| Home | E-Submission | Sitemap | Contact us |  
Sleep Med Res > Volume 10(1); 2019 > Article
Yeo, Yi, Kim, Lee, Youn, Suh, and Chung: Cancer-Related Dysfunctional Beliefs about Sleep May Influence Insomnia of Cancer Patients Regardless of Depressive Symptoms


Background and Objective

Depression is one of the major causes of insomnia among cancer patients, and should be explored among cancer patients who are suffering from insomnia. The objective of this study was to explore whether dysfunctional beliefs about sleep among cancer patients were associated with insomnia independent of depression.


Medical records of patients who visited Asan Medical Center sleep clinic for cancer were reviewed retrospectively from January to November of 2017. The data included the patient’s psychiatric symptoms and assessment of sleep disorders Insomnia Severity Index (ISI), Patient’s Health Questionnaire-9 (PHQ-9), State-Trait Anxiety Inventory (STAI), Fear of Progression (FoP), and Cancer-related Dysfunctional Beliefs about Sleep (C-DBS) and a clinical interview.


Results indicated that ISI score was significantly correlated with PHQ-9, FoP, and CDBS scores, and C-DBS score was significantly correlated with ISI, PHQ-9, and FoP scores all, p < 0.01). The ISI and C-DBS scores were not significantly correlated with age and the STAI-State scale. Linear regression analysis revealed that C-DBS (β = 0.40, p < 0.001) and PHQ-9 scores (β = 0.30, p < 0.01) predicted ISI scores among all participants. Among participants who were not depressed (PHQ-9 score ≤ 9), C-DBS scores were the only predictor for ISI scores (β = 0.46, p < 0.001).


Dysfunctional beliefs about sleep in cancer patients were significantly associated with severity of insomnia, independent of depression.


Sleep disturbance is a common symptom in cancer patients in all stages [1]. Patients suffer from sleep disturbance when they are diagnosed with cancer and undergo treatment such as chemotherapy, radiation therapy, and hormonal therapy [2]. Physical symptoms of cancer such as nausea, pain, vomiting, or hot flush can also cause insomnia. When cancer patients have difficulty sleeping, they often worry about the negative effects of insomnia. Many cancer patients believe that their disease could progress or metastasize because of their poor sleep quality [3,4]. They also have rigid beliefs about sleep timing (usually around 10 pm–2 am) and believe it is necessary to maintain good immune functioning. These beliefs are often maintained because they are supported by medical evidence. For example, one study reported the association between short sleep duration and high risk of cancer [5]. Sleep disturbance may in fact influence immune dysfunction via melatonin [6]. However, despite being true, these beliefs could still be dysfunctional, and can precipitate and perpetuate insomnia symptoms.
In one of our previous studies, we developed two items that directly address cancer-related dysfunctional beliefs about sleep (C-DBS) in cancer patients in addition to general dysfunctional beliefs about sleep that are usually held by insomnia patients [3]. The cancer-specific items were “(Q1) My immune system will suffer if I don’t go to sleep at a certain time.” and “(Q2) If I don’t sleep well at night, my cancer may recur or metastasize.” In our previous study, Q1 item scores were significantly related with the severity of insomnia and fear of disease progression. Additionally, Q2 item scores were significantly associated with young age and insomnia severity, depression, and fear of disease progression. Dysfunctional beliefs about sleep were correlated not only with insomnia but also depression among cancer patients.
Depression is very common among cancer patients, and the prevalence of depression ranges from 5.6–24.0% among cancer patients [7-10]. Depression further exacerbates physical symptoms and functional impairment of cancer patients, which could result in poor treatment adherence [11]. For example, depression increases the distress of fatigue, cognitive dysfunction, and anxiety in cancer patients. Depression also causes physical pain, and has negative effects on immune function and survival of cancer patients [12].
Depression and insomnia significantly influence each other bidirectionally [13,14]. Insomnia is included in the diagnostic criteria of depression based on the Diagnostic and Statistical Manual, fifth version (DSM-5) [15], and insomnia can be a predictor of depression [14]. Patients who suffer from depression usually have cognitive distortions which may be related with sleep-related dysfunctional beliefs [16]. For primary insomnia patients, the degree of dysfunctional beliefs about sleep was associated with depression [17] and mediated the relationship between depression and sleep quality [18]. One of our previous studies reported that dysfunctional beliefs about sleep was associated with depression among cancer patients [3]. From those reports, we can speculate that depressive symptoms in cancer patients may influence dysfunctional beliefs about sleep, and may, in turn, aggravate insomnia symptoms. Since depression is one of the major causes of insomnia in cancer patients [19], it is important to explore the existence of depression among cancer patients. The objective of this study was to explore whether dysfunctional beliefs about sleep among cancer patients was associated with insomnia, independent of depression.


