CoChat
Sign Up
Cited by 14Sleep and related disordersMindfulness and Compassion InterventionsAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Psychological inflexibility as a predictor associated with insomnia

Open access
El Rafihi‐Ferreira, Renatha, Linares, Ila Marques Porto, Paulos‐Guarnieri, Léo, Zakiei, Ali·2024·Journal of Sleep Research
DOI 10.1111/jsr.14232
Open this paper in CoChat — free accountOpen PDF

Abstract

Psychological flexibility has recently attracted the attention of researchers in the field of sleep disorders; therefore, in the study, psychological flexibility was evaluated as a predictor or factor related to the presence/severity of insomnia. We included 2218 individuals selected from the randomized–control trial for behavioural therapy for insomnia and cross-sectional studies, including 1797 individuals with insomnia and 421 controls without insomnia. All participants completed the DSM-5-based insomnia diagnosis interview, Insomnia Severity Index, Hospital Anxiety and Depression Scale, and Acceptance Action Questionnaire-II. Linear regression and multinomial logistic regression models were used. Sex, education, occupation, marital status, anxiety, depression and psychological inflexibility were possible predictors or factors associated with the severity of insomnia. Multivariate linear regression analysis demonstrated that sex (β = 0.88; t = 2.80; p = 0.005), depression (β = 0.41; t = 10.7; p < 0.001), anxiety (β = 0.58; t = 14.1; p < 0.001) and psychological inflexibility (β = 0.09; t = 5.07; p < 0.001) were predictors of insomnia. The results of the multinomial logistic regression demonstrate that, in comparison to the absence of insomnia, insomnia at all levels (mild, moderate and severe) was associated with sex, anxiety and depression. Psychological inflexibility was only associated with severe insomnia (odds ratio = 1.04). These findings are important from a public health perspective because behavioural strategies designed to treat insomnia with a focus on psychological flexibility are low-cost and may help improve sleep quality in adults with insomnia, which also influences mental health. © 2024 European Sleep Research Society.

Integrity signals

Registry

Crossref · 10.1111/jsr.14232

Cites

58 of 58 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

14 of 28 cited sources checked · 12 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Psychological inflexibility was found as a predictor of higher levels of insomnia severity.

    “Psychological inflexibility was found as a predictor of higher levels of insomnia severity (Daly-Eichenhardt et al., 2016;El Rafihi-Ferreira et al., 2022;McCracken et al., 2011;McCracken et al., 2021;McCracken et al., 2022;McCracken et al., 2023;Zakiei et al., 2022), whereas psychological flexibility was found as a predictor of lower levels of insomnia severity (McCracken et al., 2022;McCracken et”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Daly-Eichenhardt et al., 2016 source

      The Results section reports that changes in cognitive fusion, a psychological inflexibility process, positively predicted changes in insomnia severity during treatment for chronic pain. It does not establish that psychological inflexibility predicts higher absolute levels of insomnia severity; its regression outcome was change in severity. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites El Rafihi-Ferreira et al., 2022 source
    • cites McCracken et al., 2011 source
  • Premisecitation

    Psychological flexibility was found as a predictor of lower levels of insomnia severity.

    “Psychological inflexibility was found as a predictor of higher levels of insomnia severity (Daly-Eichenhardt et al., 2016;El Rafihi-Ferreira et al., 2022;McCracken et al., 2011;McCracken et al., 2021;McCracken et al., 2022;McCracken et al., 2023;Zakiei et al., 2022), whereas psychological flexibility was found as a predictor of lower levels of insomnia severity (McCracken et al., 2022;McCracken et”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites McCracken et al., 2022 source
    • cites McCracken et al., 2023 source
  • Premisecitation

    Wolgast (2014) corroborates the idea that the AAQ-II measures psychological distress rather than experiential avoidance or inflexibility.

    “Wolgast (2014) corroborates the idea that the AAQ-II measures psychological distress rather than experiential avoidance or inflexibility.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Wolgast (2014) source
  • Findingown data

    Depression is a significant predictor of insomnia severity in multiple linear regression (β = 0.41; t = 10.7; p < 0.001).

    “As shown in Table 2, multiple linear regression analysis revealed that sex (β = 0.88; t = 2.80; p = 0.005), depression (β = 0.41; t = 10.7;p < 0.001), anxiety (β = 0.58; t = 14.1; p < 0.001) and psychological inflexibility (β = 0.09; t = 5.07; p < 0.001) were significant predictors of insomnia severity.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Data from the different studies (a treatment study and cross-sectional studies) can be validly combined into a single composite sample.
  • Findingown data

    Psychological inflexibility was associated only with severe insomnia in multinomial logistic regression (OR = 1.04; 95% CI: 1.01-1.07).

