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The Impact of Level of Personality Organization and Somatization on Psychological Distress, Worrying, and Coping among Patients with Sleep Disorders 


Elisabeth H.M. Eurelings-Bontekoe, PhD1
Jurrijn A. Koelen, PhD2
Monique Thijssen, MSc3
Peter Benjamin de Ridder, MSc1
Gerard Kerkhof, PhD4


1 Institute of Psychological Research, Clinical Psychology Unit, University of Leiden, The Netherlands.
2 University of Leuven, Belgium 
3 SEIN Sleep Center Zwolle, the Netherlands
4 Faculty of Social and Behavioral Sciences, University of Amsterdam, The Netherlands



Institution at which the work was performed: Sleep Disorders Center, Medisch Centrum Haaglanden, The Hague, The Netherlands
Financial Support: None.
Conflict of Interest: None.
Correspondence: Prof. Dr. E.H.M. Eurelings-Bontekoe,
Department of Clinical and Health Psychology,
University of Leiden, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands.
Phone: 0031715273738; Email: HYPERLINK "mailto:eureling@fsw.leidenuniv.nl"eureling@fsw.leidenuniv.nl Abstract
Study background: Sleep disorders have a significant impact on daily functioning and show a high degree of overlap with mental disorders and other kinds of mental distress, such as impaired coping and worrying. More insight into factors influencing mental distress in patients with sleep disorders is needed. Methods: Two transdiagnostic factors, i.e., level of personality organization and somatization, and their impact on psychological distress, worrying, and coping was examined among 259 patients with sleep disorders. Results: Patients with the most severe structural personality pathology, i.e., with psychotic personality organization, showed the highest levels of symptoms, worrying and passive coping in comparison with patients with borderline and with neurotic personality organization. However, sleep-disordered patients with psychotic personality organization who use somatization as affect regulation reported less psychological distress, worrying and passive coping relative to psychotic personality organization patients without this affect regulation mechanism. Conclusions: Level of personality organization is associated with severity of symptoms, worrying, and coping in patients with sleep disorders. Affect regulation through somatization has a favorable impact on the most vulnerable patients with sleep disorders. It is suggested that the impact of somatization in patients with sleep disorders deserves more attention in future research.

Keywords
Personality organization; structural personality pathology; somatization; affect regulation; sleep disorders
Introduction
Sleep disorders refer to any condition that interferes with normal sleep patterns. Sleep disorders affect the amount of daily sleep, the quality or timing of sleep, or certain behaviors or physical conditions associated with sleep [1]. The International Classification of Sleep Disorders (ICSD) [2] has proposed three main categories for classification: (a) Dyssomnias (including insomnia, hypersomnia, sleep related movement disorders, circadian rhythm sleep disorders, and sleep related breathing disorders); (b) Parasomnias (including sleep terror, nightmares, sleep walking and sleep talking), and (c) Sleep disorders associated with mental, neurologic, or other medical conditions. The most commonly observed sleep disorder is primary insomnia affecting approximately 10-15% of the general population [3,4], followed by sleep apnea, and then restless legs syndrome [5]. Sleep disorders are common in at least 10% of the community suffering from a sleep disorder that is clinically significant and of public health importance. Sleep disorders have a significant effect on daily functioning and show a high degree of overlap with mental disorders [4,6,7]. 

