Insomnia, Pain, and Pain-Related Dysfunctional Beliefs about Sleep among Patients with Cancer

Seockhoon Chung; Soobeen Lee; Mohd. Ashik Shahrier; Saebom Jeon

doi:10.4143/crt.2025.372

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Original Article Insomnia, Pain, and Pain-Related Dysfunctional Beliefs about Sleep among Patients with Cancer: Seockhoon Chung^1,2, Soobeen Lee³, Mohd. Ashik Shahrier⁴, Saebom Jeon⁵; DOI: https://doi.org/10.4143/crt.2025.372
Published online: June 25, 2025

¹Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

²Life Care Center for Cancer Patient, Asan Medical Center Cancer Institute, Seoul, Korea

³University of Ulsan College of Medicine, Seoul, Korea

⁴Department of Psychology, Faculty of Biological Sciences, University of Rajshahi, Bangladesh

⁵Department of Marketing Bigdata, Mokwon University, Daejeon, Korea

Correspondence: Saebom Jeon, Department of Marketing Bigdata, Mokwon University, Doanbuk-ro 88, Seo-gu, Daejeon 35349, Korea
Tel: 82-42-829-7776 E-mail: alwaysns@mokwon.ac.kr

Co-correspondence: Seockhoon Chung, Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 86 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
Tel: 82-2-3010-3411 E-mail: schung@amc.seoul.kr

• Received: April 1, 2025 • Accepted: June 24, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

Purpose
We explored the reliability and validity of the Pain-related Beliefs and Attitudes about Sleep (PBAS) scale among patients with cancer. Further, we compared the usability of the PBAS scale with that of the Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14 (C-DBAS-14) among patients with cancer.
Materials and Methods
The medical records of 252 patients with cancer who visited the sleep clinic from August 1, 2023 to June 30, 2024 were retrospectively analyzed. The responses of the enrolled patients to the PBAS, C-DBAS-14, Insomnia Severity Index (ISI), and Numeric Rating Scale of pain were collected.
Results
The internal consistency reliability of the PBAS scale was excellent (Cronbach’s alpha of 0.96). Confirmatory factor analysis showed that the two-factor structure of the PBAS for patients with cancer is a good fit for the model (Comparative Fit Index, 0.99; Tucker-Lewis Index, 0.99; root mean square error of approximation, 0.14; standardized root mean square residual, 0.05). The convergent validity of the Korean version of the PBAS in patients with cancer was good, as indicated by its significant association with pain severity (r=0.63, p < 0.001), C-DBAS-14 (r=0.33, p < 0.001), and ISI (r=0.21, p < 0.01). The PBAS adequately reflected an increase in pain severity and was more effective and appropriate for capturing pain-related dysfunctional sleep beliefs than the C-DBAS-14.
Conclusion
The Korean version of the PBAS showed high reliability and validity in patients with cancer, and applicability across cancer types and cancer-related beliefs.
Key words: Sleep initiation and maintenance disorders, Sleep, Pain, Cognition, Neoplasms

Introduction

Patients with cancer may experience psychological distress during diagnosis and treatment [1]. They may develop depression, anxiety, and insomnia, which is one of the most common symptoms of psychiatric disorders [2]. Various factors, such as psychological stress, physical symptoms, chemotherapeutic modalities, surgical procedures, and steroid use, may influence insomnia in patients with cancer [3]. When sleep disturbances occur, patients may believe that this will negatively affect their physical health or cancer status. Many patients hold dysfunctional beliefs about sleep, such as the idea that their sleep disturbance will impair immune function or contribute to cancer recurrence or metastasis [4]. These beliefs may exacerbate sleep disturbance.

Pain is one of the physical symptoms that affects sleep disturbance [5]. The relationship between pain and insomnia is reportedly bidirectional [6]. Chronic pain can influence sleep disturbance [7], and conversely, insomnia is associated with an increased risk of developing pain and a hyperalgesic state [8]. Therefore, reducing pain alone may not improve sleep disturbance in patients with chronic pain. A study has shown that Cognitive Behavioral Therapy for Insomnia improves sleep disturbance regardless of the pain intensity reduction [9].

