Research Article| Volume 5, ISSUE 4, P370-375, August 2019

Download started.


Differences in anxiety levels among symptoms of insomnia. The HUNT study

  • Daniela Bragantini
    Corresponding author at: Department of research and development (AFFU), Department of Mental health, NTNU, PO Box 3250 Sluppen, NO-7006, Trondheim, Norway.
    Department of Research and Development (AFFU), Department of Mental Health, NTNU, PO Box 3250 Sluppen, NO-7006, Trondheim, Norway

    Division of Mental Health Care, St Olavs University Hospital, Østmarkveien 15, 7040, Trondheim, Norway
    Search for articles by this author
  • Børge Sivertsen
    Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaesgate 7, 5015 Bergen, Norway

    Department of Research and Innovation, Helse-Fonna HF Haugesund Hospital, PO Box 2170, 5504 Haugesund, Norway
    Search for articles by this author
  • Philip Gehrman
    Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market St, Suite 670, Philadelphia, PA 19104, USA

    Center for Sleep and Circadian Neurobiology, University of Pennsylvania Perelman School of Medicine, 3624 Market St, Philadelphia, PA 19104, USA
    Search for articles by this author
  • Stian Lydersen
    Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU, PO Box 8905 MTFS, 7491 Trondheim, Norway
    Search for articles by this author
  • Ismail Cüneyt Güzey
    Department of Research and Development (AFFU), Department of Mental Health, NTNU, PO Box 3250 Sluppen, NO-7006, Trondheim, Norway

    Division of Mental Health Care, St Olavs University Hospital, Østmarkveien 15, 7040, Trondheim, Norway
    Search for articles by this author
Published:February 07, 2019DOI:



      This study aim is to compare anxiety levels among individuals experiencing different symptoms of insomnia.


      Case-control study.


      The Nord-Trøndelag Health Study (the HUNT3 study, Norway).


      Of the 50,802 individuals taking part in the HUNT3 study, the current sample comprised 7933 individuals, including 4317 cases with insomnia and 3616 controls.


      Symptoms of anxiety were assessed using Hospital Anxiety and Depression Scale, whereas insomnia symptoms were assessed according to the core Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, nocturnal symptoms. Anxiety levels of the 4317 individuals reporting at least 1 insomnia symptom were compared with the 3616 controls reporting no symptoms. Level of anxiety among participants experiencing combinations of insomnia symptoms was also investigated.


      Anxiety levels were significantly higher in individuals reporting insomnia symptoms (M = 2.5, SD = 2.4) compared to controls (5.5, SD = 3.7, P < .001). Anxiety levels also differed significantly between different insomnia symptoms (P < .001). Participants reporting all 3 insomnia symptoms had the highest anxiety score (M = 6.8, SD = 4.3), followed in decreasing order by sleep onset insomnia with terminal insomnia (M = 6.7, SD = 4.0), sleep onset insomnia with sleep maintenance insomnia (M = 6.3, SD = 3.8), sleep onset insomnia only (M = 5.8, SD = 3.7), sleep maintenance insomnia with terminal insomnia (M = 5.6, SD = SD = 3.4), terminal insomnia (M = 5.2, SD = 3.4), and sleep maintenance insomnia only (M = 4.5, SD = 3).


