 · Cited by 1
“This evidence-based non-pharmacological treatment is a multi-component treat-ment that changes the sleep quality of the affected person by changing dysfunctional cognitions and behaviors (Thakral et al. 2020).”
BackgroundHardman, J. R., Rees, C. S., Bonnar, D., & Ree, M. J. (2023) · Clinical Psychologist · doi:10.1080/13284207.2022.2155034 · Cited by 1
Hartley, S., Dagneaux, S., Palethorpe, C., Londe, V., Liane, M.-T., Decalf, L., Aussert, F., Francs, C. C. D., Leymarie, R., & Royant‐Parola, S. (2022) · L Encéphale · doi:10.1016/j.encep.2022.08.022 · Cited by 1
陈, 福. (2024) · Advances in Psychology · doi:10.12677/ap.2024.148547 · Cited by 2
Lu, Y. M., Huo, Y. L., Zhang, Y., Liu, J. C., & Zhang, G. (2026) · European Journal of Integrative Medicine · doi:10.1016/j.eujim.2026.102784
Lofitou, K., Kouki, E., Gavriel, C., Achilleos, H., Themistokleous, V., Bargiotas, P., Haarbauer-Krupa, J., Paraskevopoulos, E., & Constantinidou, F. (2026) · Brain and Behavior · doi:10.1002/brb3.71556
“Research indicates that structured behavioral interventions, such as CBT-I, help realign the sleep–w ake cycle, enhance self-regulation, and mitigate insomnia symptoms by targeting dysfunctional sleep beliefs (Thakral et al. 2020 ).”
Sharma, G. S., Gupta, R. M., Kulshreshtha, P., Dhamija, P., Mohan, L., & Rao, M. R. (2026) · Sleep and Vigilance · doi:10.1007/s41782-026-00368-4
Circadian–immune crosstalk in insomnia disorder: mechanisms and therapeutic implications
Huang, Y., Wang, X., Chen, X., & Liu, Y. (2026) · Frontiers in Neuroscience · doi:10.3389/fnins.2026.1881195 · Cited by 1
“From the perspective of circadian–immune interactions, CBT-I may stabilize behavioral rhythms by improving sleep continuity, reducing pre-sleep arousal, and attenuating stress responses (Irwin et al., 2014; Thakral et al., 2020; Palagini et al., 2022).”
Zou, C., Lan, Y., Liu, X., & Zhu, X. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1804213
“Evidence that CBT-I modi fi es dysfunctional beliefs about sleep Frontiers in Psychiatry frontiersin.org provides a mechanistic rationale for improved patient expectations and subsequent engagement (35).”
Hu, J., Yang, Z.-Z., Zhang, X., Sun, X.-Y., Hou, Y., & Zhang, X.-Y. (2026) · Sleep Medicine · doi:10.1016/j.sleep.2026.109011
Lee, N., Ahn, J., Kim, H., & Kim, S. (2026) · Chronobiology in Medicine · doi:10.33069/cim.2026.0013
“Given that restructuring these mal-adaptive cognitions is a core component in Cognitive Behavioral Therapy for Insomnia, which is a treatment of choice for chronic insomnia [2,39].”
Ndekezi, D., Kyomugisha, R., Nyangoma, B., Namirembe, P., Nanyonga, B., Nyaruhuma, A., Ateo, C., Rutainama, C. R., Thomas, K. A., Batuusa, R., et al. (2026) · SLEEP Advances · doi:10.1093/sleepadvances/zpag029
“Improvements in sleep knowledge,total time in bed,longer sleep duration, and healthier attitudes reflect dur able cognitive and behavioral change [53, 54].”
Shi, X., Fan, X., Cai, Y., Luo, Z., Liu, Y., Feng, S., Gan, L., Wang, Q., Chen, L., & Pan, J. (2026) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2026.111678
Sleep Knowledge and Cognitions and Their Relation to Behavioural Sleep Indices
Boog, K., Bartholomay, E. M., & Fehr, K. K. (2026) · Journal of Sleep Research · doi:10.1111/jsr.70320
“Cognitive-behavioural therapy for insomnia (CBT-I; Thakral et al. 2020) is an evidence-based treatment for adults with insomnia that addresses both sleep-related behaviours and cognitions to improve sleep (Friedrich and Schlarb 2018).”
An app responding to behavior of people to promote mental wellbeing in anxious youth
Hagalwadi, J., Sutherland, D., Dölek, S., Marin-Dragu, S., Bagnell, A. L., Wozney, L., Orji, R., & Sandra, M. (2026) · Journal of Affective Disorders · doi:10.1016/j.jad.2026.121503
del Giudice, R., Daccordo, T., Mandelli, L., Gallucci, M., Madeddu, F., Maffeis, M., d'Albore, M., Conforti, L., Grimaudo, D., Scirica, M., et al. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70261
“In line with previous research, we expected a clinically significant post-treatment insomnia symptoms reduction (Hertenstein et al. 2022; Thakral et al. 2020; van Straten et al. 2018).”
InfluentialKim, Y., Tsai, T. C., Steel, J. L., Ramos, A. R., Laurenceau, J., & Troxel, W. (2025) · Pilot and Feasibility Studies · doi:10.1186/s40814-025-01671-z
“CBT-I is the gold standard behavioral intervention endorsed by the American Academy of Sleep Medicine for treating sleep disturbance and/or insomnia in the general population [50–52].”
Whale, K., Johnson, E. C., & Gooberman‐Hill, R. (2025) · Musculoskeletal Care · doi:10.1002/msc.70088
Dysfunctional Beliefs About Sleep in Suicidal Adolescents: Associations and Treatment Implications
Bullinger, L., Gazor, A., Buerkert, S., Dieste, S. M., Brown, W. D., & Stewart, S. M. (2025) · Behavior Therapy · doi:10.1016/j.beth.2025.03.005 · Cited by 1
Metadata
- Authors
- Thakral, M., Von Korff, M., McCurry, S. M., Morin, C. M., & Vitiello, M. V.
- Affiliations
- University of Washington (US)
- Université Laval (CA)
- Corresponding author
- Thakral, Manu
- Venue
- Sleep Medicine Reviews
- Publisher
- Elsevier BV
- Published
- 2020-02
- Volume
- 49
- Pages
- 101230
- ISSN
- 1087-0792 (ISSN-L)
- PMC
- PMC7012685
- OpenAlex
- W2985404547
- Cited by
- 117
- References
- 75
- Citations by year
- 2026: 15 · 2025: 21 · 2024: 13 · 2023: 28 · 2022: 25 · 2021: 10 · 2020: 5
- FWCI
- 1.48
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Sleep Medicine Reviews (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- cognitive behavioral therapy for insomnia, dysfunctional beliefs about sleep, sleep-related cognitions, chronic insomnia, treatment effect size, long-term follow-up
- MeSH terms
- Humans, Sleep Initiation and Maintenance Disorders, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Treatment Outcome
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