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Cited by 9Sleep and related disordersCancer survivorship and careAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

An exploration into the relationship between insomnia and repetitive negative thinking among cancer survivors.

Open access
Arditte Hall, Kimberly A., Price, Sarah N., Lucas, Alexander R., Park, Elyse R., Wagner, Lynne I., Mizrach, Helen R., Werner, Michael H., Juhel, Brooke C. +3 more·2025·Journal of Psychosocial Oncology
DOI 10.1080/07347332.2024.2356193PMC PMC11612031
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Abstract

Objective: Insomnia and repetitive negative thinking (RNT) are both prevalent among cancer survivors, yet little work has investigated their interrelationship. To explore the hypothesis that RNT and insomnia are related, we conducted secondary analyses on data from a pilot clinical trial of cognitive behavioral therapy for insomnia (CBT-I) for cancer survivors. Methods: This study analyzed survey data from 40 cancer survivors with insomnia who participated in a pilot randomized trial of CBT-I. Correlations and linear regression models were used to determine associations between aspects of RNT and related constructs (fear of cancer recurrence [FCR], cancer-specific rumination, worry, and intolerance of uncertainty) and sleep (insomnia and sleep quality), while accounting for psychiatric symptoms such as anxiety and depression. Treatment-related change in RNT was examined using a series of linear mixed models. Results: Evidence for an association between RNT and insomnia among cancer survivors emerged. Higher levels of FCR and cancer-related rumination were correlated with more severe insomnia symptoms and worse sleep quality. Notably, FCR levels predicted insomnia, even after controlling for anxiety and depression. Results identified potential benefits and limitations of CBT-I in addressing RNT that should be examined more thoroughly in future research. Conclusions: RNT is a potential target to consider in insomnia treatment for cancer survivors.

Integrity signals

Registry

Crossref · 10.1080/07347332.2024.2356193

Cites

61 of 61 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

12 of 41 cited sources checked · 3 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Existing CBT-I programs tested with cancer survivors produce medium-sized improvements in insomnia severity, sleep efficiency, sleep onset latency, and wake after sleep onset.

    “Meta-analyses by our team and others have found that existing CBT-I programs tested with cancer survivors lead to medium sized improvements in insomnia severity, sleep efficiency, sleep onset latency, and wake after sleep onset.”
    Quote in the paperSubstantial claim1 of 5 sources checked
    • cites [10] source
    • cites [11] source
    • cites [12] source

      The Introduction reports that a meta-analysis of cancer survivors found improvements in all four named outcomes. This paper’s Results report post-intervention effects primarily in patients with breast cancer, ranging from smaller effects for wake after sleep onset to larger effects for insomnia severity; the Discussion describes the earlier cancer-survivor findings as small-to-moderate. It therefore supports improvement, but not a uniformly medium-sized effect across all four outcomes and cancer survivors generally. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [13] source
    • cites [14] source
  • Premisecitation

    CBT-I has more modest effects on other sleep-related outcomes such as sleep duration continuity, perceived cognitive functioning, depression, and anxiety.

    “However, other sleep-related outcomes have more modest effects (e.g., sleep duration continuity, perceived cognitive functioning depression, anxiety).10–14”
    Quote in the paperSubstantial claim1 of 5 sources checked
    • cites [10] source
    • cites [11] source
    • cites [12] source

      The Results (Table 4; page not provided) report relatively modest effects on total sleep time and measures of sleep continuity compared with the larger effects on insomnia severity reported in Table 3. The paper does not report effects on perceived cognitive functioning, depression, or anxiety, so those parts of the claim are not supported by this source. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [13] source
    • cites [14] source
  • Premisecitation

    Two recent fear of cancer recurrence interventions that included a CBT worry-time skill found improvements in cancer survivors' sleep quality.