In clinical practice, many patients with pain and sleep disturbance often attribute their sleep problems directly to the pain, believing that their sleep will not improve without alleviating the pain [10]. These dysfunctional beliefs may worsen sleep disturbance. Dysfunctional beliefs about sleep refer to distorted or unrealistic thoughts and attitudes that can both cause and sustain insomnia [11]. These beliefs typically include exaggerated worries about the effects of not getting enough sleep, rigid and unattainable standards for how much sleep is necessary, and a sense of powerlessness or lack of control over one’s sleep. The 30-item Dysfunctional Beliefs and Attitudes about Sleep (DBAS) [12] and its abbreviated 16-item version, the DBAS-16 [13], are the commonly used rating scales to measure sleep-related dysfunctional thoughts. However, the DBAS does not include items related to pain.

Patients with cancer often experience severe pain. Previous studies have reported that 44.5% of patients experience pain of any degree, and 30.6% experience moderate or severe pain [14,15]. Nociceptive or neuropathic pain, such as metastatic bone pain, chemotherapy-induced peripheral neuropathy, or visceral pain, can disturb sleep in these patients. Dysfunctional beliefs about sleep may affect sleep disturbance or psychiatric symptoms in patients with cancer. Previous studies have shown that dysfunctional beliefs about sleep may influence fear of disease progression [16] and sleep quality [17]. The DBAS-16 is a popular rating scale designed to measure an individual’s dysfunctional beliefs about sleep, but it is not specific to cancer. To address the lack of cancer-related items in the DBAS, the 14-item Cancer-related Dysfunctional Beliefs and Attitudes about Sleep (C-DBAS-14) [18] was developed by combining the DBAS-16 with a 2-item Cancer-related Dysfunctional Beliefs about Sleep (C-DBS) scale [4]. However, the C-DBAS-14 also does not include items specific to pain experienced by patients with cancer.

Thus, to assess pain-related dysfunctional beliefs about sleep in individuals with chronic pain, the 10-item Pain-related Beliefs and Attitudes about Sleep (PBAS) scale [14] was developed. The Korean version of the PBAS was validated in patients with chronic pain at the Pain Clinic in Asan Medical Center [15]. However, the reliability and validity of the PBAS among patients with cancer have not been reported yet. In this study, we aimed to explore the reliability and validity of the PBAS scale in patients with cancer. Additionally, we compared the usability of the PBAS scale with that of the C-DBAS-14, a cancer-specific rating scale for sleep-related dysfunctional thoughts in patients with cancer.

Materials and Methods

1. Participants and procedure

We retrospectively analyzed the medical records of pati-ents with cancer and collected their responses to the PBAS scale. The study enrolled 252 patients who visited the Sleep Clinic for cancer patients at Asan Medical Center, Seoul, Korea, for the first time between August 1, 2023, and June 30, 2024. Patients were routinely asked to respond to the selected scales to assess their psychological distress at the first visit, and information on their age, sex, type, and stage of cancer, current treatment, and responses to the rating scales were collected. Patients aged between 18 and 79 years were included. Patients who (1) could not move independently, (2) had cognitive impairment, (3) had delirium or psychosis, (4) could not complete the self-rating scales, or (5) had communication difficulties were excluded.

2. Measures

1) Pain-related Beliefs and Attitudes about Sleep (PBAS)

The PBAS is a self-report rating scale designed to measure patients’ beliefs about the interaction between pain and sleep [19]. It consists of 10 items, each scored between 0 (“strongly disagree”) and 10 (“strongly agree”). A higher total score, calculated as the average score of all 10 items, indicates more rigid beliefs that pain is intrinsically linked with sleep disturbance. We translated the PBAS scale into Korean using the translation and back-translation methods and examined its reliability and validity among patients with chronic pain [20]. In this study, we applied the Korean version of the scale to patients with cancer.

2) Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14 (C-DBAS-14)

The C-DBAS-14 is a scale that measures cancer-related dysfunctional beliefs and attitudes about sleep [18]. It is a composite scale derived from the DBAS-16 [13] and C-DBS [4], containing 14 items scored from 0 (“strongly disagree”) to 10 (“strongly agree”). A higher total score, calculated by averaging the scores of all 14 items, reflects a higher level of dysfunctional beliefs about sleep in relation to cancer. We used the Korean version of the C-DBAS-14, which had a Cronbach’s alpha of 0.877 in this study.

3) Insomnia Severity Index (ISI)

The ISI is a seven-item scale used to assess the insomnia severity [21]. Each item is scored on a 5-point Likert scale. A higher total score, derived by summing all seven items, indicates greater insomnia severity. We used the Korean version in this study [22], with a Cronbach’s alpha of 0.876 for the study sample.

4) Numeric Rating Scale for pain

Pain severity was assessed using a single-item numeric rating scale. Patients were asked to rate their pain from 0 (“no pain”) to 10 (“the worst pain imaginable”) [23] with the following prompt: “On a scale of 0 to 10, with 0 being no pain at all and 10 being the worst pain imaginable, how would you rate your pain?”

3. Statistical analyses

The psychometric properties of the Korean version of the PBAS for patients with cancer were assessed using Classical Test Theory (CTT) and modern psychometric methods. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize the demographic characteristics of the participants. Data normality was evaluated using skewness and kurtosis, with values of < 2 for skewness and < 7 for kurtosis considered acceptable [24]. Under the CTT approach, average inter-item correlations, corrected item-total correlations, Cronbach’s alpha (acceptable value ≥ 0.70 [25]), and confirmatory factor analysis (CFA) were conducted to assess the psychometric properties of the PBAS in the Korean context. CFA factor loadings were used to calculate the average variance extracted (AVE; acceptable value ≥ 0.50) [26] and composite reliability (acceptable coefficient ≥ 0.70) [26]. The structural validity of the predefined two-factor model from the original PBAS validation was tested through CFA using the current sample of patients with cancer. Sampling adequacy and data suitability were checked using the Kaiser-Meyer-Olkin (KMO) index (> 0.60) [27] and Bartlett’s test of sphericity (p < 0.001), respectively [27]. During CFA, model fit was evaluated using several indices, including the Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI; both ≥ 0.90), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR; ≤ 0.08). The convergent validity of the Korean version of the PBAS was assessed by its association with pain severity and other pre-existing rating scales, including the C-DBAS-14 and ISI. Data were processed and analyzed using IBM SPSS Statistics for Windows ver. 26.0 (IBM Corp.) and RStudio ver. 2023.12.1.402.

Results

1. Reliability and validity of the PBAS in patients with cancer

The demographic characteristics of the study participants are summarized in Table 1. Among the 252 participants, 192 (76.2%) were females, and 215 (85.3%) were married, with a mean age of 56.4±12.3 years. Nearly 90% of the patients had solid organ cancer, with the most common diagnosis being breast cancer (52.9%), followed by hepatobiliary and pancreatic cancer (13.7%), gastroesophageal cancer (9.3%), pulmonary cancer (8.8%), gynecologic cancer (4.8%), colorectal and intestinal cancer (3.1%), prostate cancer (2.2%), and head and neck cancer (1.8%). The mean scores and standard deviations of the items of the Korean version of the PBAS for patients with cancer ranged from 2.50 (standard deviation [SD], 2.98; item 3) to 3.53 (SD, 3.58; item 6) (Table 2). The skewness and kurtosis values for all items were within the acceptable ranges, confirming the normality of the data.

Item-level psychometric analysis of the Korean PBAS for patients with cancer (Table 2) showed that the corrected item-total correlations ranged from 0.73 (item 1) to 0.86 (item 5). The internal consistency of the scale was excellent, with Cronbach’s alpha of 0.96. The mean inter-item correlation was 0.71, and the composite reliability (0.98) and AVE (0.83) were all within the recommended values.

