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editor-in-chief David H. Barlow, PhD scientific advisory board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD
Treatments That Work
A Cognitive-Behavioral Therapy Approach
T h e r a p i s t
G u i d e
Jack D. Edinger • Colleen E. Carney
Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With oﬃces in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright © 2008 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Edinger, Jack D. Overcoming insomnia : a cognitive-behavioral therapy approach therapist guide / Jack D. Edinger, Colleen E. Carney. p.; cm. — (Treatmentsthatwork) Includes bibliographical references. ISBN 978-0-19-536589-4 (pbk.: alk. paper) 1. Insomnia—Treatment—Popular works. 2. Cognitive therapy. I. Carney, Colleen. II. Title. III. Series: Treatments that work. [DNLM: 1. Sleep Initiation and Maintenance Disorders—therapy. 2. Cognitive Therapy—methods. WM 188 E23o 2008] RC548.E35 2008 616.8’498206—dc22 2007047486 ISBN 978-0-19-536589-4
Printed in the United States of America on acid-free paper
Stunning developments in health care have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking beneﬁt, but perhaps, inducing harm. Other strategies have been proven eﬀective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world, health care systems, and policy makers have decided that the quality of care should improve, that it should be evidence based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral health care practices and their applicability to individual patients. This new series, TreatmentsThatWork™, is devoted to communicating these exciting new interventions to clinicians on the front lines of practice.
The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating speciﬁc problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging health care system, the growing consensus is that evidencebased practice oﬀers the most responsible course of action for the mental health professional. All behavioral health care clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This therapist guide and the companion workbook for clients address the treatment of insomnia. Over one third of the adult population experiences insomnia at least intermittently and 1 to 2% of the general population suﬀers from primary insomnia (a form of insomnia devoid of secondary causes). Primary insomnia can have severe negative outcomes for the individual and has implications for the health care system. Medication is often prescribed, but can have signiﬁcant side eﬀects. Unlike pharmacological approaches, CBT insomnia intervention has been shown to yield long-term improvements. This guide outlines a safe and eﬀective treatment that targets the behavioral and cognitive components of insomnia. It includes detailed instructions for assessment and troubleshooting. The corresponding client workbook provides educational information and homework forms. Together, they form a complete insomnia treatment package for a variety of client needs. Clinicians will ﬁnd this a welcome addition to their armamentarium. David H. Barlow, Editor-in-Chief,™ TreatmentsThatWork Boston, MA
Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–878. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6
Introductory Information for Therapists Pretreatment Assessment 15
Session 1: Psychoeducational and Behavioral Therapy Components 31 Session 2: Cognitive Therapy Components 49 Follow-Up Sessions 69
Considerations in CBT Delivery: Challenging Patients and Treatment Settings 83 Sleep History Questionnaire References 109 117 97
About the Authors
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Introductory Information for Therapists
Background Information and Purpose of This Program The behavioral component of this treatment manual originally was prepared as an Appendix to the ﬁrst author’s ( JDE) National Institutes of Mental Health funded grant (MH 48187) entitled, “Cognitive-Behavioral Therapy for Treatment of Primary Insomnia.” The cognitive component of this manual was prepared by the second author (CEC) as an Appendix to a grant funded by the National Institute of Nursing Research (NR 010539) entitled “Cognitive-Behavioral Insomnia Treatment in Chronic Fatigue Syndrome.” The primary purpose of this manual is to describe and operationalize the cognitive-behavioral therapy (CBT). However, this manual has been written in such a manner as to provide other investigators and clinicians an understanding of CBT as well as step-by-step instructions for replicating treatment procedures. The speciﬁc treatment procedures presented herein have been derived from various sources. As described in more detail later in this chapter, the CBT protocol represents a “second generation” multicomponent form of therapy that evolved from several decades of cognitive and behavioral insomnia research. This treatment includes selected ﬁrst generation behavioral treatment strategies that have proven reasonably eﬀective as stand-alone treatments for insomnia or for other conditions. However, the CBT protocol combines several of these therapies to provide a more omnibus therapy designed to address the varying speciﬁc treatment needs of the insomnia patients we encounter. This CBT protocol was developed from the ﬁrst author’s early work (Edinger et al., 1992; Hoelscher & Edinger, 1988) and from the writings of Bootzin (1977), Morin et al. (1989), Spielman, Caruso, et al. (1987), and Webb (1988). The cognitive component was informed by integrative cognitive-behavioral models of
Morin (1993) and Harvey (2002). One of the cognitive strategies (i.e., Constructive Worry) was derived from Carney and Waters (2006) and Espie and Lindsay (1987). As much of our own and others’ research has focused on the type of insomnia known as Primary Insomnia, the strategies described in this manual are mainly fashioned for the treatment of this condition. However, as discussed in the last chapter of this book, these strategies may be considered for other forms of insomnia as well. This treatment manual is divided into chapters that describe methods of insomnia assessment and the implementation of our CBT protocol. Each chapter describing the treatment protocol provides a “treatment rationale” to be provided to patients undergoing treatment. Speciﬁc information and instructions to be provided to patients are highlighted with italics. Investigators who wish to replicate the procedures described should present the highlighted information and instructions to their patients verbatim. It is also recommended that those who wish to use these treatments in their own insomnia research ﬁrst review the list of References provided at the end of this text.
