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Cited by 25Sleep and related disordersAnxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPsychotherapy Techniques and Applications

Sleep Quality Improvement During Cognitive Behavioral Therapy for Anxiety Disorders

Open access
Ramsawh, Holly J., Bomyea, Jessica, Stein, Murray B., Cissell, Shadha H., Lang, Ariel J.·2016·Behavioral Sleep Medicine
DOI 10.1080/15402002.2014.981819PMC PMC4744149
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Abstract

Despite the ubiquity of sleep complaints among individuals with anxiety disorders, few prior studies have examined whether sleep quality improves during anxiety treatment. The current study examined pre- to posttreatment sleep quality improvement during cognitive behavioral therapy (CBT) for panic disorder (PD; (Formula presented.)) or generalized anxiety disorder (GAD; (Formula presented.)). Among sleep quality indices, only global sleep quality and sleep latency improved significantly (but modestly) during CBT. Sleep quality improvement was greater for treatment responders, but did not vary by diagnosis. Additionally, poor baseline sleep quality was independently associated with worse anxiety treatment outcome, as measured by higher intolerance of uncertainty. Additional intervention targeting sleep prior to or during CBT for anxiety may be beneficial for poor sleepers. Copyright © Taylor & Francis Group, LLC.

Integrity signals

Registry

Crossref · 10.1080/15402002.2014.981819

Cites

47 of 47 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

6 of 35 cited sources checked · 5 supported · 0 flagged · accuracy not yet measured

  • Interpretationcitation

    Taken together with prior findings, the current data suggest that poor sleep may serve as a general prognostic indicator in people with anxiety disorders.

    “Taken together with the findings of Zalta and colleagues (2013), these data suggest that poor sleep may be a general prognostic indicator among individuals with anxiety disorders.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Zalta et al., 2013 source
  • Premisecitation

    In people with anxiety disorders, sleep difficulties have an independent effect on functioning that goes beyond the effect of the anxiety disorder itself.

    “Among individuals with anxiety disorders, the presence of sleep difficulties independently impacts functioning over and beyond anxiety disorders alone (Ramsawh, Stein, Belik, Jacobi, & Sareen, 2009; Soehner & Harvey, 2012);”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Ramsawh, Stein, Belik, Jacobi, & Sareen, 2009 source
    • cites Soehner & Harvey, 2012 source
  • Premisecitation

    Sleep complaints are linked to impairment in cognition, social functioning, and daily activity performance.

    “sleep complaints are associated with impairment in domains including cognition, social functioning, and performance of daily activities (Soehner & Harvey, 2012);”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Soehner & Harvey, 2012 source
  • Premisecitation

    Zalta and colleagues (2013) found that sleep quality predicted treatment response to CBT in people with social anxiety disorder.

    “we are aware of only one such study in the anxiety disorders literature, in which Zalta and colleagues (2013) found that sleep quality was a predictor of treatment response to CBT among individuals with social anxiety disorder.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Zalta et al., 2013 source
  • Findingown data

    Improvement in sleep quality over time did not significantly vary by diagnosis in this sample.

    “Next, we examined whether improvement over time in sleep quality varied by diagnosis (Table 2). There were no statistically significant results at p ≤ .05.”
    • Also stated in: § Discussion · hedged
      “Further, improvement in sleep quality did not vary by diagnosis, at least in this relatively small sample and for these disorders.”
    • Also stated in: § Discussion · plain
      “However, sleep improvement did not significantly vary by diagnosis on any measure of sleep quality.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 13
  • May combine two claims. 12
  • The quote only partly states this claim. 1

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

    Study design and conductcitation

    The CBT protocol focused on anxiety symptoms and did not specifically address sleep complaints.

    “The primary focus of the CBT protocol, which has been described elsewhere (Craske et al., 2009), was on anxiety symptomatology; sleep complaints were not specifically addressed in the protocol.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Craske et al., 2009 source

      The Discussion (page unavailable) says clinicians maintain focus on the primary anxiety disorder, supporting the stated focus of the CBT protocol. The Results’ module list (page unavailable) does not include a sleep-specific module, but the copy does not explicitly establish that sleep complaints were not specifically addressed anywhere in the protocol. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

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

    Premisecitation

    Sleep disturbances have also been reported in individuals with panic disorder.