To assess the structural validity of the predefined two-factor model of the PBAS for patients with cancer in the Korean context, CFA was conducted. Before CFA, the sampling adequacy was confirmed with a KMO value of 0.93, and Bartlett’s test of sphericity yielded a χ²=2,683.74 (p < 0.001), supporting the suitability of the data. The two-factor model from the original PBAS validation demonstrated a good fit for the current data, with the following indices: χ²/df, 5.82; CFI, 0.99; TLI, 0.99; RMSEA, 0.14; and SRMR, 0.05. The CFA factor loadings for factor 1 (pain as the primary cause of insomnia) ranged from 0.83 to 0.96, while they ranged from 0.89 to 0.94 for factor 2 (inevitable consequences of insomnia on pain and coping) (Table 2).

The convergent validity of the Korean version of the PBAS for patients with cancer was evaluated through its associations with the other established rating scales (Table 3). The PBAS significantly correlated with pain severity (r=0.63, p < 0.001), C-DBAS-14 (r=0.33, p < 0.001), and ISI (r=0.21, p < 0.01), suggesting that higher levels of PBAS are associated with greater pain severity, more dysfunctional cancer-related sleep beliefs, and more severe insomnia symptoms.

2. Comparison of the PBAS and C-DBAS-14 among patients with cancer

While the reliability and validity of the PBAS have been demonstrated, including its convergent validity with the C-DBAS-14, its effectiveness in measuring dysfunctional beliefs and attitudes about sleep across different cancer types warrants consideration. Given the variability in pain severity across different cancer types, we compared the distributional characteristics and clinical utility of the PBAS with the C-DBAS-14.

Exploratory comparisons of the PBAS and C-DBAS-14 scores across cancer types are depicted in Figs. 1 and 2, highlighting the differences and variability across cancer types. These figures provide insight into how pain-related and sleep-related beliefs and attitudes vary according to the cancer type and related symptomatology.

Fig. 1 shows that the ISI, pain, PBAS, and C-DBAS-14 scores differed by cancer type. Patients with prostate cancer reported the highest scores on the ISI, pain, C-DBAS-14, and PBAS, indicating stronger perceived pain, insomnia, and dysfunctional beliefs about sleep. In contrast, patients with gynecologic cancer had lower scores, reflecting milder symptoms and dysfunctional sleep beliefs. These differences suggest that both pain-specific and cancer-specific beliefs about sleep disturbance vary according to the cancer type and associated symptoms. Cancer-specific factors, such as the symptom burden or treatment side effects, likely contribute to these differences, indicating that sleep problems may need to be addressed with a cancer-specific approach.

Additionally, certain cancer types, such as prostate and breast cancer, displayed consistently high or low scores on both the PBAS and C-DBAS-14, suggesting a general predisposition toward dysfunctional sleep beliefs related to the pain severity and perceived impact of cancer. However, discrepancies were observed among other cancer types. For example, patients with gastroesophageal and intestinal cancer had low scores on the PBAS, suggesting lower pain levels, but higher scores on the C-DBAS-14 and ISI, indicating that their sleep-related dysfunctional beliefs and insomnia were more closely related to cancer-specific factors (e.g., nausea, reflux) or treatment side effects. Conversely, patients with head and neck cancer exhibited higher PBAS scores in line with the severe pain levels despite lower C-DBAS-14 scores, suggesting that the PBAS more accurately reflects pain-related dysfunctional beliefs in cancers with chronic, severe pain.

In addition, the pain-related scores (pain and PBAS) in Fig. 1 demonstrate greater variability across cancer types compared to the general insomnia scores (ISI and C-DBAS-14). This highlights significant individual differences in pain-related perceptions and beliefs among patients with cancer. This substantial variability in pain-related scores was observed consistently across most cancer types, irrespective of the pain severity, spanning from cancers with severe pain, such as prostate cancer, to those with milder pain, such as gastroesophageal and intestinal cancers. These findings highlight the importance of considering the type of cancer and the level of pain perceived by the individual patient when addressing sleep disturbances in patients with cancer.

