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Prospective study of predictors and

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DOI: 10.1016/j.sleep.2015.12.002

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 Sleep Medicine 20 (2016) 51–58

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Sleep Medicine
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / s l e e p

Original Article

Prospective study of predictors and consequences of insomnia:

personality, lifestyle, mental health, and work-related stressors
Øystein Vedaa a,b,*, Elfrid Krossbakken a, Ingse Dagny Grimsrud c, Bjørn Bjorvatn d,e,
Børge Sivertsen b,f,g, Nils Magerøy h, Ståle Einarsen a, Ståle Pallesen a,e
a Department of Psychosocial Science, University of Bergen, Bergen, Norway
b Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway
c
Akershus University Hospital, Lørenskog, Norway
d Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
e Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
f The Regional Centre for Child and Youth Mental Health and Child Welfare, Uni Research Health, Bergen, Norway
g
Department of Psychiatry, Helse Fonna HF, Haugesund, Norway
h Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To prospectively investigate the reciprocal relationships between personality traits, lifestyle
Received 15 October 2015 factors, mental health, sleepiness, and work-related stressors against insomnia.
Received in revised form 29 November Methods: A total of 799 Norwegian shift-working nurses (mean age 33.2 years, 90% female) partici-
2015
pated in this prospective cohort study. They were assessed on self-report instruments (Bergen Insomnia
Accepted 1 December 2015
Available online 15 December 2015
Scale, Diurnal Type Scale, Hospital Anxiety and Depression Scale, Negative Acts Questionnaire-Revised,
Work–Family Interface Scale, among others) in 2008/2009 (wave 1) and 2011 (wave 3). Structural equa-
tion modeling was employed to investigate the bidirectional relationship between a wide range of individual
Keywords:
Insomnia and work-related variables and insomnia.
Predictors Results: Languidity (β = 0.18***), anxiety (β = 0.11**), depression (β = 0.14***), exposure to bullying be-
Personality havior (β = 0.08*), and negative spillover between work and family life (work to family, β = 0.08*; family
Mental health to work, β = 0.07*) predicted increased symptoms of insomnia over time. Morningness (β = −0.09*) and
Bullying positive spillover from work to family (β = −0.11**) predicted less symptoms of insomnia over time. No
Work–family spillover support was found for night work as a predictor of increased insomnia. Insomnia was a precursor for
anxiety (β = 0.11**), but not for depression (*p < 0.05, **p < 0.01, ***p < 0.001).
Conclusion: The data suggested that insomnia more often emerges as a consequence of individual and
work-related factors than as a precursor to them. The scope of factors causing insomnia, and factors pro-
tecting against it, should be further investigated. Insomnia should be considered in prediction models
for mental illnesses and as an outcome of adverse work-related experiences.
© 2015 Elsevier B.V. All rights reserved.

1. Introduction
Insomnia is a sleep disorder characterized by difficulties initi-
ating or maintaining sleep, which impair daytime functioning [1].
The reported prevalence of insomnia varies from 2% to about 48%,
depending on the stringency of definitions and operationalization
of the construct [2,3]. Trend studies have pointed to a rising occur-
rence of insomnia in the general adult population over the past
decades [4–9]. This may be related to an aging population and
* Corresponding author. Department of Psychosocial Science, University of Bergen,
Christies gate 12 (4. story), 5015 Bergen, Norway. Tel.: +47 555 83 305; fax: +47 555
89 879.
E-mail address: oystein.vedaa@psysp.uib.no (Ø. Vedaa).
increase in being overweight. Increased use of shift work and in-
creased job-related stress may be other important predictors for the
rising occurrence of insomnia [4]. In addition, increased use of elec-
tronic devices at bedtime may hamper sleep [10]. Finally, increased
awareness of the significance of sleep may have spurred the report
of sleep problems [11]. Health problems related to insomnia include
a range of medical conditions such as: heart disease, hyperten-
sion, neurological disease, gastrointestinal problems, cancer, and
diabetes, among others [12–15]. More inextricably linked to in-
somnia, however, are mental health conditions such as anxiety and
depression [16,17]. Anxiety and stressful life events are also often
seen as precursors to sleep difficulties, whereas persistent insom-
nia is typically seen as a risk factor for depression [18].
Stress and prolonged arousal are key features that may cause sleep
difficulties, which is a relationship believed to be mediated by worry
and intrusive or repetitive thoughts [19,20]. One such highly intrusive