    “Psychological inflexibility was only associated with severe insomnia (odds ratio = 1.04).”
    • Also stated in: § 4.1.2 | Factors associated with insomnia · plain
      “However, psychological inflexibility was only associated with severe insomnia.”
    • Also stated in: § 4.1.2 | Factors associated with insomnia · plain
      “OR = 1.04; 95% CI: 1.01-1.07”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Data from the different studies (a treatment study and cross-sectional studies) can be validly combined into a single composite sample.
  • Classified as probably not a substantial claim. 15
  • May combine two claims. 15

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

    Study design and conductcitation

    The Brazilian version of the HADS was translated and validated by Botega, Bio and Zomignani (1995), with Cronbach's alpha values of 0.68 and 0.77 for anxiety and depression, respectively.

    “The Brazilian version was translated and validated by Botega, Bio and Zomignani (1995), with Cronbach's alpha values of 0.68 and 0.77 for anxiety and depression, respectively.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Botega, Bio and Zomignani (1995) source

  • May combine two claims.

    Study design and conductcitation

    The Brazilian version of the AAQ-II was translated and validated by Barbosa and Murta (2015), and demonstrated satisfactory reliability and suitability for use in this study.

    “The Brazilian version of the tool was translated and validated by Barbosa and Murta (2015), and demonstrated satisfactory reliability and suitability for use in this study.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Barbosa and Murta (2015) source

  • Classified as probably not a substantial claim.

    Premisecitation

    Psychological inflexibility and experiential avoidance are theorized to contribute to the development, maintenance and exacerbation of a broad range of psychological problems, including insomnia.

    “Psychological inflexibility and experiential avoidance are theorized to contribute to the development, maintenance and exacerbation of a broad range of psychological problems (Levin et al., 2014), including insomnia.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Levin et al., 2014 source

  • May combine two claims.

    Interpretationown data

    The co-occurrence of psychiatric symptoms (anxiety and depression) and insomnia in this study supports the premise that inflexibility is a transdiagnostic process that can occur in different disorders.

    “The co-occurrence of psychiatric symptoms (anxiety and depression) and insomnia in this study supports the premise that inflexibility is a transdiagnostic process that can occur in different disorders (Levin et al., 2014).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Levin et al., 2014 source

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

    Premisecitation

    Insomnia is more prevalent in people with little education.

    “Among sociodemographic factors, studies have suggested that insomnia is more prevalent in women (Sidani et al., 2019), people with little education (Hirotsu et al., 2014), the unemployed (Ohayon, 1996), and those who are not married (single, widowed or divorced; Kawata et al., 2020).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hirotsu et al., 2014 source

  • May combine two claims.

    Premisecitation

    Some studies have raised concerns about the apparent validity of the AAQ-II and its discriminant validity (experiential avoidance versus distress, such as negative affect and neuroticism).

    “This is because some studies have raised concerns about the apparent validity of the AAQ-II (Francis et al., 2016;Vaughan-Johnston et al., 2017) and its discriminant validity (experiential avoidance versus distress, such as negative affect and neuroticism; Gámez et al., 2011).”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Francis et al., 2016 source
    • cites Vaughan-Johnston et al., 2017 source
    • cites Gámez et al., 2011 source

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

    Premisecitation

    Insomnia is more prevalent in women.

    “Among sociodemographic factors, studies have suggested that insomnia is more prevalent in women (Sidani et al., 2019), people with little education (Hirotsu et al., 2014), the unemployed (Ohayon, 1996), and those who are not married (single, widowed or divorced; Kawata et al., 2020).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Sidani et al., 2019 source

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

    Premisecitation

    Being diagnosed with depression and anxiety are risk factors for insomnia.

    “Other risk factors include being diagnosed with depression and anxiety (Batterham et al., 2012;Nutt et al., 2008).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Batterham et al., 2012 source
    • cites Nutt et al., 2008 source

      The “Incidence of sleep symptoms in depression” section reports that insomnia symptoms are much more common among people with depression, supporting the depression-related part of the claim as an association. It does not establish that a depression diagnosis precedes or causes insomnia, and the passages do not identify an anxiety diagnosis as a risk factor for insomnia. The “Increased risk of depression in insomnia” section chiefly reports the reverse temporal relationship: insomnia preceding depression. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premiseown data

    Psychological inflexibility, despite being strongly correlated with insomnia severity, was not a predictor of insomnia severity in the presence of other transdiagnostic factors (physical concerns, repetitive negative thinking and neuroticism) after controlling for depressive and anxiety symptoms and demographic factors.