The ridge line plot in Fig. 2 compares the ISI, C-DBAS-14, and PBAS scores across different cancer types stratified by the pain severity (pain ≤ 4 in blue and pain ≥ 5 in orange). The comparison demonstrates that the PBAS is particularly useful in cancers with severe pain (e.g., gynecologic and head and neck cancers), where pain-related dysfunctional beliefs play a significant role. For most cancers, the ISI scores largely overlap between the low- and high-pain groups, suggesting that the ISI score is not significantly related to the level of pain. While the C-DBAS-14 scores tend to shift slightly to the right in patients with higher pain levels (orange-colored), the PBAS scores show notably more pronounced differences between pain levels (pain ≤ 4 in blue and pain ≥ 5 in orange) compared to the other two scales for most cancers. This suggests that the PBAS scores adequately reflect an increase in pain severity. Accordingly, the PBAS is more effective and appropriate for capturing pain-related dysfunctional sleep beliefs. These findings highlight the importance of tailoring assessments and interventions to cancer-specific factors and pain severity.

Discussion

Recent research [20] on PBAS among patients with chronic pain has demonstrated the robust psychometric properties, including excellent reliability and validity, of the Korean version of the PBAS. Consistently, in the current study, we observed that the Korean version of the PBAS has high reliability and validity in patients with cancer. We demonstrated the applicability of this measure across cancer types and cancer-related beliefs. Moreover, the significant association of PBAS with pain severity, C-DBAS, and ISI indicates the validity of this measure in patients with cancer.

The original validation study of the PBAS [19] and its subsequent validation in a Korean sample of patients with chronic pain [20] reported a two-factor structure using CFA. To confirm the predefined two-factor model of the PBAS, we used CFA in this study. Consequently, good model fit indices for the two-factor solution were confirmed for the Korean PBAS in patients with cancer. CFA factor loadings were very good for the two factors (F1: 0.83-0.96, F2: 0.89-0.94). The PBAS total score, as well as the two factors independently, had significantly positive associations with other relevant rating scales such as pain severity, ISI, and C-DBAS-14. Moreover, the PBAS demonstrated good internal consistency reliability (Cronbach’s alpha=0.96) in patients with cancer. Based on the satisfactory reliability and validity findings, the Korean version of the PBAS can be effectively used for measuring sleep disturbances arising from pain-related cognitions and attitudes among patients with cancer.

For further validation of the PBAS in patients with cancer, we determined the clinical utility of this measure across varying levels of pain depending on the cancer type, which influences beliefs and attitudes about sleep dysfunctions. To this end, our findings revealed that the joint effects of cancer-specific and pain-specific beliefs about sleep disturbances were consistent in patients with prostate and breast cancer. However, for other cancer types, the differences between cancer-specific factors and pain-specific approaches to sleep problems led us to explore the unique contribution of pain- and cancer-specific approaches to sleep dysfunction. Accordingly, it was observed (Fig. 1) that low pain severity, lower pain-related beliefs (PBAS), and higher cancer-specific dysfunctional beliefs (C-DBAS-14) contributed to sleep dysfunction in patients with gastroesophageal and intestinal cancer. In contrast, high pain severity scores, higher pain-related beliefs (PBAS), and lower cancer-specific symptoms (C-DBAS-14) resulted in dysfunctional sleep cognitions among patients with head and neck, and gynecologic cancers. These findings suggest that depending on the perceived pain symptoms as well as the pain-related beliefs across different cancer types, PBAS can better assess the sleep disturbances resulting from either pain-specific or cancer-specific factors and, thereby, facilitate targeted interventions for dysfunctional sleep cognitions based on the cancer type. As shown in Fig. 2, PBAS scores can differentiate among pain levels in most cancers compared to the other scales, suggesting that the scale effectively reflects varying levels of pain severity across cancer types and captures pain-related dysfunctional beliefs about sleep.