http://dx.doi.org/10.1016/j.sleep.2015.12.002
1389-9457/© 2015 Elsevier B.V. All rights reserved.
52 Ø. Vedaa et al./Sleep Medicine 20 (2016) 51–58
stressor is exposure to bullying behaviors in the work place; this
is defined as the persistent exposure to negative actions from others
in a situation or at an intensity that the targeted employee finds it
difficult to defend against [21]. Exposure to bullying behavior leads
to psychological distress [22] and has been found to predict sub-
sequent sleep difficulties [23,24], with a call for more studies on
the relationship between bullying and sleep difficulties [25].
Another important stressor in contemporary work-life is the chal-
lenge of combining work and family life, where too much strain and
worry in one domain may spill over to the other in a cyclic process
that leads to deficient recovery and poor sleep quality [26]. Work-
related strain may also be increasing due to a growing number of
24-hour services and businesses. In order to extend operating hours,
these businesses need to organize the staffing through shift work,
which has well-known detrimental effects on the workers’ health
and sleep [27,28]. However, some people have the ability to adapt
to shift work without substantial detrimental effects. Some of the
characteristics associated with higher shift work tolerance include
low scores on the personality trait ‘morningness’, high scores on
flexibility, and low scores on languidity [29]. These three person-
ality characteristics describe different aspects that are related to how
the individual relates to the act of sleeping. Morningness refers to
individual preferences of timing for sleep and active periods during
the 24-hour day [30]; flexibility refers to individual differences in
capacity to sleep at odd times [31]; and languidity describes dif-
ferences in the ability to withstand and overcome drowsiness upon
losing sleep [31]. Although these traits are directly related to the
individual’s sleep and wakefulness, there are few studies that have
looked at whether they predict the development of insomnia over
time.
Much is known about the precursors of insomnia, but the ma-
jority of studies are still cross-sectional, which precludes inferences
about directionality [26,32]. Although an increasing number of
studies have used longitudinal designs over the past 15 years, they
have tended to focus on only a few variables as predictors of in-
somnia [16,23,33], and very few have studied the potential
bidirectional relationship between these variables and insomnia
[16,17,23].
Therefore, the purpose of the current study was to employ a pro-
spective design to investigate the reciprocal relationship between
a wide range of individual and work-related variables against in-
somnia (personality traits, lifestyle factors, mental health, sleepiness,
and work-related stressors).
2. Material and methods
2.1. Subjects and procedure
The current study was based on data from the Norwegian Survey
of Shiftwork, Sleep and Health (SUSSH) project. The SUSSH is a cohort
study that was established in 2008/2009, where surveys are carried
out annually. Registered members of the Norwegian Nurses Orga-
nization (NNO) were recruited to participate (N = 5400). The current
study includes data from 2009 (wave 1) and 2011 (wave 3), where
the data collection for both waves took place during winter and
spring. The total number of respondents (response rate) across the
two waves was 2048 (38.0%) for wave 1 and 1533 (77.5%) for wave
3 (the latter percentage refers to the proportion of those who also
participated in wave 1). Only complete datasets that were avail-
able from both assessment points among respondents actively
working as nurses during both waves were used (N = 799). The sub-
jects’ ages ranged from 21 to 63 years, with a relatively low average
of 33.2 years (SD = 8.1); however, the 5% trimmed mean was 32.7
years, which suggested no significant outliers of greater age. In both
waves, males were two years older than females, and the gender
ratios were stable at about 90% females. A total of 85% of the nurses
worked on a rotating two/three shift schedule, 8% worked perma-
nent night shifts and 7% worked permanent day shifts. Data on how
long the workers had been working the different shifts up until the
assessment point were unfortunately unavailable. The survey was
sent to each nurse’s home address by letter, together with a pre-
paid return envelope. Two reminders were sent to the non-
respondents. Twenty-five randomly selected respondents from each
wave received a gift card of 500 NOK (approximately 65 Euro/60
USD). Participation was voluntary, and the project was approved by
the Regional Committee for Medical Research Ethics in Western
Norway (No. 088.88), by the Norwegian Data Inspectorate (08/
01235/IUR) and by the Norwegian Health Directorate.
2.2. Survey data
The survey included questions on demographics, work situa-
tion (eg, percentage of full-time equivalent, number of night shifts
during the last year), and lifestyle (ie, daily smoking and cups of
caffeinated beverages per day). The subjects were also assessed on
standardized questionnaires measuring insomnia and sleepiness,