    “However, as mentioned above, sleep disturbances have also been reported among individuals with PD (Mellman & Uhde, 1989; Overbeek et al., 2005; Stein et al., 1993).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Mellman & Uhde, 1989 source
    • cites Overbeek et al., 2005 source
    • cites Stein et al., 1993 source

  • May combine two claims.

    Findingown data

    At baseline, 35 participants (57.4%) were poor sleepers according to the PSQI, and most participants reported poor sleep quality.

    “At baseline, 35 (57.4%) participants were poor sleepers on the PSQI, with GAD participants having worse overall sleep quality than PD participants.”
    • Also stated in: § Discussion · plain
      “In the current study, poor sleep, as measured by a widely validated self-report instrument of sleep quality (Buysse et al., 1989), was endorsed by most participants at baseline”
    • Also stated in: § Conclusions · plain
      “most individuals receiving CBT for anxiety disorders have poor self-reported sleep quality at baseline”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    From baseline to end of treatment, PSQI global score and sleep latency component score improved significantly, with medium to large effect sizes, while overall sleep quality improved modestly.

    “Significant improvements in PSQI global score [F(1, 36) = 4.122, p = .05] and sleep latency component score [F(1, 41) = 6.637, p = .014] were observed, yielding medium to large effect sizes.”
    • Also stated in: § Discussion · plain
      “Sleep quality improved significantly during CBT from baseline to end of treatment, as has been reported in prior literature (Bélanger et al., 2004; Gosselin et al., 2006), with medium to large effect sizes observed.”
    • Also stated in: § Discussion · plain
      “Overall, sleep quality improved modestly during treatment for anxiety.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The mean global sleep quality score at Session 10 was 5.8, which remains above the cutoff of greater than 5 for poor sleep quality.

    “Furthermore, the mean global sleep quality score at Session 10 of the current study was 5.8, still above the cutoff of > 5 for poor sleep quality (Buysse et al., 1989).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Buysse et al., 1989 source

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

    Findingown data

    Results for PSWQ and ASI were not reported because their omnibus models were nonsignificant.

    “Results are not shown for PSWQ and ASI, as the omnibus models were nonsignificant.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Treatment responders showed significant improvement in sleep latency from pre- to post-treatment, while treatment non-responders did not.

    “Specifically, post-hoc analyses stratified by responder status showed that treatment responders had significant improvement in their sleep latency component score from pre-to post treatment [F(1, 20) = 14.439, p = .001], whereas treatment non-responders did not show such improvements [F(1, 21) = 0.098, p = .757].”
    • Also stated in: § Discussion · plain
      “Among those that did respond to anxiety treatment, they also had improvements in sleep latency (i.e., they took less time to fall asleep), whereas non-responders showed no such improvements in sleep latency.”
    • Also stated in: § Conclusions · plain
      “Improvement in sleep latency was observed among anxiety treatment responders, but not among non-responders.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    Generalizability may be limited because the sample came from a larger fMRI study and the primary sleep quality analyses were restricted to treatment completers.

    “Second, generalizability may be limited, as the sample consisted of participants in a larger fMRI study, and primary analyses concerning sleep quality improvement were limited to treatment completers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The sample size was relatively modest, which may have inflated Type II error, especially for subgroup analyses such as diagnostic subgroups.

    “Third, the current sample size is relatively modest, which may have led to inflated Type II error, particularly with regard to subgroups analysis (e.g., diagnostic subgroups).”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    All study clinicians received weekly supervision from licensed clinical psychologists with CBT expertise.

    “All study clinicians received weekly supervision by licensed clinical psychologists with CBT expertise.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Sleep quality was assessed with the well-validated Pittsburgh Sleep Quality Index at baseline and at end of treatment.