Impact of sleep disorders: worrying and coping
  	 Sleep disorders have a profound impact on cognitive resources of the patient. Besides actual sleep disturbances, individuals suffering from these disorders often complain that unpleasant intrusive thoughts and pathological worry prevents them from getting a reasonable amount of sleep. Lichstein and Rosenthal [8], for example, examined 296 patients diagnosed with insomnia and found that intrusive cognitions more so than somatic factors can be considered as the main determinant of sleep disturbance. In addition, Borkovec [9] in his review on literature devoted to personality characteristics of patients suffering from insomnia, described these patients as anxious and obsessively worrisome. Not surprisingly, insomnia often co-occurs with generalized anxiety disorder (GAD), a disorder marked by pathological worry [10], and patients with insomnia often catastrophize about the consequences of their sleep difficulties [11,12]. 
Sleep disturbances may also have an impact on the way individuals cope with stress, such as minor daily hassles. Morin [11] found no difference in the frequency of minor daily hassles between good sleepers and insomnia patients, but these groups differed regarding the perceived impact of these minor stressors. In comparison with good sleepers, insomniacs tended to perceive their lives as more stressful and reported higher levels of bedtime arousal. 
The type of coping strategy used can act as an important factor moderating the relationship between stress and sleep. According to Lazarus and Folkman [13] there are two types of coping strategies, emotion-focused (EFC) and problem-focused coping (PFC). Emotion-focused coping is usually established when there is an appraisal that the threatening environmental conditions are beyond control. On the other hand, problem-focused coping is implemented when these conditions are appraised as manageable. In a sample of 36 students, Sadeh, Keinan and Daon [14] assessed sleep by using actigraphy and daily logs during high-stress and low-stress periods. The findings confirmed the hypotheses: Changes in sleep were significantly moderated by the coping strategies used. In high-stress periods, individuals with high EFC shortened their sleep and their perceived sleep quality decreased, whereas individuals with low EFC extended their amount of sleep, and also experienced improved sleep quality [14]. Patients with insomnia tend to rely more often on EFC strategies [13]. These findings support earlier research suggesting that EFC is an ineffective coping strategy, at least in stressful situations in which the individual still has some level of control [15].

Comorbidity with other psychiatric disorders
   	Sleep disorders, in particular insomnia, are common in a range of psychiatric disorders, including depression (MDD), post-traumatic stress disorders (PTSD), schizophrenia, and borderline personality disorder (BPD). For example, Pigeon and Perlis [6] found that insomnia is a risk factor for new onset and recurrent MDD. Both MDD and insomnia are highly prevalent in the general population and are often comorbid in all age ranges, particularly in the elderly, and in women [4]. Also, several studies suggest that insomnia is highly prevalent in PTSD, with rates of insomnia ranging between 60-90% in trauma populations [16,17]. Furthermore, research of Krahn [18] suggests that schizophrenia is commonly associated with insomnia. Polysomnography results revealed an increase in sleep fragmentation, shortened REM latency, and a decrease in slow wave sleep. Finally, in a recent review on the link between BPD and sleep impairments, Hafizi [19] showed that this disorder is associated with a broad range of sleep impairments, such as: low sleep quality, short sleep duration, short REM sleep latency, short NREM sleep duration, frequent awakening, increased sleep latency, and long REM sleep duration. In addition, Harty et al. [20] examined subjective reports of sleep problems from 513 jail inmates and concluded that BPD symptoms were significantly associated with sleep problems, even when controlling for depression. In sum, these findings indicate that a number of � often comorbid � psychiatric disorders are strongly associated with disturbed sleep patterns, and therefore this should be considered in the diagnostic process. 

Structural personality pathology
  	 In this paper, we focus on two transdiagnostic features in patients with sleep disorders: level of personality organization and affect regulation through somatization. The majority of research of sleep disorders focuses on its association with discrete psychiatric disorders according to the DSM-IV [21] classification. A major problem concerning a categorical, purely descriptive, approach, such as the DSM, is that patients receiving the same diagnosis may have widely different underlying characteristics [22,23]. A transdiagnostic approach, on the other hand, describes underlying (etiopathogenetic) features that cut across discrete diagnostic entities. One such approach is the structural approach to personality pathology [24]. Within this approach, several levels of personality functioning are distinguished, often referred to as levels of �personality organization� (PO). The concept of PO denotes a relative stable personality structure that consists of various inner representations of early relationships of the self with significant others [25]. Usually, three levels of PO are described: the psychotic (PPO), the borderline (BPO), and the neurotic (NPO) levels [25,26]. In patients with a psychotic personality organization, both reality testing and boundaries between the self and other are severely impaired. The borderline personality organization is mainly associated with poorly integrated representations of self and others, poor affect regulation, and the use of primitive defences, such as splitting. In the neurotic personality organization (NPO), both identity and moral values are well integrated and the patient is able to reflect on his inner conflicts instead of acting them out [26]. Therefore, patients with PPO are assumed to have the highest level of impairment. Indeed, a recent study among patients with 43 chronic pain showed that those with low levels of PO had higher levels of comorbidity on DSM-IV axis I and II than those with high levels of PO [27], indicating that level of PO can be construed as a transdiagnostic factor, parsimoniously accounting for high comorbidity. Given the high degree of comorbidity in sleep disorders, the structural approach also seems relevant for this group of disorders. Moreover, there is increasing evidence that transdiagnostic factors, such as the level of PO, impact the course and outcome of treatment [28]. In this context, assessment of level of PO in both research and clinical practice may help to complement and individualize assessment based on descriptive criteria.