diurnal preference, alcohol use, mental health, workplace bully-
ing, and work–life balance.
2.2.1. Bergen insomnia scale
The Bergen Insomnia Scale (BIS) [34] comprises six items that
assess symptoms of insomnia based on the American Psychiatric
Association’s (APA) Diagnostic and Statistical Manual of Mental
Disorders-IV-TR [35]. Subjects are asked to indicate how many days
a week (0–7) during the last month they have struggled with six
specified symptoms of insomnia. The scale can be used as a con-
tinuous measure, where higher scores indicate more symptoms of
insomnia; or as a dichotomous measure, where the diagnostic cri-
teria of insomnia are met with a score of >2 on one or more of the
first four items (nighttime symptoms) and a score of >2 on one or
more of the last two items (daytime symptoms). In the current study
the scale was used as a continuous measure. Cronbach’s alpha of
BIS was 0.81 in both wave 1 and wave 3.
2.2.2. Diurnal type scale
The Diurnal Type Scale (DTS) comprises seven items designed
to assess the morningness–eveningness dimension, where a higher
score indicates a tendency toward morningness [30]. Subjects are
asked questions pertaining to their preferred bedtime and rise time,
and their preferred time for activities during the day. The DTS has
shown adequate convergent validity in relation to other scales mea-
suring the morningness–eveningness dimension [36]. In the present
study, the Cronbach’s alpha of the DTS for wave 1 and wave 3 were
0.65 and 0.64, respectively.
2.2.3. Revised circadian type inventory
The revised Circadian Type Inventory (rCTI) comprises 11 items;
five assessing flexibility and six assessing languidity [31]. High scores
on flexibility reflect better ability to sleep and work at odd times,
whereas high scores on languidity indicate difficulties overcom-
ing drowsiness and feelings of lethargy following sleep loss. In
previous research, the rCTI has demonstrated good reliability and
validity in a working sample [31]. In this study, Cronbach’s alphas
for the flexibility and languidity subscales were 0.81 and 0.71 for
wave 1, and 0.82 and 0.74 for wave 3, respectively.
2.2.4. Epworth sleepiness scale
The Epworth Sleepiness Scale (ESS) consists of eight items in-
tended to identify the individual’s tendency to falling asleep or dozing
off in different everyday situations [37]. Higher total scores on the
ESS indicate higher chances of dozing off, where the clinical cut-off
for excessive daytime sleepiness is >10. The ESS is a widely used
 Ø. Vedaa et al./Sleep Medicine 20 (2016) 51–58
measure of daytime sleepiness and has shown high reliability and
validity. The Cronbach’s alphas for the ESS in this study for wave 1
and wave 3 were 0.74 and 0.76, respectively.
2.2.5. Hospital anxiety and depression scale
The Hospital Anxiety and Depression Scale (HADS) is used as
measure of symptoms of anxiety and depression [38]. The scale com-
prises 14 questions pertaining to non-vegetative symptoms of anxiety
and depression. Higher scores on the two respective subscales in-
dicate higher symptom severity. A review of the scale identified it
as an accurate instrument for assessing symptom severity of anxiety
and depression in the general population [39]. Cronbach’s alphas
for the depression and anxiety subscales were 0.81 and 0.80 for wave
1, and 0.80 and 0.82 for wave 3, respectively.
2.2.6. Alcohol use disorders identification test – consumption
Alcohol consumption was assessed using the Alcohol Use Dis-
orders Identification Test – Consumption (AUDIT-C). The AUDIT-C
scale is a valid primary care screening test for heavy drinking and/
or active alcohol abuse or dependence [40]. The scale comprises three
items addressing the frequency and quantity of drinking, where
higher scores indicate higher alcohol consumption. In the current
study, the Cronbach’s alphas of AUDIT-C at wave 1 and wave 3 were
0.38 and 0.37, respectively.
2.2.7. Negative acts questionnaire-revised
Exposure to bullying behaviors was measured with nine items
from the Negative Acts Questionnaire-Revised (NAQ-R) [41]. Sub-
jects are asked questions about exposure to personal and work-
related bullying, as well as acts of social exclusion and isolation, as
perceived over the last 6 months. A high score indicates more ex-
posure to such negative behavior. The Cronbach’s alphas for wave
1 and wave 3 were 0.74 and 0.80, respectively.
2.2.8. Work–family interface scale
Positive and negative spillover between work and family were
assessed with 14 items in the Work–Family Interface Scale (WFIS)
[42]. The WFIS assesses negative spillover from work to family and
family to work, as well as positive spillover from work to family and
family to work. High scores indicate more spillover in the respec-
tive dimension. Cronbach’s alphas on wave 1 and wave 3 for the
four dimensions were respectively 0.80 and 0.79 for negative work
to family; 0.77 and 0.80 for negative family to work; 0.56 and 0.56
for positive work to family; and 0.57 and 0.62 for positive family
to work.
2.3. Statistics
Reliability analysis of the instruments and a non-responder anal-
ysis were carried out using IBM SPSS Statistics 22.0 (IBM SPSS
Statistics, New York, USA). Structural equation modeling (SEM) was