This study has certain limitations. First, the retrospective, single-center nature of the study may limit its generalizability. We collected data from a specially designed sleep clinic for patients with cancer, and this may have led to a selection bias. The patients were referred for significant sleep problems, possibly skewing the sample toward those with more severe insomnia or complex cases. Our findings might not represent all patients with cancer who experience insomnia. In addition, psychological distress was measured using self-reported rating scales rather than structured interview tools, which may have led to bias. Second, most patients who participated in the study were diagnosed with either psychiatric disorders or sleep disorders. Psychiatric problems or sleep disturbances may influence the severity of pain. Thus, we need to consider the possibility of selection bias in this study, as the psychological distress of study participants might have been higher than that of non-participants. Furthermore, psychiatric symptoms such as depression or anxiety might influence the association between insomnia, pain, and dysfunctional beliefs about sleep among patients with cancer. In this study, we did not measure the depression or anxiety symptoms, and this may be one of the limitations. However, the main objective of this study was to explore the reliability and validity of the PBAS among patients with cancer. In our next study, we aim to explore whether the association between insomnia, pain, and dysfunctional beliefs about sleep is maintained even after excluding the mediating effect of depression and anxiety. Third, because our study was cross-sectional, it was not possible to determine whether pain-related beliefs contribute to the development of insomnia as a consequence of experiencing both pain and insomnia. These factors influence each other in a reciprocal manner. Longitudinal studies are required to clarify the direction of these relationships and establish causality. Fourth, in our study, patients with breast cancer accounted for half of the solid tumor cases, with women comprising three-quarters of the sample. This demographic imbalance may introduce potential bias that can affect the findings. To minimize potential bias, we assessed the PBAS and C-DBAS-14 scores within each specific cancer group. Fifth, despite the description of scale scores across different cancer types, we did not perform statistical comparisons between these groups. This was because of the relatively small sample size within each cancer type subgroup, which limited statistical power and raised concerns about multiple testing. Furthermore, pain experiences among patients with cancer are highly individualized and can be influenced by various factors such as tumor location, disease stage, and specific treatment modalities, which were not fully controlled for in our analysis. Consequently, our findings may not capture the nuanced differences in pain-related dysfunctional beliefs that could exist between cancer types. Future studies with larger and more diverse samples and more detailed clinical information are required to clarify the impact of cancer type and treatment characteristics on pain-related beliefs.

In conclusion, the Korean version of the PBAS is a reliable and valid rating scale that can measure pain-related dysfunctional beliefs about sleep among patients with cancer and has good reliability and validity. Furthermore, the PBAS was more useful than the C-DBAS-14 with regard to dysfunctional beliefs about sleep specific to pain severity among patients with cancer.

NOTES

Ethical Statement

The study protocol was approved by the Asan Medical Center Institutional Review Board (2024-1085). Obtaining written informed consent was waived by the IRB.

Author Contributions

Conceived and designed the analysis: Chung S, Lee S, Shahrier MA, Jeon S.

Collected the data: Chung S.

Contributed data or analysis tools: Chung S, Lee S, Shahrier MA, Jeon S.

Performed the analysis: Chung S, Lee S, Shahrier MA, Jeon S.

Wrote the paper: Chung S, Lee S, Shahrier MA, Jeon S.

Conflict of Interest

Conflict of interest relevant to this article was not reported.

Fig. 1.

Scores of the rating scales across cancer types. C-DBAS-14, Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14; ISI, Insomnia Severity Index; PBAS, Pain-related Beliefs and Attitudes about Sleep.

Fig. 2.

Comparison of scores of the rating scales among cancer types based on the pain severity. C-DBAS-14, Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14; ISI, Insomnia Severity Index; PBAS, Pain-related Beliefs and Attitudes about Sleep.

Table 1.