The protocol of this retrospective medical records review study was approved by the Asan Medical Center Institutional Review Board (2018-0130), which waived the requirement for informed consent. During their first visit, participants were routinely evaluated for psychiatric symptoms with the Insomnia Severity Index (ISI) [20], Patient’s Health Questionnaire-9 (PHQ-9) [21], state subcategory of the State-Trait Anxiety Inventory (STAI) [22], Fear of Progression (FoP) [23], and C-DBS [3], and psychiatric diagnosis was established by clinical interview with psychiatrists. Sleep disorders were assessed with clinical interview by psychiatrists who were trained in sleep medicine (S. C. & S. Y.).
Medical records of patients who visited Asan Medical Center sleep clinic for cancer patients were reviewed retrospectively from January to November of 2017. We included a total of 264 subjects that met the following criteria: 1) self-report questionnaire scores were completely recorded in medical records, 2) never diagnosed with major psychotic disorders such as schizophrenia or bipolar disorders, 3) never diagnosed with organic brain disorders or brain metastasis, 4) no other sleep disorders such as restless legs syndrome or suspicious of obstructive sleep apnea, and 5) cancer types were gradable using the TNM staging system.

Statistical Analysis

Statistical analyses were performed using SPSS version 21.0 for Windows (IBM Corp., Armonk, NY, USA). Correlation and regression analyses were performed, and the level of significance was defined as p < 0.05 in two-tailed tests.


The mean age of participants was 54.0 ± 11.2 years old, and 67.1% were female. The most common cancer types were breast (48.3%), lung (12.0%), pancreatic and biliary tract (11.1%), and gastro-esophageal cancers (11.1%) (Table 1). Subjects’ cancer stages were 0 (2.1%), I (22.2%), II (30.8%), III (19.2%), and IV (25.6%). The most common psychiatric diagnoses were major depressive disorder (40.2%) and insomnia (32.1%). Based on PHQ-9 score, participants were divided into depressed (PHQ-9 score > 9, n = 137) and not depressed (PHQ-9 score ≤ 9, n = 97)[24]. When comparing the two groups, all scores on self-report questionnaires were significantly higher in depressed subjects than not depressed subjects (Table 2). Among all subjects, ISI score was significantly correlated with PHQ-9, FoP, and C-DBS scores, and C-DBS score was significantly correlated with ISI, PHQ-9, and FoP scores. The ISI and C-DBS scores were not significantly correlated with age and the STAI-state scale (Table 3).
Linear regression analysis results indicated that when age and symptoms rating scales scores (such as ISI, PHQ-9, STAI, FoP, and C-DBS) were included as covariates, C-DBS and PHQ-9 scores significantly predicted ISI scores (F = 48.6, p < 0.001) (Table 4). Among subjects who were not depressed (PHQ-9 score ≤ 9), the C-DBS score was the only predictor for ISI scores (F = 25.9, p < 0.001).