carried out using IBM SPSS AMOS 22.0 (IBM SPSS Statistics, New
York, USA). For the subjects to be included in the analysis, struc-
tural equation modeling analysis required all items to be answered
in both wave 1 and wave 3. Single item variables were manifest vari-
ables, and these included the number of nightshifts during the last
year, caffeine consumption (cups per day), and daily cigarette
smoking. Therefore, these were directly related to the continuous
measure of insomnia symptoms. The latent variables were con-
structs composed of multiple items, where measurement errors were
partialized into separate components. In the present study, latent
variables were constructed for insomnia, morningness–eveningness,
flexibility, languidity, sleepiness, alcohol consumption, anxiety, de-
pression, exposure to bullying behavior, and work to family spillover.
Explorative factor analysis was carried out on the data for the latent
variables, where factors related to the construct were extracted and
53
distributed on two parcels. The item with highest loading was par-
titioned to parcel 1, the second highest to parcel 2, and third highest
to parcel 1, and so forth. This was done to ensure an equal charge
between the parcels. The relationship between the constructs was
then examined by use of SEM (Fig. 1 for the latent variables; Fig. 2
for the manifest variables). The primary interest was to inspect
whether the different variables (ie, personality variables, lifestyle
factors, mental health, bullying behavior, work to family spillover,
and night shifts) could predict symptoms of insomnia over time (Path
B, Figs. 1 and 2); and whether symptoms of insomnia could predict
scores on the other constructs over time (Path C, Figs. 1 and 2).
3. Results
In order to elucidate any potential differences between non-
responders (ie, those who only responded on wave 1) and responders
(those who both responded on wave 1 and 3), independent sample
t-tests (for continuous variables) and Chi-square test for indepen-
dence (for categorical variables) were employed. Those who only
responded on wave 1 (ie, ‘non-responders’) were significantly older
(p < 0.001), more often without a partner (p < 0.001), more often
without children living at home (p < 0.001), had higher percent-
age of full-time work (p < 0.001), scored higher on insomnia
(p = 0.013), lower on flexibility (p < 0.001), lower on alcohol use
(p < 0.001), higher on caffeine use (p = 0.009), were more often
smokers (p = 0.019), reported more negative work-to-family and
family-to-work spillover (both p < 0.001), and had more night shifts
during the last year (p < 0.001) compared with those who re-
sponded on both wave 1 and wave 3. No significant differences were
observed between the two groups in terms of the other variables
investigated in this study.
The results for the association between the latent variables and
the continuous measure of symptoms of insomnia are shown in
Table 1. Table 2 shows the results for the association between the
manifest variables and insomnia. Both Tables 1 and 2 also provide
an evaluation of model fit using Chi-square, comparative fit index
(CFI), and the root mean square error of approximation (RMSEA).
The autoregressive analysis showed that morningness was in-
versely related to increased symptoms of insomnia over the 2-year
period between wave 1 and wave 3, β = −0.09, B = −0.30, SE = 0.122,
p < 0.05; while languidity predicted more symptoms of insomnia
over time, β = 0.19, B = 0.59, SE = 11, p < 0.001. Both symptoms of de-
pression and anxiety predicted an increase in symptoms of insomnia
from wave 1 to wave 3, β = 0.14, B = 0.57, SE = 0.15, p < 0.001 and
β = 0.11, B = 0.35, SE = 0.12, p < 0.01, respectively. Exposure to bul-
lying behavior predicted more symptoms of insomnia over time,
β = 0.08, B = 0.32, SE = 0.15, p < 0.05. Both negative spillover from work
to family and from family to work predicted more symptoms of in-
somnia over time, β = 0.08, B = 0.22, SE = 0.10, p < 0.05 and β = 0.07,
B = 0.26, SE = 0.12, p < 0.05, respectively. Conversely, positive spill-
over from work to family predicted less symptoms of insomnia over
time, β = −0.11, B = −0.78, SE = 0.29, p < 0.01. The other variables, as
listed in Tables 1 and 2, showed no significant predictive power on
symptoms of insomnia over time.
Furthermore, the current study investigated whether symp-
toms of insomnia over time predicted mental health, sleepiness,
lifestyle factors (ie, daily smoking, caffeine consumption, and alcohol
consumption), personality traits (ie, morningness–eveningness,
languidity and flexibility), exposure to bullying behavior, and neg-
ative and positive spillover from work to family and family to work,
respectively. The results showed that symptoms of insomnia pre-
dicted higher scores on measures of anxiety over time, β = 0.11,
B = 0.04, SE = 0.01, p < 0.01. There was no significant predictive power
of symptoms of insomnia on depression. Furthermore, symptoms
of insomnia predicted more negative spillover from work to family
life over time, β = 0.11, B = 0.04, SE = 0.02, p < 0.01. Insomnia also
54 Ø. Vedaa et al./Sleep Medicine 20 (2016) 51–58