Somatization as an affect regulation mechanism		
Another transdiagnostic feature that is addressed in this study is the degree of somatization. In his seminal contribution, Lipowski [29] defined somatization as �a tendency to experience and communicate psychological distress in the form of somatic symptoms, and to seek medical help for them� (p.294). This definition is congruent with the multidimensional Minnesota Multiphasic Persoanlity Inventroy (MMPI) concept of somatization, which includes the Hysteria subscale. As such, it is considered a mechanism by which psychological tension and negative affects are �translated� into bodily symptoms, which in turn may prevent acting out of these affects [30]. As such, it can be seen as an affect regulation mechanism. A low tendency to somatize may be a complicating factor, suggesting low or absent awareness of bodily sensations, which can be seen as the first level of emotional awareness according to the model of emotional awareness proposed by Lane and Schwartz [31]. Absence of the ability to somatize may result in acting out, and social incompetence [30]. It is not unlikely therefore, that absent bodily awareness impacts psychosocial functioning, whereas the ability to somatize may serve as a buffer that safeguards mental functioning and integrity in vulnerable patients. 
There is some suggestive evidence for this. Koelen et al. [32], for example, examined the impact of a high tendency to somatize in a sample of patients with severe somatoform disorder compared to a psychiatric control group to assess whether this may have a buffering impact on mental functioning. They used the Social Cognition and Object Relations Scale (SCORS) [33], a system to score narratives produced on Thematic Apperception Test [34] pictures with regard to complexity of mental representations of self and others, and understanding of social causality. Results indicated that narratives of both subjects in the somatoform sample as well as in the control sample had relatively low levels of inner complexity, and understanding of social causality. However, SFD patients with PPO had higher levels of mental complexity and social causality than the PPO control subjects. The authors interpret this finding as a potentially buffering impact of somatization on mental functioning in the most vulnerable group of patients [32].  
This paper addresses somatization and its impact on mental functioning in patients with sleep disorders. Importantly, sleep disorders are highly common among patients with high levels of somatization, for example among those with somatoform disorder [35,36]. It is therefore of great importance for both assessment and treatment of patients with sleep disorders to examine the impact of both high and low tendencies to somatize. 

Study objectives and hypotheses
  	 The main aim of this study was to assess the association between severity of structural personality pathology (level of PO) and severity of psychological distress, amount of worrying and coping among patients with sleep disorders. In addition, the role of somatization as an affect regulator will be investigated. To the best of our knowledge, this is the first study to address the level of PO among patients with sleep disorders.
We hypothesized that of all patients those with PPO, who are assumed to suffer from the highest impairments, would show the highest level of distress, worrying and passive coping. Second, we hypothesized that a high tendency to somatize, i.e. to convert psychological tension into somatic complaints, would have a favorable effect on the severity of psychological distress, worrying and passive coping, especially among those with PPO.

Materials and Methods

Participants 
The sample consisted of 259 participants who all participated in a study about sleep pathology. See table 1 for the main characteristics of the patients. ICSD sleep disorder diagnoses were available for 246 patients (95%). Diagnosis of sleep disorder was postponed in 3 patients (1.2%), and 10 patients (3.9%) did not receive a sleep disorder diagnosis. 