    “The well-validated Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds III, Monk, Berman, & Kupfer, 1989) was administered at baseline and at end of treatment in the current study.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Buysse, Reynolds III, Monk, Berman, & Kupfer, 1989 source

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

    Study design and conductnone given

    Diagnostic interviews were conducted by an experienced doctoral-level clinical psychologist or by master's level clinicians supervised by clinical psychologists.

    “Interviews were conducted by an experienced, doctoral-level clinical psychologist, or by master’s level clinicians who were supervised by clinical psychologists.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Some researchers have found that poor or disturbed sleep at baseline is related to worse treatment outcome in depression.

    “Although some investigators have found a relationship between poor or disturbed sleep at baseline and worse treatment outcome for depression (Buysse et al., 2001; Buysse et al., 1999; Thase, Simons, & Reynolds III, 1996; Troxel et al., 2012),”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Buysse et al., 2001 source
    • cites Buysse et al., 1999 source
    • cites Thase, Simons, & Reynolds III, 1996

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

  • May combine two claims.

    Premisecitation

    Available data indicate that some anxiety disorders are more strongly linked to sleep problems than others, and generalized anxiety disorder appears to be the anxiety diagnosis other than posttraumatic stress disorder most closely associated with sleep disturbance.

    “Second, the available data suggest that certain anxiety disorders are more closely associated with sleep problems than others, with GAD emerging as the anxiety diagnosis other than posttraumatic stress disorder that may be most closely associated with sleep disturbance (Marcks, Weisberg, Edelen, & Keller, 2010; Monti & Monti, 2000; Ramsawh et al., 2009).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Marcks, Weisberg, Edelen, & Keller, 2010 source
    • cites Monti & Monti, 2000 source
    • cites Ramsawh et al., 2009 source

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

    Study design and conductown data

    Treatment response and primary diagnosis were included as covariates in the GLM ANCOVA models.

    “treatment response and primary diagnosis were entered as covariates in GLM ANCOVA models.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    The current exploratory study did not apply corrections for multiple comparisons.

    “First, there were no corrections for multiple comparisons in the current, exploratory study.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Prior work has addressed sleep complaints in generalized anxiety disorder, but to the authors' knowledge only one earlier CBT study has examined sleep in panic disorder patients.

    “Further, while sleep complaints associated with generalized anxiety disorder (GAD) have been addressed in prior work (Bush et al., 2012; Bélanger et al., 2004; Gosselin et al., 2006), to our knowledge, only one prior CBT study has examined sleep in patients with panic disorder (PD) (Cervena et al., 2005).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Bush et al., 2012

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

    • cites Bélanger et al., 2004 source
    • cites Cervena et al., 2005 source

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

    Premisecitation

    Anxiety disorders are frequently accompanied by sleep complaints, and these complaints can occur before, alongside, or after the onset of the anxiety disorder.

    “Anxiety disorders, the most common group of psychiatric disorders in the United States (Kessler, Berglund, Demler, Jin, & Walters, 2005), are often accompanied by sleep complaints, which can precede, co-occur, or follow the onset of anxiety disorders (Jansson-Fröjmark & Lindblom, 2008; Johnson, Roth, & Breslau, 2006; Ohayon & Roth, 2003).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Jansson-Fröjmark & Lindblom, 2008 source
    • cites Johnson, Roth, & Breslau, 2006 source
    • cites Ohayon & Roth, 2003 source

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

    Study design and conductown data

    Linear regression analyses were adjusted for demographics (age and years of education) and primary diagnosis (GAD or PD).

    “linear regression analyses with adjustments for demographics (age, years of education) and primary diagnosis (GAD or PD) were carried out.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Sleep may be important for fear extinction learning, memory consolidation, and other learning processes involved in exposure-based treatments.

    “sleep may be critical for fear extinction learning, memory consolidation, and other learning processes implicated in exposure-based treatments (Kleim et al., 2013; Pace-Schott, Verga, Bennett, & Spencer, 2012).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Kleim et al., 2013

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

    • cites Pace-Schott, Verga, Bennett, & Spencer, 2012 source

  • Classified as probably not a substantial claim.

