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Volume 14 No. 03
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Letters to the Editor

Does Perfectionism Increase the Risk for Dropout From Cognitive Behavioral Therapy for Insomnia?

Anna F. Johann, MSc1,2; Dieter Riemann, PhD1; Kai Spiegelhalder, MD, PhD1
1Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; 2Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany

Associations between personality and objective markers of poor sleep are still poorly studied. Particularly the relationship between perfectionism and objective sleep measures is relatively overlooked, as Akram1 correctly points out. Thus, we take this opportunity to briefly sketch potential routes further research in this area may take because perfectionism may play a crucial role for whether or not cognitive behavioral therapy for insomnia (CBT-I) is successful.

Evidence shows that those who do not adhere to CBT-I often drop out when they are to be restricting their sleep.2 This finding is particularly pertinent as sleep restriction is the core element of CBT-I3 and as such, crucial for treatment success. Sleep restriction is a process that may be understood as a set of repeated attempts to determine a patient's individual sleep duration in an iterative manner by gradually approximating the appropriate sleep duration. This process necessarily involves trial and error. Indeed, sleep restriction may be conceived of as a behavioral experiment in which patients are required to explore their individual sleep time independent from dysfunctional beliefs, such as a person needs 7 to 8 hours of sleep. Patients with insomnia presenting with high levels of perfectionism may find it difficult to submit to that type of experiment. The reason behind this may be the very nature of the process of sleep restriction, which necessarily involves the repeated experience of failure, although that failure may ultimately be only partial and temporary. From this perspective, sleep restriction may pose a crucial obstacle for patients with increased levels of perfectionism and may prevent them from entering one of the most effective aspects of the CBT-I curriculum and progressing to treatment success.

There is a further dimension to the relationship between perfectionism and poor sleep. Not all patients with insomnia presenting with increased levels of perfectionism may have the same risk for not adhering to treatment. The risk may vary according to sleep duration and levels of perfectionism. Recent research suggested that there are two groups of patients with insomnia that differ with respect to their sleep duration, patients with normal sleep duration (> 6 hours) and patients with short sleep duration (< 6 hours).4 The patients with short sleep duration may have a higher risk for not adhering to treatment if they present with increased levels of perfectionism because these patients may experience a larger difference between the commonly held ideal of a sleep duration of 7 to 8 hours and the CBT-I imposed sleep duration (eg, 4 hours) than the patients with insomnia and normal sleep duration. That difference may cause even greater distress in those patients because it increases their perceived failure to not comply with the purported norm of 7 to 8 hours of sleep.5

Thus far, perfectionism is not part of the established CBT-I curriculum. However, in light of the aforementioned findings, we would argue that those who do not adhere to CBT-I who present with high perfectionism scores may benefit from a modified CBT-I. Therefore, we propose that future research may investigate whether a modified CBT-I curriculum that takes perfectionism into account may increase treatment success.


All authors have seen and approved the manuscript. The authors report no conflicts of interest.


Johann AF, Riemann D, Spiegelhalder K. Does perfectionism increase the risk for dropout from cognitive behavioral therapy for insomnia? J Clin Sleep Med. 2018;14(3):487–488.



Akram U. Objective sleep and personality. J Clin Sleep Med. 2018;14(3):485–486


Ong JC, Gracy FK, Manber R. Who is at risk for dropout from group cognitive-behavior therapy for insomnia? J Psychosom Res. 2008;64(4):419–425. [PubMed Central][PubMed]


Riemann D, Baum E, Cohrs S, et al. S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen: Kapitel ”Insomnie bei Erwachsenen“ (AWMFRegisternummer 063-003), Update 2016. Somnologie. 2017;21(1):2–44


Vgontzas AN, Fernandez-Mendoza J, Liao D, Bixler EO. Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder. Sleep Med Rev. 2013;17(4):241–254. [PubMed Central][PubMed]


Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015;38(6):843–844. [PubMed Central][PubMed]