      Difficulties initiating sleep, both alone and in combination with 1 or 2 of the other symptoms, seem to play a key role in rising anxiety levels.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Health: Journal of the National Sleep Foundation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cox R.C.
        • Olatunji B.O.
        A systematic review of sleep disturbance in anxiety and related disorders.
        J Anxiety Disord. 2016; 37: 104-129
        • Jansson-Frojmark M.
        • Lindblom K.
        A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population.
        J Psychosom Res. 2008; 64: 443-449
        • Glidewell R.N.
        • McPherson Botts E.
        • Orr W.C.
        Insomnia and anxiety: diagnostic and management implications of complex interactions.
        Sleep Med Clin. 2015; 10: 93-99
        • Palmer C.A.
        • Alfano C.A.
        Sleep and emotion regulation: an organizing, integrative review.
        Sleep Med Rev. 2017; 31: 6-16
        • Blake M.J.
        • Trinder J.A.
        • Allen N.B.
        Mechanisms underlying the association between insomnia, anxiety, and depression in adolescence: implications for behavioral sleep interventions.
        Clin Psychol Rev. 2018; 63: 25-40
        • Staner L.
        Sleep and anxiety disorders.
        Dialogues Clin Neurosci. 2003; 5: 249-258
        • Association AP
        Diagnostic and Statistical Manual of Mental Disorders (DSM-5®).
        American Psychiatric Pub, 2013
        • Canivet C.
        • Staland-Nyman C.
        • Lindeberg S.I.
        • Karasek R.
        • Moghaddassi M.
        • Ostergren P.O.
        Insomnia symptoms, sleep duration, and disability pensions: a prospective study of Swedish workers.
        Int J Behav Med. 2014; 21: 319-328
        • Cervena K.
        • Espa F.
        • Perogamvros L.
        • Perrig S.
        • Merica H.
        • Ibanez V.
        Spectral analysis of the sleep onset period in primary insomnia.
        Clin Neurophysiol. 2014; 125: 979-987
        • Taylor D.J.
        • Lichstein K.L.
        • Durrence H.H.
        • Reidel B.W.
        • Bush A.J.
        Epidemiology of insomnia, depression, and anxiety.
        Sleep. 2005; 28: 1457-1464
        • Pillai V.
        • Roth T.
        • Drake C.L.
        The nature of stable insomnia phenotypes.
        Sleep. 2015; 38: 127-138
        • Krokstad S.
        • Langhammer A.
        • Hveem K.
        • et al.
        Cohort profile: the HUNT Study, Norway.
        Int J Epidemiol. 2013; 42: 968-977
        • Engstrøm M.
        • Oslash
        • Degård S.
        • et al.
        The reliability of a new sleep screening questionnaire for large population-based studies: the third Nord-Trøndelag Health Study.
        Open Sleep J. 2011; 4: 14-19
        • Zigmond A.S.
        • Snaith R.P.
        The Hospital Anxiety and Depression Scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Bjelland I.
        • Dahl A.A.
        • Haug T.T.
        • Neckelmann D.
        The validity of the Hospital Anxiety and Depression Scale. An updated literature review.
        J Psychosom Res. 2002; 52: 69-77
        • Puhan M.A.
        • Frey M.
        • Büchi S.
        • Schünemann H.J.
        The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease.
        Health Qual Life Outcomes. 2008; 6: 46
        • Chan K.S.
        • Aronson Friedman L.
        • Bienvenu O.J.
        • et al.
        Distribution-based estimates of minimal important difference for hospital anxiety and depression scale and impact of event scale-revised in survivors of acute respiratory failure.
        Gen Hosp Psychiatry. 2016; 42: 32-35
        • Vgontzas A.N.
        • Fernandez-Mendoza J.
        • Liao D.
        • Bixler E.O.
        Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.
        Sleep Med Rev. 2013; 17: 241-254
        • Belleville G.
        • Cousineau H.
        • Levrier K.
        • St-Pierre-Delorme M.E.
        • Marchand A.
        The impact of cognitive-behavior therapy for anxiety disorders on concomitant sleep disturbances: a meta-analysis.
        J Anxiety Disord. 2010; 24: 379-386
        • Viens M.
        • De Koninck J.
        • Mercier P.
        • St-Onge M.
        • Lorrain D.
        Trait anxiety and sleep-onset insomnia: evaluation of treatment using anxiety management training.
        J Psychosom Res. 2003; 54: 31-37
        • Uhlig B.L.
        • Sand T.
        • Odegard S.S.
        • Hagen K.
        Prevalence and associated factors of DSM-V insomnia in Norway: the Nord-Trondelag Health Study (HUNT 3).
        Sleep Med. 2014; 15: 708-713
        • Pallesen S.
        • Sivertsen B.
        • Nordhus I.H.
        • Bjorvatn B.
        A 10-year trend of insomnia prevalence in the adult Norwegian population.
        Sleep Med. 2014; 15: 173-179
        • Ohayon M.M.
        • Sagales T.
        Prevalence of insomnia and sleep characteristics in the general population of Spain.
        Sleep Med. 2010; 11: 1010-1018
        • Baguley T.
        Standardized or simple effect size: what should be reported?.
        Br J Psychol. 2009; 100: 603-617