In this study, C-DBS and depressive symptoms were significantly associated with severity of insomnia. Higher C-DBS score were also significantly associated with the severity of insomnia among cancer patients who did not report depressive symptoms. Thus, this indicates that cancer-related dysfunctional beliefs about sleep were significantly associated with severity of insomnia, independent of depressive symptoms.
Among patients with primary insomnia, dysfunctional beliefs about sleep are associated with insomnia symptoms [25], and reduction in those beliefs may improve insomnia [26]. However, dysfunctional beliefs are also associated with patients’ depressive symptoms [27]. Depressed mood may be related with negative beliefs, and it is important to tease apart the relationship between dysfunctional beliefs and insomnia, regardless of depression. One study reported that even after controlling for the effects of depressive symptoms, beliefs about sleep in patients with major depressive disorder or fibromyalgia were as dysfunctional as those of primary insomnia sufferers and were even more dysfunctional than those of good sleepers [27].
In this study, dysfunctional beliefs about sleep were significantly associated with insomnia regardless of depression in cancer patients. C-DBS seems to have strong association with depressive symptoms in cancer patients. Patients suffering from depression usually have cognitive distortions, which may be related dysfunctional beliefs about sleep [16]. This study was to explore whether C-DBS is associated with insomnia independent of depression, and it showed meaningful relationship between C-DBS and insomnia even in the patients who did not have depression.
Dysfunctional beliefs can also be influenced by available knowledge. The modern era makes it possible for patients to easily access information about insomnia and its adverse effects. This could lead to an increased possibility of conceiving negative belief about insomnia and its negative effects on health and life [28].
However, it is still remains controversial whether correcting dysfunctional beliefs could improve sleep quality. One study reported that improvement in dysfunctional beliefs following cognitive-behavioral therapy for insomnia (CBT-I) did not result in improvement in insomnia [29]. However, this evidence is not sufficient to question the efficacy of CBT-I. Findings from another study suggest that improvement in negative beliefs after CBT-I could result in considerable and maintained improvements in symptoms of insomnia and psychosocial deterioration [26]. Although the total score of DBAS does not tend to be correlated with total sleep time and total wake time variables [17], change in dysfunctional beliefs seems to have positive effect on general perceptions about sleep quality, distress, and daytime functioning. In this respect, we can still think of dysfunctional beliefs as an essential target of insomnia treatment.
This study is a retrospective study assessing cancer patient’s symptoms. One limitation of the study was that objective sleep data, such as polysomnography or actigraphy were not measured, and other sleep disorders such as periodic limb movement disorder or obstructive sleep apnea were not completely ruled out. Finally, individual subjects of the study sample had different cancer sites, stages, and each of them received different treatment. This could be the reason why many studies on insomnia of cancer patients show inconsistent results, and future studies should consider sample heterogeneity as one of the confounding variables.
In conclusion, cancer-related dysfunctional beliefs about sleep were useful in predicting insomnia severity regardless of depression. Further study is needed whether improvement of this cancer-related dysfunctional belief has positive effect on sleep problems.


Conflicts of Interest
The authors have no financial conflicts of interest.
Authors’ Contribution
Conceptualization: Chung S. Data curation: Chung S, Youn S, Yeo S, Lee J. Formal analysis: Chung S. Suh S. Investigation: Chung S, Youn S, Suh S. Methodology: Chung S, Youn S, Suh S. Project administration: Chung S. Resources: Chung S, Youn S. Software: Chung S, Yeo S. Supervision: Chung S, Suh S. Validation: Chung S, Yeo S, Lee J. Writing—original draft: Yeo S, Chung S. Writing— review & editing: Chung S, Youn S, Lee J, Suh S.