    Premisecitation

    The authors of that meta-analysis concluded that the overall effect of CBT for anxiety on co-occurring sleep problems remains unclear because the available data are limited.

    “One recent meta-analysis found that of more than 1,200 studies on CBT for anxiety disorders, only 19 studies reported original and interpretable sleep data--based on these limited data, the authors concluded that the overall impact of CBT for anxiety on concomitant sleep problems is currently unclear (Belleville, Cousineau, Levrier, St-Pierre-Delorme, & Marchand, 2010).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Belleville, Cousineau, Levrier, St-Pierre-Delorme, & Marchand, 2010

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

  • Classified as probably not a substantial claim.

    Premisecitation

    In the depression literature, patients classified as partial or non-responders to CBT showed less improvement in sleep.

    “although in the depression literature, participants who were considered partial or non-responders to CBT also had less improvement in sleep (Thase, Reynolds, Frank, & Jennings, 1994).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Thase, Reynolds, Frank, & Jennings, 1994 source

  • May combine two claims.

    Study design and conductcitation

    The Overall Anxiety Severity and Impairment Scale is a 5-item measure of anxiety severity and impairment with good psychometric properties, including excellent 1-month test-retest reliability and evidence of convergent and divergent validity.

    “It is a 5-item measure of anxiety severity and impairment with good psychometric properties, including excellent 1-month test-retest reliability and evidence of convergent and divergent validity (Norman et al., 2006).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Norman et al., 2006 source
23 of 23

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • ConsistentF(1, 36) = 4.122reported p = .05 · recomputed p = .050

    “F(1, 36) = 4.122, p = .05”

  • ConsistentF(1, 41) = 6.637reported p = .014 · recomputed p = .014

    “F(1, 41) = 6.637, p = .014”

  • ConsistentF(1, 41) = 12.623reported p = .001 · recomputed p < .001

    “F(1, 41) = 12.623, p = .001”

  • ConsistentF(1, 20) = 14.439reported p = .001 · recomputed p = .001

    “F(1, 20) = 14.439, p = .001”

  • ConsistentF(1, 21) = 0.098reported p = .757 · recomputed p = .757

    “F(1, 21) = 0.098, p = .757”

  • Consistentt(51) = 1.753reported p = .086 · recomputed p = .086

    “t (51) = 1.753, p = .086”

  • Consistentt(50) = 2.465reported p = .017 · recomputed p = .017

    “t (50) = 2.465, p = .017”

7 of 7

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Diagnosis-group counts are reversed in the abstract

    Minor

    The abstract gives 26 participants with panic disorder and 24 with generalized anxiety disorder, while the Methods section gives the opposite counts for the 50 treatment completers.

1 of 1

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Authors
Ramsawh, H. J., Bomyea, J., Stein, M. B., Cissell, S. H., & Lang, A. J.
Affiliations
  • Uniformed Services University of the Health Sciences (US)
  • San Diego State University (US)
  • University of California San Diego (US)
Corresponding author
Ramsawh, Holly J.
ORCID
Venue
Behavioral Sleep Medicine
Publisher
Informa UK Limited
Published
2015-08-05
Volume
14
Issue
3
Pages
267-278
ISSN
  • 1540-2002 (ISSN-L)
  • 1540-2010
DOI
10.1080/15402002.2014.981819
PMC
PMC4744149
OpenAlex
W1619093724
Cited by
25
References
47
Citations by year
2026: 3 · 2025: 6 · 2024: 4 · 2023: 3 · 2022: 3 · 2021: 2 · 2020: 1 · 2019: 1 · 2018: 1 · 2017: 1
FWCI
1.00
Type
journal article
Language
en
Open access
Locations
  • Behavioral Sleep Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institutes of Health (MH64122, MH65413, F31MH088170-01)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
sleep quality, cognitive behavioral therapy, anxiety disorders, panic disorder, generalized anxiety disorder, sleep latency, intolerance of uncertainty, treatment outcomes
MeSH terms
Adult, Anxiety, Anxiety Disorders, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Sleep, Cognitive Behavioral Therapy, Panic Disorder, Treatment Outcome

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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