    “Two recent FCR interventions that included a CBT skill for managing interference from worry (i.e., worry time) also found improvements in survivors’ sleep quality.44,45”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [44] source
    • cites [45] source

      The Phase 1 Qualitative Study describes adding “Worry Time” to address cancer-related worries that interfere with sleep, and Results §3.3 reports significantly greater improvement in sleep quality with the Survivorship Sleep Program than with enhanced usual care. But the Introduction identifies this program as an intervention for insomnia, tailored to address fear of recurrence as a barrier to sleep—not as a fear-of-cancer-recurrence intervention. This verdict concerns this source only, not the other study cited in the sentence. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • Findingown data

    In qualitative interviews, multiple cancer survivors with insomnia identified worry as a bothersome symptom that interfered with sleep and quality of life.

    “multiple survivors identified worry, and to a lesser extent, rumination as bothersome symptoms that interfered with their sleep and quality of life.”
    Quote in the paperSubstantial claim
  • Findingown data

    Among cancer survivors with insomnia, higher cancer-related rumination is associated with poorer subjective sleep quality.

    “Greater FCR and cancer-related rumination were associated with greater insomnia severity and poorer subjective sleep quality.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 10
  • May combine two claims. 11
  • The quote only partly states this claim. 2

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Fear of cancer recurrence severity is independent of cancer type, treatment history, and time since treatment.

    “Like insomnia, the FCR severity is independent of cancer type, treatment history, or time since treatment.25–33”
    Quote in the paperNot a substantial claim2 of 9 sources checked
    • cites [25] source
    • cites [26] source
    • cites [27] source

      The Methods describe only younger breast cancer survivors 2–4 years posttreatment, and the Discussion addresses associations between cancer-related uncertainty, insomnia, fatigue, and mood. Searches for recurrence severity, cancer type, treatment history, and time since treatment found no analysis establishing that fear-of-recurrence severity is independent of those factors. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [28] source
    • cites [29] source
    • cites [30] source

      The Discussion (page unavailable) says fear of recurrence or progression can persist for years after treatment and that its role in linking symptoms to stress was unchanged when the model accounted for time since diagnosis. Those findings do not establish that fear severity is independent of time since treatment. The paper includes survivors with varied cancer types and treatment histories, but does not report that fear severity is independent of either. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [31] source
    • cites [32] source
    • cites [33]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    CBT-I is the gold standard treatment for insomnia in cancer survivors and in the general population.

    “Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard for treating insomnia in cancer survivors and the general population.3,7–9”
    Quote in the paperSubstantial claim2 of 4 sources checked
    • cites [3] source
    • cites [7] source
    • cites [8] source

      The Discussion (page unavailable) calls CBT-I “the current standard treatment for insomnia,” supporting the general-population portion of the claim. Our copy does not address its status as a treatment for insomnia in cancer survivors. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [9] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Repetitive negative thinking includes worry and rumination and is both a risk factor for and a common symptom of anxiety and depression.

    “Repetitive negative thinking (RNT), which includes worry and rumination, is both a risk factor for and a common symptom of anxiety and depression15–17”
    Quote in the paperNot a substantial claim3 of 3 sources checked
    • cites [15] source
    • cites [16] source

      The Introduction (p. 3) identifies chronic worry as central to generalized anxiety disorder, and “Worry and Depression” (p. 12) describes depressive rumination as similar to worry and as a possible factor maintaining depression. The paper does not establish that repetitive negative thinking as a whole is a common symptom of both conditions or a risk factor for developing both. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [17] source

      The section on factors influencing depression and anxiety discusses distress, uncertainty and anxiety around a cancer diagnosis, but does not identify repetitive negative thinking or define it as worry and rumination. Searches for “repetitive negative thinking,” “worry,” and “rumination” found no passage establishing the claimed risk-factor and symptom relationship. (LLM, conf=0.77)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    Repetitive negative thinking has been linked with sleep difficulties in populations with and without psychiatric diagnoses.