    “was not a predictor of insomnia severity in the presence of other transdiagnostic factors (i.e.physical concerns, repetitive negative thinking, and neuroticism) after controlling for depressive and anxiety symptoms and demographic factors.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Habibi Asgarabad et al., 2023 source

  • May combine two claims.

    Findingown data

    In this sample, psychological inflexibility was associated only with severe insomnia, not with mild-to-moderate insomnia.

    “Psychological inflexibility was associated only with severe insomnia.”
    • Also stated in: § 6 | CONCLUSION · plain
      “Given that our study did not find inflexibility to be a predictor of mild-to-moderate insomnia”
    • Also stated in: § 6 | CONCLUSION · hedged
      “the association between psychological inflexibility and insomnia is possible among individuals with severe insomnia.”
    Quote in the paperSubstantial claim

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

    Study design and conductcitation

    The Insomnia Severity Index was developed by Morin (1993) and validated in Portuguese by Castro (2011).

    “The ISI was developed by Morin (1993) and validated in Portuguese by Castro (2011).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Morin (1993)

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

    • cites Castro (2011)

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

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

    Study design and conductnone given

    All data were obtained from research approved by the ethics committee of the University of São Paulo, and all participants had provided informed consent prior to their inclusion.

    “All data were obtained from research approved by the ethics committee of the University of São Paulo, and all participants had provided informed consent prior to their inclusion.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    For this study, the reliability indices of the general factor of the ISI indicated high internal consistency (α = 0.92).

    “For this study, the reliability indices of the general factor of ISI indicated a high internal consistency (α = 0.92).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The cross-sectional design of the present study does not allow for conclusions regarding causality.

    “Third, the cross-sectional design of the present study does not allow for conclusions regarding causality.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    The associations found in this study may have been confounded by other variables that were not assessed and consequently not adjusted for.

    “Second, the associations found in this study may have been confounded by other variables that were not assessed and, consequently, not adjusted for.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The analysis was adjusted for important covariates to estimate the individual contributions of these factors.

    “Our analysis was adjusted for important covariates to estimate the individual contributions of these factors.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    Only participants with some level of social integration and access to the internet and social networks were included in the study.

    “Only participants with some level of social integration and access to the internet and social networks were included in the study.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The study did not include elderly individuals, so the outcomes cannot be generalized to all adults with insomnia.

    “Fourth, we did not include elderly individuals; therefore, the outcomes cannot be generalized to all adults with insomnia.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    In the current study, the HADS achieved good reliability indices (α = 0.91 for all items; α = 0.87 for the anxiety subscale and α = 0.87 for the depression subscale).

    “In the current study, we achieved good reliability indices (α = 0.91 for all items; α = 0.87 for the anxiety subscale and α = 0.87 for the depression subscale).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The current study found a possible relationship between psychological inflexibility and severe insomnia, indicating a possible relationship between the mechanisms hypothesized in these models.

    “The current study found a possible relationship between psychological inflexibility and severe insomnia, indicating a possible relationship between the mechanisms hypothesized in these models.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    In terms of psychological distress, the BEAQ has greater discriminant validity than the AAQ-II, and an alternative instrument for psychological inflexibility may be needed to assess core outcomes in ACT intervention research.

    “In terms of psychological distress, the BEAQ has greater discriminant validity than that of the AAQ-II, and an alternative instrument for psychological inflexibility may be needed to assess core outcomes in ACT intervention research.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Our findings may contribute to the advancement of treatment, including transdiagnostic proposals, by demonstrating that psychological inflexibility is associated with insomnia severity and co-occurs with anxiety and depression.

    “Our findings may contribute to the advancement of treatment, including transdiagnostic proposals, by demonstrating that psychological inflexibility is associated with insomnia severity and co-occurs with anxiety and depression.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Insomnia complaints are multifaceted and associated with sociodemographic, psychiatric and psychological factors.

    “Our results support the idea that insomnia complaints are multifaceted, and associated with sociodemographic, psychiatric and psychological factors.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Insomnia is more prevalent in those who are not married (single, widowed or divorced).