[Insert table 1 here]

Measurement
Personality organization: Personality organization (PO) was assessed using the theory driven profile interpretation of the Dutch Short Form of the MMPI (DSFM) [37]. The Dutch short form of the MMPI is an 83-item questionnaire, which measures the following five dimensions: Negativism (22 items), Somatization (20 items), Shyness (15 items), Psychopathology (13 items) and Extraversion (13 items). All 83 items can be answered with �agree� (2) to �disagree� (0). Luteijn and Kok [38] report � coefficients of the five scales, based on seven clinical groups: for Negativism � ranged between .76 and .83, for Somatization � ranged between .71 and .88, for Shyness the range was .82-.92, for Severe Psychopathology: .61-.81 and for Extraversion the range was .66-.81. Eurelings-Bontekoe, Van Dam, Luyten, et al. [39] found comparable internal consistency coefficients in a study among 576 psychiatric outpatients.
Three out of five DSFM dimensions are used for structural diagnosis: Severe Psychopathology as a measure of anxiety tolerance/psychoticism; Shyness as a measure of constraint and impulse control, and Negativism as a measure of negative affectivity/anger [40]. These dimensions of the DSFM are not interpreted in isolation, but the raw scores on the dimensions Severe Psychopathology, Shyness and Negativism are combined a priori in a theory driven way into specific profiles based on psychodynamic theory [37]. In structural terms, subgroups of patients are being distinguished on the basis of anxiety tolerance and level of control, two nonspecific markers of ego weakness and/or ego strength. Negativism is an important dimension for distinguishing between patients with PPO (low levels of Negativism) and (psychotic) BPO (high levels of Negativism). Several studies have provided support for the ability of the theory driven profile interpretation of the DSFM to capture features of structural personality organization [39-43]. 

Affect regulation through somatization: To measure affect regulation through somatization, the DSFM �Somatization� subscale (20 items) was used. This subscale measures the amount and degree of experienced bodily symptoms, and hence, the ability to subjectively report, and be aware of bodily sensations. In line with the shown relevance of studying combinations of scales instead of using single scales [37], we expressed present/absent affect regulation through somatization as the relative position of scores on the subscale Somatisation to that on the subscale Severe Psychopathology [30]. In other words, scores on Somatization are interpreted in the context of scores on Severe Psychopathology. If the score on Severe Psychopathology is high and the score on Somatization is above average, affect regulation through somatization is considered insufficient. In this case, the body insufficiently channels the reported levels of anxiety and anger. However, if an above average score on Somatization is observed in a patient with a low score on Severe Psychopathology, affect regulation through somatization is considered present. Note that the score on Somatization is equally high in both examples, but that the level of Severe Psychopathology differs. The classification of present/absent affect regulation through somatization is thus based on the combination of raw scores for Severe Psychopathology and for Somatization.  
The cut offs for the classification scheme are based on the distribution of scores in the psychiatric norm group. Affect regulation through somatization is considered absent if the score on Severe Psychopathology is low (d" 3), and the score on Somatization is low as well (d" 7); if the score on Severe Psychopathology is average (e" 4 but d" 7) and the score on Somatization is below average (d" 11) or if the score on Severe Psychopathology is high to very high (e" 8) and the score on Somatization is above average and lower (d" 23). Affect regulation through somatization is considered present if the score on Severe Psychopathology is low (d" 3) and the score on Somatization is average and higher (e" 12), if the score on Severe Psychopathology is average (e" 4 but d" 7) and the score on Somatization is above average and higher (e" 19) or if the score on Severe Psychopathology is high to very high scores (e" 8) and the score on Somatization is also high to very high (e" 24). 

Symptomatic distress: Symptomatic distress was assessed using the Symptom Checklist (SCL-90) [44]. The SCL-90 is an internationally applied 90-item self-report measure which assesses eight dimensions of psychological well being: Agoraphobia (7 items, e.g. fear for public and open places), Anxiety (10 items, e.g. generalized anxious mood condition), Depression (16 items, e.g. low self-esteem, low mood and loss of pleasure), Somatic Complaints (12 items, distress about physical symptoms), insufficiency of thoughts and actions (9 items, e.g. thoughts, impulses and feeling pressured), paranoid ideation and interpersonal sensitivity (19 items, distrust toward others), Hostility (6 items, e.g. hostile feelings or actions) and Sleep difficulties (3 items, e.g. not falling asleep). All questions can be answered on a 5-point Likert scale ranging from �not at all� (1) to �very much� (5). The SCL-90 is widely used and has over a thousand independent studies supporting both the validity and reliability. 