    “RNT has been linked with sleep difficulties in various populations, both with and without psychiatric diagnoses.15”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] source

      The discussion of major depression (section “Nolen”; page unavailable) mentions poor sleep maintenance as a possible state-dependent process, but does not link sleep difficulties to rumination. Searches for sleep difficulties and insomnia found no passage reporting the claimed association in populations with and without psychiatric diagnoses. (LLM, conf=0.75)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based).

    Findingnone given

    Compared with enhanced usual care, CBT-I did not produce a greater decrease in fear of cancer recurrence from baseline to one-month follow-up.

    “Relative to participants in the EUC condition, participants in the CBT-I condition demonstrated a greater decrease in FCR from baseline to T1, but not from baseline to T2, and the effect remained significant after controlling for employment status and insurance type.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Compared with enhanced usual care, CBT-I produced a greater decrease in fear of cancer recurrence from baseline to post-intervention.

    “Relative to participants in the EUC condition, participants in the CBT-I condition demonstrated a greater decrease in FCR from baseline to T1, but not from baseline to T2, and the effect remained significant after controlling for employment status and insurance type.”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    The greater post-intervention decrease in fear of cancer recurrence for CBT-I versus enhanced usual care remained significant after adjustment for employment status and insurance type.

    “Relative to participants in the EUC condition, participants in the CBT-I condition demonstrated a greater decrease in FCR from baseline to T1, but not from baseline to T2, and the effect remained significant after controlling for employment status and insurance type.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    As many as two-thirds of cancer survivors experience elevated fear of cancer recurrence.

    “As many as two-thirds of cancer survivors live with elevated FCR.23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] source

  • May combine two claims.

    Premisecitation

    The parent trial found that the CBT-I protocol was feasible, acceptable, and preliminarily efficacious for self-reported insomnia symptom severity in cancer survivors with insomnia.

    “Primary results from the study found that the CBT-I protocol was feasible, acceptable, and preliminarily efficacious for addressing self-reported insomnia symptom severity in cancer survivors with insomnia46”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [46] source

  • May combine two claims.

    Interpretationown data

    Preliminary evidence indicates that certain types of repetitive negative thinking, particularly fear of cancer recurrence and cancer-related rumination, are associated with insomnia severity and poorer sleep quality but are not strongly influenced by standard CBT-I.

    “Preliminary evidence indicates that certain types of RNT, particularly FCR and cancer-related rumination, are associated with insomnia severity and poorer sleep quality, but do not appear to be strongly influenced by CBT-I in its standard format.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    Outcomes were analyzed using an intent-to-treat approach with separate linear mixed models comparing CBT-I and enhanced usual care over time.

    “Outcomes were then analyzed using intent-to-treat, with separate linear mixed models examining the effects of CBT-I (n=20) vs. EUC (n=20) over time.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Survivors randomized to enhanced usual care were more likely to be employed and to have private insurance than those randomized to the Survivorship Sleep Program.

    “However, as noted earlier, survivors randomized to EUC were more likely to be employed and have private insurance than survivors randomized to the SSP.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    The study was an exploratory secondary analysis of a pilot randomized controlled trial, so its results should be interpreted with caution and replicated in a larger sample.

    “It is important to note that the current study was an exploratory secondary analysis of a pilot randomized controlled trial; thus, results should be interpreted with caution and replication in a larger sample is encouraged.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    There may be opportunities to refine CBT-I so that it addresses repetitive negative thinking and improves its effects for cancer survivors.

    “Thus, there may be additional opportunities to refine CBT-I to address RNT and enhance its effects for this population.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The weakened association between cancer-related rumination and insomnia after adjustment suggests that cancer-related rumination is related to comorbid anxiety or mood disturbance and may need to be treated as a symptom of those conditions.

    “The attenuated association between cancer-related rumination and insomnia in regression analyses suggests that this aspect of RNT is related to comorbid anxiety or mood disturbance and may need to be addressed as a symptom of these conditions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two independent primary coders identified repetitive negative thinking themes, and discrepancies were resolved by consensus with the first and senior authors.