Demographic and clinical characteristics of the participants (n=252)

Variable	Value
Female sex	192 (76.2)
Age (yr)	56.4±12.3
Marital status (married)	215 (85.3)
Cancer type
Solid tumor	227 (90.1)
Breast cancer	120 (52.9)
Hepatobiliary and pancreatic cancer	31 (13.7)
Gastroesophageal cancer	21 (9.3)
Pulmonary cancer	20 (8.8)
Gynecologic cancer	11 (4.8)
Intestinal and colorectal cancer	7 (3.1)
Prostate cancer	5 (2.2)
Head and neck cancer	4 (1.8)
Other malignancy	8 (3.5)
Hematologic malignancy	24 (9.5)
Cancer stage (among 194 patients with available data)
Stage 0	19 (9.8)
Stage I, II, III	129 (66.5)
Stage IV	46 (23.7)
Surgery within 3 months	46 (18.3)
Current cancer treatment, presence
Chemotherapy	97 (38.5)
Radiation therapy	13 (5.2)
Anti-hormonal therapy	84 (33.3)
Immunotherapy	30 (11.9)
Psychiatric diagnosis
Insomnia and other sleep disorders	148 (58.7)
Major depressive disorder or adjustment disorder	62 (24.6)
Anxiety disorder or somatic symptom disorder	21 (8.3)
Others (delirium, delusional disorder)	3 (1.2)
None	18 (7.1)
Questionnaires, score
Pain-related Beliefs and Attitudes about Sleep (PBAS)	3.0±2.5
Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14 (C-DBAS-14)	5.1±1.7
Insomnia Severity Index (ISI)	14.6±5.5
Pain Numeric Rating Scale (NRS)	3.4±2.8

Values are presented as number (%) or mean±standard deviation.

Table 2.

Item level properties of the Korean version of the PBAS in patients with cancer (n=252)

Item	Mean	SD	Skewness	Kurtosis	Corrected item-total correlation	Factor loading
Item	Mean	SD	Skewness	Kurtosis	Corrected item-total correlation	F1	F2
Item 1	2.69	3.03	0.82	–0.57	0.73	0.83	-
Item 2	2.90	3.11	0.79	–0.60	0.84	0.96	-
Item 3	2.50	2.98	1.01	–0.10	0.83	0.95	-
Item 4	3.36	3.43	0.61	–1.00	0.83	0.90	-
Item 5	3.13	3.47	0.70	–0.95	0.86	0.93	-
Item 6	3.53	3.58	0.49	–1.24	0.82	-	0.91
Item 7	3.27	3.39	0.61	–0.99	0.81	-	0.91
Item 8	2.92	3.24	0.74	–0.78	0.84	-	0.94
Item 9	3.05	3.33	0.71	–0.91	0.82	-	0.90
Item 10	3.02	3.30	0.71	–0.87	0.83	-	0.89

F1: pain as the primary cause of insomnia; F2: inevitable consequences of insomnia on pain and coping. PBAS, Pain-related Beliefs and Attitudes about Sleep; SD, standard deviation.

Table 3.

Pearson correlation coefficients for all variables among all participants

Variable	Pain-severity	PBAS_total	PBAS_F1	PBAS_F2	C-DBAS-14	ISI
Pain-severity	-
PBAS_total	0.63^**	-
PBAS_F1	0.65^**	0.96^**	-
PBAS_F2	0.57^**	0.96^**	0.85^**	-
C-DBAS-14	0.33^**	0.49^**	0.42^**	0.53^**	-
ISI	0.21^**	0.24^**	0.24^**	0.23^**	0.34^**	-

C-DBAS-14, Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14; ISI, Insomnia Severity Index; PBAS, Pain-related Beliefs and Attitudes about Sleep.

^** p < 0.01.

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Insomnia, Pain, and Pain-Related Dysfunctional Beliefs about Sleep among Patients with Cancer

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Abstract
Introduction
Materials and Methods
Results
Discussion
NOTES
REFERENCES

Insomnia, Pain, and Pain-Related Dysfunctional Beliefs about Sleep among Patients with Cancer

Fig. 1. Scores of the rating scales across cancer types. C-DBAS-14, Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14; ISI, Insomnia Severity Index; PBAS, Pain-related Beliefs and Attitudes about Sleep.

Fig. 2. Comparison of scores of the rating scales among cancer types based on the pain severity. C-DBAS-14, Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14; ISI, Insomnia Severity Index; PBAS, Pain-related Beliefs and Attitudes about Sleep.