Fig. 1. Structural equation modeling of latent variables against the insomnia construct.

Fig. 2. Structural equation modeling of manifest variables against the insomnia construct.
 Ø. Vedaa et al./Sleep Medicine 20 (2016) 51–58 55

Table 1
Structural equation modeling of insomnia and latent variables wave 1 and wave 3, n = 799.

Standardized beta and correlation Model fit

Path A Path B Path C Path D Path E χ2 (df = 15) CFI RMSEA

Morningness 0.65*** −0.09* −0.03 0.98*** −0.35*** 304.07 0.91 0.155

Languidity 0.61*** 0.18*** −0.04 0.99*** 0.35*** 250.01 0.92 0.140
Flexibility 0.70*** −0.03 −0.03 0.80*** −0.06 146.80 0.96 0.105
Alcohol 0.70*** 0.04 −0.01 0.95*** 0.05 128.53 0.96 0.097
Sleepiness 0.68*** 0.04 −0.04 0.78*** 0.31*** 295.41 0.91 0.153
Depression 0.63*** 0.14*** −0.03 0.74*** 0.44*** 211.43 0.94 0.128
Anxiety 0.66*** 0.11** 0.11** 0.68*** 0.46*** 179.70 0.95 0.117
Bullying 0.66*** 0.08* 0.03 0.65*** 0.30*** 119.88 0.96 0.094
Negative spillover
- Work to family 0.67*** 0.08* 0.11** 0.63*** 0.38*** 160.39 0.95 0.110
- Family to work 0.70*** 0.07* 0.07 0.66*** 0.12** 115.51 0.96 0.092
Positive spillover
- Work to family 0.67*** −0.11** 0.02 0.80*** −0.25*** 163.06 0.93 0.111
- Family to work 0.70*** −0.02 0.05 0.62*** −0.03 87.31 0.97 0.078

Abbreviations: df, degree of freedom; CFI, comparative fit index; RMSEA, root mean square error of approximation.
Note. Path A is insomnia at wave 1 to insomnia at wave 3; Path B is all variables at wave1 to insomnia at wave 3; Path C is insomnia at wave 1 to all variables at wave 3;
Path D is all variables at wave 1 to all variables at wave 3; Path E is all variables at wave 1 to insomnia at wave 1.
* p < 0.05.
** p < 0.01.
*** p < 0.001.