1. Harris B, Ross J, Sanchez-Reilly S. Sleeping in the arms of cancer: a review of sleeping disorders among patients with cancer. Cancer J 2014;20:299-305.
crossref pmid
2. Ancoli-Israel S. Sleep disturbances in cancer: a review. Sleep Med Res 2015;6:45-9.
3. Chung S, Youn S, Choi B. Assessment of cancer-related dysfunctional beliefs about sleep for evaluating sleep disturbance in cancer patients. Sleep Med Res 2017;8:98-101.
4. Youn S, Kim C, Lee J, Yeo S, Suh S, Chung S. Development of Dysfunctional Beliefs and Attitude about Sleep scale for cancer patients. Behav Sleep Med 2019 Feb 21;[Epub]. Available at: https://doi.org/10.1080/15402002.2019.1578773.
5. Thompson CL, Li L. Association of sleep duration and breast cancer OncotypeDX recurrence score. Breast Cancer Res Treat 2012;134:1291-5.
crossref pmid pmc
6. Haus EL, Smolensky MH. Shift work and cancer risk: potential mechanistic roles of circadian disruption, light at night, and sleep deprivation. Sleep Med Rev 2013;17:273-84.
crossref pmid
7. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monog 2004;2004:57-71.
8. Krebber AM, Buffart LM, Kleijn G, Riepma IC, de Bree R, Leemans CR, et al. Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psychooncology 2014;23:121-30.
crossref pmid
9. Yang YL, Liu L, Wang Y, Wu H, Yang XS, Wang JN, et al. The prevalence of depression and anxiety among Chinese adults with cancer: a systematic review and meta-analysis. BMC Cancer 2013;13:393.
crossref pmid pmc
10. Park B, Youn S, Yi KK, Lee SY, Lee JS, Chung S. The prevalence of depression among patients with the top ten most common cancers in South Korea. Psychiatry Investig 2017;14:618-25.
crossref pmid pmc
11. Fann JR, Thomas-Rich AM, Katon WJ, Cowley D, Pepping M, Mc-Gregor BA, et al. Major depression after breast cancer: a review of epidemiology and treatment. Gen Hosp Psychiatry 2008;30:112-26.
crossref pmid
12. Spiegel D, Giese-Davis J. Depression and cancer: mechanisms and disease progression. Biol Psychiatry 2003;54:269-82.
crossref pmid
13. Benca RM, Peterson MJ. Insomnia and depression. Sleep Med 2008;9 Suppl 1:S3-9.
crossref pmid
14. Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord 2011;135:10-9.
crossref pmid
15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington (VA): American Psychiatric Association; 2013.

16. Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry 2008;165:969-77.
crossref pmid
17. Morin CM, Vallières A, Ivers H. Dysfunctional beliefs and attitudes about sleep (DBAS): validation of a brief version (DBAS-16). Sleep 2007;30:1547-54.
crossref pmid pmc
18. Gadam SR, Elayoubi J, Ma X, Ward CP. Dysfunctional cognitions mediate the relationship between symptoms of depression, anxiety, and sleep quality in a non-clinical population. J Sleep Med Disord 2015;2:1031.

19. Palesh OG, Collie K, Batiuchok D, Tilston J, Koopman C, Perlis ML, et al. A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer. Biol Psychol 2007;75:37-44.
crossref pmid
20. Cho YW, Song ML, Morin CM. Validation of a Korean version of the insomnia severity index. J Clin Neurol 2014;10:210-5.
crossref pmid pmc
21. Han C, Jo SA, Kwak JH, Pae CU, Steffens D, Jo I, et al. Validation of the Patient Health Questionnaire-9 Korean version in the elderly population: the Ansan Geriatric study. Compr Psychiatry 2008;49:218-23.
crossref pmid
22. Spielberger CD, Sydeman SJ. State-Trait Anxiety Inventory and State-Trait Anger Expression Inventory. In Maruish ME (ed.), The use of psychological testing for treatment planning and outcome assessment. Hillsdale (NJ): Lawrence Erlbaum Associates, Inc; 1994. pp. 292-321.

23. Shim EJ, Shin YW, Oh DY, Hahm BJ. Increased fear of progression in cancer patients with recurrence. Gen Hosp Psychiatry 2010;32:169-75.
crossref pmid
24. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
crossref pmid pmc
25. Carney CE, Edinger JD. Identifying critical beliefs about sleep in primary insomnia. Sleep 2006;29:444-53.
crossref pmid
26. Eidelman P, Talbot L, Ivers H, Bélanger L, Morin CM, Harvey AG. Change in dysfunctional beliefs about sleep in behavior therapy, cognitive therapy, and cognitive-behavioral therapy for insomnia. Behav Ther 2016;47:102-15.
crossref pmid
27. Carney CE, Edinger JD, Manber R, Garson C, Segal ZV. Beliefs about sleep in disorders characterized by sleep and mood disturbance. J Psychosom Res 2007;62:179-88.
crossref pmid
28. Gupta R. Presleep thoughts and dysfunctional beliefs in subjects of insomnia with or without depression: Implications for cognitive behavior therapy for insomnia in Indian context. Indian J Psychiatry 2016;58:77-82.
crossref pmid pmc
29. Okajima I, Nakajima S, Ochi M, Inoue Y. Reducing dysfunctional beliefs about sleep does not significantly improve insomnia in cognitive behavioral therapy. PLoS One 2014;9:e102565.
crossref pmid pmc

