Sleep-related attentional and interpretive-bias in insomnia: A systematic review and meta-analysis

Umair Akram, Nicola Barclay, Bronwyn Milkins, Jodie Stevenson, Maria Gardani

Research output: Contribution to journalReview articlepeer-review

7 Citations (Scopus)


Cognitive models of insomnia highlight internal and external cognitive-biases for sleep-related "threat" in maintaining the disorder. This systematic review of the sleep-related attentional and interpretive-bias literature includes meta-analytic calculations of each construct. Searches identified N = 21 attentionalbias and N = 8 interpretive-bias studies meeting the inclusion/exclusion criteria. Seventeen attentionalbias studies compared normal-sleepers and poor-sleepers/insomnia patients. Using a random effects model, meta-analytic data based on standardized mean differences of attentional-bias studies determined the weighted pooled effect size to be moderate at 0.60 (95%CI:0.26-0.93). Likewise, seven of eight interpretive-bias studies involved group comparisons. Meta-analytic data determined the weighted pooled effect size as moderate at .44 (95%CI:0.19-0.69). Considering these outcomes, disorder congruent cognitive-biases appear to be a key feature of insomnia. Despite statistical support, absence of longitudinal data limits causal inference concerning the relative role cognitive-biases in the development and maintenance of insomnia. Methodological factors pertaining to task design, sample and stimuli are discussed in relation to outcome variation. Finally, we discuss the next steps in advancing the understanding of sleep-related biases in insomnia. (c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (

Original languageEnglish
Article number101713
Number of pages14
JournalSleep Medicine Reviews
Publication statusPublished - Feb 2023


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