Table 2
Structural equation modeling of insomnia and manifest variables wave 1 and wave 3, n = 799.

Standardized beta and correlation Model fit

Path A Path B Path C Path D Path E χ2 (df = 15) CFI RMSEA

Daily smoking 0.69*** 0.05 0.05 0.64*** 0.13*** 81.74 0.96 0.126
Caffeine 0.70*** 0.03 –0.05* 0.73*** 0.06 70.54 0.97 0.116
Night shifts 0.70*** –0.02 –0.02 0.58*** –0.05 70.35 0.97 0.116

Abbreviations: df, degree of freedom; CFI, comparative fit index; RMSEA, root mean square error of approximation.
Note. Path A is insomnia at wave 1 to insomnia at wave 3; Path B is all variables at wave1 to insomnia at wave 3; Path C is insomnia at wave 1 to all variables at wave 3;
Path D is all variables at wave 1 to all variables at wave 3; Path E is all variables at wave 1 to insomnia at wave 1.
* p < 0.05.
** p < 0.01.
*** p < 0.001.

appeared to predict less caffeine consumption over time, β = −0.05,
B = −0.03, SE = 0.02, p < 0.05. No significant predictive power of in-
somnia was observed on any of the other variables investigated.
4. Discussion
Employing a prospective design, the current study investigated
the reciprocal relationship between a wide range of theoretically
relevant individual and work-related variables (ie, personality traits,
lifestyle factors, mental health, sleepiness, and work-related stress-
ors) and insomnia.
The aim was to explore whether the three personality traits
(morningness, languidity and flexibility) would play a role in the
development of insomnia, based on the fact that aspects of these
traits, in different ways, encapsulate how the individual relates to
the act of sleeping. Indeed, it was found that higher scores on
morningness predicted a reduction of insomnia over the 2-year as-
sessment period. Although this observation has previously been
pointed out [32,43], the current study adds conviction to this by using
a prospective design. This result is also somewhat noteworthy as
the majority of subjects were shift workers, where lower scores on
morningness are usually associated with better tolerance to shift
work (eg, they experience less sleep problems) [29]. Individuals
scoring high on morningness have better lifestyle regularity and more
regular sleep patterns compared with eveningness individuals
[44,45], which may be protective against the development of chronic
insomnia. In addition, low scores on morningness have been asso-
ciated with more dysfunctional beliefs about sleep [45] and more
frequent reports of symptoms of insomnia [46]. Higher scores on
morningness also involve sleep behaviors that are in better harmony
with the established social rhythm (ie, early to bed and early to rise)
[47], which may help to explain the beneficial effects of being high
on morningness on sleep.
The personality trait ‘languidity’ was found to predict in-
creased symptoms of insomnia over the 2-year period from wave
1 to wave 3. High scores on languidity describe individuals who more
easily suffer from drowsiness and feelings of lethargy upon losing
sleep, for example, due to shift work [31]. These characteristics
overlap with the daytime symptoms of insomnia. It is, therefore,
easy to see how languidity might increase reports of insomnia over
time, especially considering that the passage of time for these sub-
jects equals more exposure to shift work. Languidity has previously
been associated with less tolerance for shift work [29]. In the current
study, it is, however, a matter of speculation as to whether it was
exposure to shift work (or some other stressor) that triggered more
symptoms of insomnia over time for those who scored higher on
languidity. Subjects’ scores on the personality trait, flexibility, which
is the ability to sleep or stay awake at unusual hours, did not predict
symptoms of insomnia over time. This is contrary to previous ob-
servations that have found high flexibility to be associated with less
symptoms of insomnia [43]. One of the attributes of insomnia is a
general hyperarousal that impedes sleep from occurring [48]. In-
tuitively, high flexibility seems to reflect the opposite of hyperarousal,
which then allows for a more flexible sleep pattern. It is thus note-
worthy that an effect of this trait was not observed on symptoms
of insomnia. When the abovementioned investigation was turned
56 Ø. Vedaa et al./Sleep Medicine 20 (2016) 51–58
around, symptoms of insomnia showed no predictive power on either
of the personality traits. However, these traits are individual char-
acteristics assumed to be relatively stable over time and one would
not expect substantial changes to occur over such a short time as
2 years.
The detrimental effects of lifestyle factors, such as smoking
[49,50], caffeine [51] and alcohol consumption [52], on sleep quality
are well known. That is why abstinence from these substances is a
fundamental part of good sleep hygiene. However, none of the life-
style factors predicted insomnia over time in the current study. On