Worrying: To assess worrying, we used the Penn State Worry Questionnaire (PSWQ) [45]. The PSWQ is a 16-item self-report questionnaire used to measure worrying, in particular generalization of worrisome thoughts, frequency and intensity of worrying and feelings of control over worrying. Subjects are asked to rate all items on a 5-point Likert scale, ranging from �not at all typical of me� (1) to �very typical of me� (5). Brown [46] examined the PSWQ in a sample of 1200 outpatients, and found strong evidence for a single construct (�excessive worry�) underlying all 16 items of the instrument, thereby underscoring its internal consistency. According to Meyer et al. [45], the PSWQ has a high internal consistency and good test-retest reliability. As expected, the questionnaire correlates with other psychological measures related to worry, and does not correlate with other measures unrelated to worry.

Coping: Coping was assessed using the Utrecht Coping List (UCL) [47]. The UCL is a 47-item self-report questionnaire that is used to determine participants� coping style. Participants are requested to indicate how often they use certain coping behaviors on a 4-point Likert scale, ranging from �rarely if never� (1) to �very often� (4), The UCL consists of seven coping subscales: Active coping (7 items, e.g. thinking about a variety of possible solutions to a problem), Palliative reacting (8 items, e.g. trying to find distraction), Avoidance (8 items, e.g. trying to avoid stressful situations), Seeking social support (6 items, e.g. seeking support from others), Passive coping (7 items, e.g. feelings of not being able to change the stressful situation), Expression of emotions (3 items, e.g. showing frustrations), Comforting thoughts (5 items, e.g. trying to focus on positive thoughts). Literature supports both the reliability and validity of the UCL. Schreurs and Van de Willige [48] found, in a study among Dutch males (n=1493), females (n=712), scholars (n=865) and students (n=55) reasonable to good internal consistencies ranging from .43 to .89. Moreover, according to the test manual [47], the test-retest reliability was reasonably high (r=.45-.85). A study by Schaufeli and Van Dierendonk [49] supported the predictive validity of the UCL. Self-efficacy, negative affect and neuroticism are strongly associated with a passive coping mechanism. On the other hand, coping mechanisms such as active approach and seeking social support correspond with self-efficacy and positive affect. Furthermore, research by Schreurs and Van de Willige [48] found a reasonable degree of the construct validity of the UCL by comparing results on all subscales of the UCL with 23 well-validated tests.

Procedure
All patients who participated in an ambulant polysomnography registration (APSG) study at the Medical Center Haaglanden Sleep Disorders Unit (The Hague, the Netherlands) were asked whether they were willing to participate in this study. Participants received a letter in which they were asked to fill in four questionnaires (DSFM, PSWQ, SCL-90 and UCL) at the location where they received their treatment. The APSG-study lasted for two days. On the first day, participants were asked to fill in the DSFM and the UCL questionnaires on paper. On the second day, participants filled in the SCL-90 and the PSWQ on the computer. 

Statistical Analyses
The design used in this study is a cross-sectional design, with level of PO (NPO, BPO, PPO), and affect regulation through somatization (present/absent) as independent variables. Dependent variables were the sum scores on the PSWQ, the SCL-90 and the seven subscale scores on the UCL. Associations between gender and level of education on the one hand, and level of PO on the other hand, were investigated using chi square analyses. Likewise, we used chi-square analyses to examine the associations between gender and level of education with affect regulation (present/absent). Associations between age on the one hand, and level of PO and affect regulation on the other hand, were investigated with ANOVA. Two-way MANCOVA was utilized to compare the NPO, BPO, and PPO groups with and without affect regulation through somatization on the dependent variables. Significance level was set at p<0.05, two-tailed. Effect sizes (ES) of the MANCOVA were expressed as partial eta squared (�p�). According to conventional criteria an �p� of 0.01 is considered a small ES, an �p� of 0.06 is a medium ES, and an �p� of 0.14 is a large ES [50]. Effect sizes (ES) of differences between two groups were expressed in Cohen s d, with d=-0.15 to d=0.15 considered a negligible, d=0.15 to d=0.40 considered a small ES, d=0.40 to d=0.75 a medium ES, d=0.75 to d=1.10 a large ES, d=1.10 to d=1.45 a very large ES, and d>1.45 a huge ES. All analyses were conducted using SPSS, version 19. 