    “Among sociodemographic factors, studies have suggested that insomnia is more prevalent in women (Sidani et al., 2019), people with little education (Hirotsu et al., 2014), the unemployed (Ohayon, 1996), and those who are not married (single, widowed or divorced; Kawata et al., 2020).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kawata et al., 2020

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

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

    Premisecitation

    Insomnia is more prevalent in the unemployed.

    “Among sociodemographic factors, studies have suggested that insomnia is more prevalent in women (Sidani et al., 2019), people with little education (Hirotsu et al., 2014), the unemployed (Ohayon, 1996), and those who are not married (single, widowed or divorced; Kawata et al., 2020).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Ohayon, 1996 source

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

    Study design and conductcitation

    The insomnia interview was based on the revised version of the Structured Clinical Interview for DSM-5 Sleep Disorders-Revised (SCISD-R).

    “The insomnia interview was based on the revised version of the Structured Clinical Interview for DSM-5 Sleep Disorders-Revised (SCISD-R;Taylor et al., 2019).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Taylor et al., 2019

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

26 of 26

  • The paper relies on this without support.

    Studies on the sleep-interference process are lacking.

    “However, studies on the sleep-interference process are lacking.”

  • The paper relies on this without support.

    Data from the different studies (a treatment study and cross-sectional studies) can be validly combined into a single composite sample.

    “Data for 1797 individuals with insomnia were gathered from three studies, including a treatment study evaluating the efficacy of ACT versus CBT-I (El Rafihi-Ferreira et al., 2023;El Rafihi-Ferreira et al., 2024) and two cross-sectional studies (Carmo et al., 2023;El Rafihi-Ferreira et al., 2022), and 421 healthy controls (without insomnia) enrolled in a cross-sectional study (Carmo et al., 2023).”

  • The paper relies on this without support.

    Studies on the association between psychological inflexibility and insomnia are lacking.

    “Despite the importance of psychological inflexibility in the development and maintenance of insomnia, studies on the association between psychological inflexibility and insomnia are lacking.”

  • The paper relies on this without support.

    Few studies have explored the association between psychological inflexibility and levels of insomnia severity.

    “Few studies have explored the association between psychological inflexibility and levels of insomnia severity.”

  • The paper relies on this without support.

    Psychological inflexibility is important in the development and maintenance of insomnia.

    “Despite the importance of psychological inflexibility in the development and maintenance of insomnia”

  • The paper relies on this without support.

    Psychological flexibility is associated with both positive and negative health outcomes.

    “Given that psychological flexibility is associated with both positive and negative health outcomes, understanding this association is crucial.”
6 of 6

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. American Academy of Sleep Medicine, 2014, International classification of sleep disorder
  2. Castro L. S.(2011).Adaptação e validação do Índice de Gravidade de Insônia (IGI) [Adaptation and validation of the Insomnia Severity Index (IGI)]. [Master's Dissertation] Universidade Federal de São Paulo. UNIFESP Campus. Repository.https://repositorio.unifesp.br/handle/11600/23193.
  3. Paulos‐Guarnieri L., 2023, OSF

Cited by

Sorted by citations

Related

Authors
El Rafihi‐Ferreira, R., Linares, I. M. P., Paulos‐Guarnieri, L., & Zakiei, A.
Affiliations
  • Department of Clinical Psychology Universidade de São Paulo São Paulo Brazil
  • Universidade de São Paulo (BR)
  • Kermanshah University of Medical Sciences (IR)
ORCID
Venue
Journal of Sleep Research
Publisher
Wiley
Published
2024-05-04
Volume
33
Issue
6
Pages
e14232-e14232
ISSN
  • 0962-1105 (ISSN-L)
  • 1365-2869
DOI
10.1111/jsr.14232
OpenAlex
W4396639247
Cited by
14
References
58
Citations by year
2026: 6 · 2025: 7 · 2024: 1
FWCI
5.70
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Journal of Sleep Research (publishedVersion)
  • PubMed (publishedVersion)
Funders
Fundação de Amparo à Pesquisa do Estado de São Paulo (23/06859‐5, 2018‐19506‐5)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
psychological inflexibility, insomnia, insomnia severity, acceptance and commitment therapy, depression, anxiety, sex differences, sleep quality
MeSH terms
Adult, Anxiety, Cross-Sectional Studies, Depression, Female, Humans, Sleep Initiation and Maintenance Disorders, Male, Middle Aged, Surveys and Questionnaires, Severity of Illness Index, Sex Factors

About these checks

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 by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-11.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-11.

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.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review