Table 1.
Clinical characteristics of the study subjects
Variable Subjects (n = 234)
Female, n (%) 157 (67.1)
Age (years) 54.0 ± 11.2
Cancer type (%)
 Breast 113 (48.3)
 Lung 28 (12.0)
 Pancreatic and biliary tract 26 (11.1)
 Gastro-esophageal 26 (11.1)
 Colorectal 15 (6.4)
 Urinary tract 8 (3.4)
 Kidney 6 (2.6)
 Liver 5 (2.1)
 Thyroid 4 (1.7)
 Others 3 (1.3)
Cancer stages (%)
 Stage 0 5 (2.1)
 Stage I 52 (22.2)
 Stage II 72 (30.8)
 Stage III 45 (19.2)
 Stage IV 60 (25.6)
Psychiatric diagnosis (%)
 No diagnosis 22 (9.4)
 Acute stress reaction/adjustment disorder 12 (5.1)
 Major depressive disorder 94 (40.2)
 Insomnia 75 (32.1)
 Anxiety disorder/somatic symptom disorder 29 (12.4)
 Others 2 (0.9)
Table 2.
Clinical characteristics of patients who were depressed or not
Depressed (n = 137) Not depressed (n = 97) p-value
Male/female, n (%) 54 / 95 (36.2/63.8) 28 / 87 (24.3/75.7) 0.04
Age (years 54.4 ± 11.6 53.6 ± 10.7 0.58
Rating scales score
 ISI 17.5 ± 5.8 13.6 ± 5.7 < 0.01
 FoP 41.1 ± 10.8 30.8 ± 9.8 < 0.01
 State subcategory of STAI 41.3 ± 10.0 38.5 ± 9.2 0.03
 C-DBS 12.7 ± 5.4 11.0 ± 5.8 0.02

ISI: Insomnia Severity Index, FoP: Fear of Progression, STAI: State-Trait Anxiety Inventory, C-DBS: Cancer-related Dysfunctional Beliefs about Sleep.

Table 3.
Pearson’s correlation analysis of insomnia and dysfunctional beliefs with age and self-report questionnaires scores
Age 0.004 -0.09
Self-report questionnaires
 ISI - 0.47*
 PHQ-9 0.38* 0.20*
 FoP 0.20* 0.35*
 C-DBS 0.47* -
 State subcategory of STAI 0.03 -0.01

* p < 0.01.

ISI: Insomnia Severity Index, C-DBS: Cancer-related Dysfunctional Beliefs about Sleep, PHQ-9: Patient’s Health Questionnaire-9, FoP: Fear of Progression, STAI: State-Trait Anxiety Inventory.

Table 4.
Results of linear regression analysis of clinical predictors for the severity of insomnia
Model β SE p-value
All subjects (n = 234)
 C-DBS F = 48.6, p < 0.001 0.40 0.06 < 0.001
 PHQ-9 0.30 0.06 < 0.001
Not depressed (n = 97)*
 C-DBS F = 25.9, p < 0.001 0.46 0.09 < 0.001

Regression analysis was adjusted for age, symptoms rating scales scores (such as Insomnia Severity Index, Patient’s Health Questionnaire-9, State-Trait Anxiety Inventory, Fear of Progression, C-DBS).

* PHQ-9 score ≤ 9.

SE: standard error, C-DBS: Cancer-related Dysfunctional Beliefs about Sleep, PHQ-9: Patient Health Questionnaire-9.