Results

Influence of demographic variables on the outcome variables
All 259 included patients could be classified using the classification scheme of Eurelings-Bontekoe, Onnink, Williams, et al. [37]. Thirty-eight patients (14.7%) were classified as having NPO, 210 patients (81.1%) were classified with BPO and 11 patients (4.2%) were classified as having PPO. From the initial sample of 259 participants, 210 (81.1%) participants fulfilled our criteria for present/absent affect regulation through somatization. Affect regulation through somatization was present in 146 patients (69.5%); in 64 patients (30.5%) it was absent.
Chi square analyses showed that the three PO groups marginally differed from each other regarding level of education  (�2=20.36, df=12, p=0.06), but the affect regulation groups did not correspond to level of education (�2=4.21, df=6, NS). Analyses of variance showed no association between age and level of PO (F2, 259=0.14, NS) nor between age, and affect regulation (F1, 208=2.62, NS). Gender was equally distributed across all three levels of PO (�2=4.84, df=2, NS). However, chi-square analyses of the association between gender and affect regulation showed a significant effect, in that more females than males (86.0% vs. 58.1%) had present affect regulation through somatization (�2=18.77, df=1, p<0.001). Therefore, gender was used as a covariate in all subsequent analyses.

Personality organization, affect regulation through somatization, worrying and symptomatic distress
A two-way MANCOVA, with level of PO and affect regulation as the independent variables and the sum score of the PSWQ and the SCL-90 as the dependent variables, and gender as covariate, showed a significant main effect of the level of PO (F4, 390=6.89, p<0.001, �p2=0.07). Test of between-subject effects showed that the effect of level of PO on worrying was nonsignificant (F2, 195=2.55, NS, �p2=0.03), whereas level of PO was significantly associated with symptomatic distress (F2, 195=14.23, p<0.001, �p2=0.13). Post-hoc comparisons showed that patients with PPO reported a higher mean score on symptomatic distress (mean=205.63, std.=42.60), compared to patients with BPO (mean=148.01, std.=40.02, and patients with NPO (mean=162.93, std.=45.79). ES of the difference between patients with PPO and BPO expressed in Cohen�s d was 1.44 (very large), ES for the difference between patients with PPO and NPO was 0.84 (large). 
There was no significant multivariate main effect of affect regulation on both worrying and symptomatic distress (F2, 194=0.62, NS, �p2=0.006). However, there was a significant interaction effect of affect regulation and level of PO (F4, 390=3.45, p<0.01, �p2=0.03) on both worrying (F2, 195=3.40, p<0.05, �p2=0.03) and symptomatic distress (F2, 195=6.56, p<0.05, �p2=0.06) (see figures 1 and 2). Post hoc comparisons showed that patients with PPO with affect regulation through somatization reported to worry less (mean= 46.83, std.=12.78) than PPO patients without affect regulation through somatization (mean=62.00, std.=14.14). ES of the difference between the two PPO groups was 1.35 (very large). Moreover, patients with PPO with affect regulation through somatization reported less symptomatic distress (mean=186.00, std.=20.78) than PPO patients without affect regulation through somatization (mean=264.50, std.=36.06). ES was huge (d=3.75).

[Insert figures 1 and 2 here]