the other hand, symptoms of insomnia did predict less caffeine con-
sumption over time. People with insomnia generally do not
significantly differ from people without insomnia in terms of sleep
hygiene practices such as nicotine, caffeine and alcohol use [53,54].
One study of women found that those who suffered from insom-
nia had significantly less caffeine intake per day compared with those
without insomnia [54]. It is a matter of speculation as to whether
the reduction of caffeine intake for those who scored higher on in-
somnia in this study was a conscious decision to remedy the sleep
problem or due to some other unknown reason. Nonetheless, the
current findings refute a potential causal relationship between life-
style habits, such as nicotine, caffeine and alcohol intake, on
symptoms of insomnia over time.
A strong bidirectional relationship between insomnia, depres-
sion and anxiety has previously been identified [16,17,55,56]. By and
large this was reaffirmed by the results in the current study, where
both symptoms of anxiety and symptoms of depression predicted
symptoms of insomnia over time, with symptoms of insomnia pre-
dicting anxiety over time, albeit not depression. The mechanisms
believed to govern the relationship between mental health and in-
somnia are thoroughly discussed elsewhere [56–59]. It is surprising
that insomnia did not predict depression, considering the strong ev-
idence linking insomnia to depression [17,60,61]. The majority of
subjects in this study were shift workers who are expected to suffer
more from sleep problems due to odd working hours, as com-
pared to people on fixed daytime schedules [62]. It is thus reasonable
to assume that symptoms of insomnia in this sample, to a larger
extent, were externally driven by odd working hours, which may
imply a different pathogenesis without the same connection with
depression found in more endogenous insomnia. In addition, scores
on the depression scale were somewhat lower in this sample (HADS
mean score 2.4) compared with what has previously been re-
ported in a working population (HADS mean score 3.7) [63]. As a
result, symptoms of insomnia may have failed to predict depres-
sion in this study due to a floor effect.
Wide ranges of work-related stressors have been found to in-
crease the risk for poor sleep quality and symptoms of insomnia
[27,64–66]. One such stressor is exposure to bullying behaviors [64],
which in the current study was also found to predict more symp-
toms of insomnia over time, with no support for the opposite
relation. Exposure to such bullying may lead to worry and stress
[64], which are among the leading reasons for sleep problems among
workers. Targets of workplace bullying do suffer the objective risk
of being excluded not only from the social working environment
but also from the organization, as well as working life in general,
proving it to be a stressor worth worrying about [67]. Conversely,
it has been suggested that sleep difficulties and reduced daytime
functioning call for less social support from colleagues, and that these
processes may have a circular nature [66]. Poor sleep quality could
also give rise to a more gloomy perception of the psychosocial climate
at work [66]. Nevertheless, the current study delineates this re-
versed relationship.
Another potential source of the worry and stress that have been
found to affect sleep is the bilateral inter-role conflict that may arise
between work and family life [42,68]. Indeed, in the current study,
negative spillover both from work to family and from family to work
predicted more symptoms of insomnia over time. Correspond-
ingly, positive spillover from work to family predicted less symptoms
of insomnia over time, but this relation was not observed in terms
of positive spillover from family to work. A conceptual framework
to understand the relationship between work and family on health
and sleep is the effort–recovery model [26,69]: the basic idea being
that efforts and strains in one domain are likely to spill over in the
other domain in a cyclic manner, which prevents sufficient recov-
ery and eventually cause ill health (eg, poor sleep quality). In contrast,
resources in one domain are energizing, may spill over to the other
domain, facilitate adequate recovery and have a protective effect on
health (eg, better sleep quality). Positive spillover from family to
work has previously been associated with better sleep quality in
one cross-sectional study [26], however, the current prospective anal-
ysis did not find support for this. Symptoms of insomnia were also
examined as a predictor for the four variations of work and family
spillover, and the only significant effect was the relationship between
insomnia and future negative spillover from work to family. Work-
to-family conflicts are reported more frequently than family-to-
work conflicts [42,70,71], and this observation may reflect that work-