Fig. 1.

Fig. 2.

Insomnia, Pain, and Pain-Related Dysfunctional Beliefs about Sleep among Patients with Cancer

Variable	Value
Female sex	192 (76.2)
Age (yr)	56.4±12.3
Marital status (married)	215 (85.3)
Cancer type
Solid tumor	227 (90.1)
Breast cancer	120 (52.9)
Hepatobiliary and pancreatic cancer	31 (13.7)
Gastroesophageal cancer	21 (9.3)
Pulmonary cancer	20 (8.8)
Gynecologic cancer	11 (4.8)
Intestinal and colorectal cancer	7 (3.1)
Prostate cancer	5 (2.2)
Head and neck cancer	4 (1.8)
Other malignancy	8 (3.5)
Hematologic malignancy	24 (9.5)
Cancer stage (among 194 patients with available data)
Stage 0	19 (9.8)
Stage I, II, III	129 (66.5)
Stage IV	46 (23.7)
Surgery within 3 months	46 (18.3)
Current cancer treatment, presence
Chemotherapy	97 (38.5)
Radiation therapy	13 (5.2)
Anti-hormonal therapy	84 (33.3)
Immunotherapy	30 (11.9)
Psychiatric diagnosis
Insomnia and other sleep disorders	148 (58.7)
Major depressive disorder or adjustment disorder	62 (24.6)
Anxiety disorder or somatic symptom disorder	21 (8.3)
Others (delirium, delusional disorder)	3 (1.2)
None	18 (7.1)
Questionnaires, score
Pain-related Beliefs and Attitudes about Sleep (PBAS)	3.0±2.5
Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14 (C-DBAS-14)	5.1±1.7
Insomnia Severity Index (ISI)	14.6±5.5
Pain Numeric Rating Scale (NRS)	3.4±2.8

Item	Mean	SD	Skewness	Kurtosis	Corrected item-total correlation	Factor loading
Item	Mean	SD	Skewness	Kurtosis	Corrected item-total correlation	F1	F2
Item 1	2.69	3.03	0.82	–0.57	0.73	0.83	-
Item 2	2.90	3.11	0.79	–0.60	0.84	0.96	-
Item 3	2.50	2.98	1.01	–0.10	0.83	0.95	-
Item 4	3.36	3.43	0.61	–1.00	0.83	0.90	-
Item 5	3.13	3.47	0.70	–0.95	0.86	0.93	-
Item 6	3.53	3.58	0.49	–1.24	0.82	-	0.91
Item 7	3.27	3.39	0.61	–0.99	0.81	-	0.91
Item 8	2.92	3.24	0.74	–0.78	0.84	-	0.94
Item 9	3.05	3.33	0.71	–0.91	0.82	-	0.90
Item 10	3.02	3.30	0.71	–0.87	0.83	-	0.89

Variable	Pain-severity	PBAS_total	PBAS_F1	PBAS_F2	C-DBAS-14	ISI
Pain-severity	-
PBAS_total	0.63^**	-
PBAS_F1	0.65^**	0.96^**	-
PBAS_F2	0.57^**	0.96^**	0.85^**	-
C-DBAS-14	0.33^**	0.49^**	0.42^**	0.53^**	-
ISI	0.21^**	0.24^**	0.24^**	0.23^**	0.34^**	-

Table 1. Demographic and clinical characteristics of the participants (n=252)

Values are presented as number (%) or mean±standard deviation.

Table 2. Item level properties of the Korean version of the PBAS in patients with cancer (n=252)

F1: pain as the primary cause of insomnia; F2: inevitable consequences of insomnia on pain and coping. PBAS, Pain-related Beliefs and Attitudes about Sleep; SD, standard deviation.

Table 3. Pearson correlation coefficients for all variables among all participants

C-DBAS-14, Cancer-related Dysfunctional Beliefs and Attitudes about Sleep-14; ISI, Insomnia Severity Index; PBAS, Pain-related Beliefs and Attitudes about Sleep.

p < 0.01.