Level of personality organization, affect regulation through somatization, and coping
A two-way MANCOVA, with level of PO and affect regulation through somatization (present/absent) as the independent variables and the seven subscale scores of the UCL as the dependent variables, and gender as covariate, showed a significant main effect of level of PO on coping (F14, 356=2.96, p<0.001, �p2=0.10). Tests of between-subject effects showed a significant effect of level of PO on the subscales Active coping (F2, 183=7.72, p<0.05, �p2=0.08), Avoidance (F2, 183=5.91, p<0.05, �p2=0.06), and Passive coping (F2, 183=10.90, p<0.001, �p2=0.11). Patients with PPO scored lower on Active coping (mean=16.14, std.=3.72) compared to patients with BPO (mean=19.83, std.=3.71, d=1.00) who, in turn, showed more active coping than patents with NPO (mean=17.18, std.=3.58, d=0.72). ES for the difference between patients with PPO and NPO was 0.30 (small). Further, patients with PPO and NPO had higher mean scores on Avoidance (mean=18.43, std.=1.90, and mean=18.11, std.=2.56, respectively) than those with BPO (mean=15.81, std.=3.14). ES of the difference between patients with PPO and BPO expressed in Cohen�s d was 0.85 (large), ES for the difference between patients with NPO and BPO was 0.75 (large). The ES of the differences between PPO and NPO patients was negligible (d=0.14). Compared to BPO patients (mean=11.96, std.=3.42), both PPO patients (mean= 15.43, std.=4.83), and NPO patients (mean=14.75, std.=3.05) had higher scores on Passive coping (ESs: d=1.00 and d=0.83, respectively).  The ES of the difference between NPO and PPO patients was small (d=0.20). Taken together, BPO patients in general report to cope more actively with problems and to be less avoidant and passive than both NPO and PPO patients.
There was no significant main effect of affect regulation through somatization (F7, 177=0.94, NS, �p2=0.04). However, the effect of the interaction between level of PO and affect regulation was significant (F14, 356=2.27, p<0.01, �p2=0.08). Univariate analyses showed that this interaction effect was present only for the subscale Passive coping (F2, 183=6.58, p<0.05, �p2=0.08) (see figure 3). Post-hoc comparisons showed that PPO patients with affect regulation through somatization showed a lower mean score for Passive coping (mean=13.20, std.=2.95) than patients with PPO without affect regulation through somatization (mean=21.00, std.=4.24). ES of the difference between the two PPO groups was 2.83 (huge). 

[Insert figure 3 here]