to-family spillover is also the most easily affected by sleep problems.
Finally, the effect of night shifts on symptoms of insomnia was
investigated. Night work has previously been associated with various
sleep difficulties [27]. However, the result from the current study
revealed no significant relationship between exposure to night shifts
and symptoms of insomnia over time. The relationship between night
shift and disturbed sleep may have a more acute nature than the
2-year period investigated in the current study, although no cross-
sectional correlation was observed either. Analysis of non-responders
showed that the current sample was younger and generally less bur-
dened compared with those who dropped out before wave 3. The
actual effects may have, thus, been obscured because of a selected
and more robust sample. Furthermore, one problem with shift work
research is that people who start with and are able to remain in shift
work basically have better health compared to people who quit or
actively avoid shift work [72]. This phenomenon is denoted ‘the
healthy worker effect’, and implies an underestimation of the real
negative effects of shift work, which may help to explain why no
effect of night shifts was observed on insomnia in this study. Shift
workers often represent a self-selected group that are likely to have
sleep behaviors that facilitate adaptation to odd working hours [72].
In addition, the institutions that use shift work increasingly incor-
porate ergonomic shift scheduling, which makes it reasonable to
expect a corresponding decline in the negative consequences. In the
current sample, night shifts were typically no more than two or three
in a row followed by a period of rest. This may have made the strain
of night work too small to constitute a significant predictor of sub-
sequent insomnia.
An important limitation to the current study pertained to the
issue of generalizability, which may have been due to the relative-
ly low response rate on wave 1 (38%), and a homogeneous sample
mainly comprising relatively young females (90%) and all edu-
cated nurses, where the majority were also shift workers.
Nevertheless, a substantial proportion of those who participated in
wave 1 also responded in wave 3 (78%). This enabled analysis with
repeated measures that, to some extent, can compensate for the low
response rate. The highly homogenous sample also has the advan-
tage that it reduces potential confounders and refines the effects
that were observed. Furthermore, model fit was not optimal, which
suggests that the result should be interpreted with some caution.
However, the interests primarily attained to the single paths B and
C (Figs. 1 and 2), where it is reasonable to assume that the overall
model fit did not influence too much (eg, [73]). Reliability analysis
revealed somewhat low internal consistency for the Diurnal Type
Scale (morningness) and AUDIT-C (alcohol consumption). This has
also been pointed out in previous studies [74,75] and is likely due
 Ø. Vedaa et al./Sleep Medicine 20 (2016) 51–58
to the low number of items in the instruments. This survey was based
on self-report instruments, which have limitations in terms of biases
related to subjective reports. However, most of the variables were
based on standardized questionnaires. Furthermore, most vari-
ables are subjective in their very nature; hence they must be
measured with subjective reports.
In conclusion, the current study adds to the understanding of
the development and consequences of insomnia by delineating the
degree to which personality traits, lifestyle factors, mental health,
sleepiness, and work-related stressors relate reciprocally to the in-
somnia construct in a shift-working population. It is believed that
the present study is the most comprehensive to date, in terms of
the number and variety of insomnia antecedents and conse-
quences included. Precursors of insomnia include high scores on
languidity, symptoms of anxiety and depression, exposure to bul-
lying behavior, negative spillover from work to family and family
to work. High scores on morningness and positive spillover from
work to family seem to be protective of developing insomnia over
time. Reversing the analysis showed that insomnia was a precur-
sor for anxiety, but surprisingly, not for depression. Also, no support
was found for night work as a significant predictor of insomnia over
a 2-year period. Overall, this study suggests that insomnia more often
emerges as a consequence of individual and work-related factors
than as a precursor to them.
Conflict of interest
None of the authors have any conflicts of interest related to the
content of this paper.
The ICMJE Uniform Disclosure Form for Potential Conflicts of In-
terest associated with this article can be viewed by clicking on the
following link: http://dx.doi.org/10.1016/j.sleep.2015.12.002.
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