    “Two independent primary coders (BCJ and MHW) identified RNT-related themes; discrepancies were resolved by consensus through discussion with first (KAH) and senior (DLH) authors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Aspects of repetitive negative thinking are associated with patient-reported insomnia and sleep quality, and repetitive negative thinking may be an important target within insomnia interventions for cancer survivors.

    “Results of the current investigation indicated that aspects of RNT were associated with patient-reported insomnia and sleep quality and suggest that RNT may be an important target to consider within insomnia interventions for this population.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Regression analyses were conducted both unadjusted and adjusted for employment status and insurance type.

    “Thus, regression analyses were conducted unadjusted and adjusting for these factors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Repetitive negative thinking has been proposed as a factor that perpetuates insomnia, but it has not been clearly established as a mechanism through which CBT-I reduces insomnia symptoms.

    “Although RNT has been proposed as one important factor perpetuating insomnia,56 it has not been clearly delineated as a mechanism by which CBT-I reduces insomnia symptoms.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [56] source

  • May combine two claims.

    Premisecitation

    Meta-analyses of CBT-I in non-oncological populations show moderate-to-large effects on worry but only small and unreliable effects on rumination.

    “Meta-analyses of CBT-I in non-oncological populations show moderate-to-large effects of CBT-I on worry (Hedges’ g range: −.41 to −.71),58,59 but only small and unreliable effects on rumination.58”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [58] source
    • cites [59] source
20 of 20

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Öcalan S, Özçetin YSU. Rumination, fatigue and psychological resilience in cancer experience. Curr Approaches in Psychiatr. 2020;12(3):421–433.
  2. Hall DL, Park ER, Schnipper HH, Denninger JW, Yeh GY. Relaxation response resiliency program for fear of recurrence (3RP-FOR): Development and preliminary feasibility/acceptability of a multimodal, mind-body intervention for fear of recurrence among cancer survivors. International Conference of the Society for Integrative Oncology; 2018. Scottsdale, AZ.
  3. Ehrnstrom C, Brosse AL. End the Insomnia Struggle: A Step-by-Step Guide to Help You Get to Sleep and Stay Asleep. Oakland, CA: New Harbinger Publications; 2016.

Cited by

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Authors
Arditte Hall, K. A., Price, S. N., Lucas, A. R., Park, E. R., Wagner, L. I., Mizrach, H. R., Werner, M. H., Juhel, B. C., Goldstein, M. R., Gorman, M. J., & Hall, D. L.
Affiliations
  • Department of Psychology and Philosophy, Framingham State University, Framingham, Massachusetts, USA
  • Wake Forest University Health Sciences (US)
  • Virginia Commonwealth University (US)
  • Harvard University (US)
  • Massachusetts General Hospital (US)
  • Beth Israel Deaconess Medical Center (US)
Corresponding author
Hall, Daniel L.
ORCID
Venue
Journal of Psychosocial Oncology
Publisher
Informa UK Limited
Published
2024-06-03
Volume
43
Issue
1
Pages
59-72
ISSN
  • 0734-7332 (ISSN-L)
  • 1540-7586
DOI
10.1080/07347332.2024.2356193
PMC
PMC11612031
OpenAlex
W4399327308
Cited by
9
References
61
Citations by year
2026: 3 · 2025: 6
FWCI
3.66
Type
journal article
Language
en
Open access
Locations
  • Journal of Psychosocial Oncology (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
Funders
  • American Cancer Society
  • National Center for Complementary and Integrative Health
  • National Cancer Institute
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Health Sciences › Medicine › Oncology › Cancer survivorship and care
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
insomnia, repetitive negative thinking, cancer survivors, cognitive behavioral therapy for insomnia, fear of cancer recurrence, worry, intolerance of uncertainty, sleep quality, anxiety, depression
MeSH terms
Pessimism, Cancer Survivors, Rumination, Cognitive, Adult, Aged, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Pilot Projects, Cognitive Behavioral Therapy

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