Discussion
The first aim of this study was to investigate the associations between two transdiagnostic factors, i.e., the level of personality organization (PO), and affect regulation through somatization, and their impact on symptomatic distress, worrying, and coping style in patients with sleep disorders. We hypothesised that patients with PPO would show the highest level of psychological distress, worrying and passive coping. The second aim was to examine the impact of affect regulation through somatization at distinct levels of PO. In this context, we hypothesized that a high tendency to somatize would have a favorable effect on the severity of psychological distress, worrying and passive coping among patients with a psychotic level of PO.
As expected, patients with PPO showed the highest level of symptomatic distress relative to patients with BPO or patients with NPO. The results are in line with a growing body of research showing that lower levels of PO are typically associated with higher level of psychopathology [51]. A recent study indicated that normal adults, DSM-IV axis I diagnosed patients, and DSM-IV axis II diagnosed patients could be differentiated with structural personality assessment [52]. As noted in the introduction, another study among 43 patients with chronic pain showed that higher DSM-IV axis I/axis II comorbidity corresponded with lower levels of PO [27]. Contrary to expectations, however, the level of PO was not associated with severity of worrying. Therefore, results suggest that severity of worrying is indeed a pervasive characteristic of all patients with sleep disorders, irrespective of level of structural personality pathology, as shown by Lichstein and Rosenthal [8] and Borkovec [9]. 
With respect to coping, patients with PPO, and those with NPO, scored equally low on active coping and equally high on avoidance and passive coping, whereas patients with BPO reported the highest level of active coping and the lowest level of passive coping, suggesting that BPO patients in general consider themselves as more able to actively cope with stress in an adequate manner than NPO and PPO patients do. These findings coincide with the observation that patients with NPO and PPO are generally more avoidant and introverted than patients with BPO [42,53]. Another possible explanation for this finding might be that BPO patients in general are more prone to externalize than NPO and PPO patients, as previously found [42].  
The second aim was to investigate the role of somatization as an affect regulation mechanism. We hypothesised that especially PPO patients with affect regulation through somatization would report lower levels of psychological distress, worrying and more active coping than PPO patients without this type of affect regulation. Results showed that the tendency to somatize as affect regulation had no effect on the level of psychological distress, worrying and coping across all three levels of PO. However, interaction effects were found showing that patients with the most severe personality pathology, i.e. patients with PPO, with affect regulation through somatization reported less symptomatic distress, worrying and passive coping compared with PPO patients without this affect regulation mechanism. 
This finding is consistent with a previous study, showing that PPO patients with somatoform disorder have a higher level of complexity of inner mental representations and understanding of social causality than PPO patients without somatoform disorder [32]. For patients with PPO, contrary to patients with NPO and BPO, somatic distress may not necessarily correlate with psychological distress. Together, these findings suggest that for the structurally most vulnerable patients, a tendency to somatize may act as a coping mechanism, which might maintain psychological wellbeing. However, more research is needed to clarify the underlying mechanism.
Assessment of level of PO and affect regulation through somatization in both research and clinical practice may help to complement and individualize assessment based on DSM criteria, since patients receiving the same DSM diagnosis may differ with respect to personality dynamics and other etiopathogenetic characteristics [22,23,24]. Treatment purely focused on discrete symptoms may be counterproductive. For example, Eurelings-Bontekoe, Van Dam, Luyten et al. [39] found that psychiatric outpatients with a psychotic PO that remained in cognitive-behavioral group therapy deteriorated at follow-up, showing increased hostility and decreased cognitive coherence after termination of treatment. These findings call for a transdiagnostic approach, in which underlying characteristics in terms of affect regulation and personality are considered. 
Together, the findings of this study indicate that a low level of PO is associated with higher levels of psychopathology and suggest that a tendency to somatize has an affect regulatory function especially in vulnerable PPO patients. The �translation� of psychological distress into bodily symptoms in this subgroup of patients with sleep disorders might motivate these patients to seek social support (in line with the MMPI Hysteria concept, as outlined in the introduction). Therefore, if somatization is present among these patients, it may have to be preserved rather than tackled clinically. Caution is therefore required in the treatment of this vulnerable group of patients with sleep disorders. Perhaps recently modified mentalization-based treatments for patients with somatic complaints may be indicated, because these treatments aim to increase the awareness of the link between physical distress and psychological distress [54,55].  
The results of this study have to be interpreted within the context of several limitations. First, patients with NPO, and more importantly, PPO, were relatively underrepresented in this study, thus affecting statistical power, especially of the interactions studied. Second, all instruments used were self-report instruments, so the findings could in part be due to shared-method variance. It is therefore important to examine somatization from an observer-based perspective in future studies. Third, even though we focused in this study on transdiagnostic mechanisms that allegedly cut across diagnostic categories, the results of this study cannot necessarily be generalized to other groups of patients, without further study. 
In summary, this is the first study about the association between the level of PO and psychopathology among patients with sleep disorders. The results of this study suggest that it is useful to assess the level of PO among patients with sleep disorders and to take into account the role of somatization as an affect regulation mechanism. Considering both the level of PO and the tendency to somatize as transdiagnostic features in these patients might considerably improve treatment outcome by enhancing the match between patient and treatment.

Acknowledgement
None.
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Figure 1: PSWQ interaction of level of personality organization and affect regulation 


Figure 2: SCL-90 interaction of level of personality organization and affect regulation




Figure 3: UCL passive coping interaction with personality organization and affect regulation 	



Table 1 - Characteristics of patients with sleep disorders (N = 259)Age46.6 (13.0)Male151 (58.3)ICSD Diagnosis  Primary insomnia 110 (44.7)  Sleep related breathing disorders 90 (36.6)  Sleep related movement disorders27 (11.0)  Circadian rhythm sleep disorders 11 (4.5)  Hypersomnias 6 (2.4)  Parasomnias 2 (0.8)Body Mass Index26.5 (5.8)Education  Less than college degree8 (3.1)  College degree146 (56.4)  More than college degree105 (40.5)SCL-90  Symptomatic distress151.1 (42.0)PSWQ Worrying45.9 (12.8)UCL  Active coping19.0 (3.8)  Palliative reaction17.7 (3.4)  Avoidance16.3 (3.1)  Social support13.4 (3.6)  Passive coping12.5 (3.6)  Emotion expression6.4 (1.6)  Comforting thoughts12.1 (2.5)Data are presented as n (%) or mean (standard deviation), as appropriate.ICSD, International Classification of Sleep Disorders.SCL-90, Symptom Checklist.PSWQ, Penn State Worry Questionnaire. UCL, Utrecht Coping List.
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