Nature and Significance of Primary Insomnia The sleep disorder insomnia is characterized by diﬃculties initiating, sustaining, or obtaining qualitatively satisfying sleep that occur despite adequate sleep opportunities/circumstances and result in notable waking deﬁcits (Edinger et al., 2004). Over one third of the adult population experiences insomnia at least intermittently, whereas 10% to 15% suﬀer chronic, unrelenting sleep diﬃculties. Insomnia may result from various medical disorders, psychiatric conditions, substance abuse, and other primary sleep disorders (e.g., sleep apnea). However, 1% to 2% of the general population suﬀers from primary insomnia, a form of insomnia disorder that persists either in the absence or independent of any such comorbid condition. Whereas the middle-aged and older adults are most prone to develop one of the many subtypes of insomnia, primary insomnia is the most common diagnosis found in younger age groups. As such, the risk for developing this condition remains relatively stable across the life span. Although many insomnia suﬀerers go undetected (Ancoli-Israel &
Roth, 1999), primary insomnia is common in primary care settings and accounts for over 20% of all insomnia suﬀerers who present to specialty sleep disorders centers (Coleman et al., 1982; Simon & VonKorﬀ, 1997). Thus, primary insomnia appears suﬃciently prevalent and disturbing that it frequently comes to the attention of both sleep specialists and general medical practitioners. Since primary insomnia is devoid of secondary causes, this problem was traditionally viewed as less serious than those insomnias arising from medical, psychiatric, substance abuse, or other serious sleep disorders (e.g., sleep apnea). However, epidemiologic evidence suggests insomnia, uncomplicated by comorbid psychiatric, substance abuse, or medical disorders, substantially increases health-care utilization/costs and accounts for as many as 3.5 disability days per month among aﬀected individuals (Ozminkowski, Wang, & Walsh, 2007; Simon & VonKorﬀ, 1997; Weissman, Greenwald, Nino-Murcia, & Dement, 1997). Also, several studies have shown that primary insomnia dramatically increases subsequent risk for developing a depressive illness, serious anxiety disorder, or substance abuse problem even after other signiﬁcant risk factors are controlled (Breslau, Roth, Rosenthal, & Andreski, 1996; Chang, Ford, Mead, Cooper-Patrick, & Klag, 1997; Ford & Kamerow, 1989; Livingston, Blizard, & Mann, 1993; Vollrath, Wicki, & Angst, 1989). In addition, primary insomnia contributes to reduced productivity, accidents at work, increased alcohol consumption, serious falls among older adults, and a sense of being in poor health (Brassington, King, & Bliwise, 2000; Gislason & Almqvist, 1987; Johnson, Roehrs, Roth, & Breslau, 1998; Johnson & Spinweber, 1983; Katz & McHorney, 1998). Thus, when encountered clinically, primary insomnia patients warrant safe, eﬀective, and enduring treatment.
Diagnostic Criteria for Primary Insomnia Disorder Primary Insomnia is a diagnosis speciﬁc to the American Psychiatric Association’s sleep disorder classiﬁcation system outlined in recent versions of its Diagnostic and Statistical Manual of Mental Disorders. This diagnosis ﬁrst appeared in the revised, third edition of the Association’s Diagnostic and Statistical Manual (American Psychiatric Association, 1987) and has
Table 1.1 Diagnostic Criteria for Primary Insomnia
A. The predominant complaint is diﬃculty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. B. The sleep disturbance (or associated daytime fatigue) causes clinically signiﬁcant distress or impairment in social, occupational, or other important areas of functioning. C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia. D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, delirium). E. The disturbance is not due to the direct physiologic eﬀects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Taken from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR, APA, 2000)
been maintained through subsequent revisions of this text (DSM-IV-TR, American Psychiatric Association, 1994, 2000). Primary insomnia’s diagnostic criteria listed in Table 1.1 highlight the primary or central role that sleep-wake disturbance serves in deﬁning this condition. In fact, these criteria specify that a primary insomnia diagnosis is assigned when the insomnia does not occur exclusively during the course of another primary sleep or psychiatric disorder and is not the direct result of a general medical disorder or substance use/abuse. As such, primary insomnia is perhaps best conceptualized as a diagnosis established by exclusion of other primary and secondary forms of sleep disturbance. Nevertheless, primary insomnia can usually be discerned from clinical interview, as expensive and time-consuming laboratory tests are seldom needed for diagnosis of insomnia.
Development of This Treatment Program and Evidence Base It seems intuitively obvious that practicing good sleep habits (i.e., following a routine sleep-wake schedule; avoiding daytime napping, etc.) and relaxing before bedtime facilitates nocturnal sleep. As such, it seems reasonable to speculate that psychological and behavioral strategies designed to improve sleep habits and reduce bedtime arousal may be useful for treating insomnia. However, not until the late 1950s did the use-
fulness of behavioral interventions receive attention in the scientiﬁc literature. In 1959, Schultz and Luthe were the ﬁrst to formally report their success in treating a patient with sleep-onset insomnia using the form of relaxation therapy (RT) known as autogenic training. Several years later, Jacobson (1964) reported similar results in a case he treated with his progressive muscle relaxation. However, not until the early 1970s were the ﬁrst randomized clinical trials conducted to document the eﬃcacy of RTs (Borkovec & Fowles, 1973; Nicassio & Bootzin, 1974). Although limited in number, these early reports were suﬃcient to spawn substantial research and clinical interest in the use of psychological and behavioral therapies for insomnia treatment during the past two decades. Arguably one of the more monumental breakthroughs in behavioral insomnia research was Bootzin’s (1972) observation concerning the important role of behavioral conditioning in disrupting or promoting sleep. Indeed, Bootzin was the ﬁrst to suggest that sleep, like other overt behaviors, should respond to instrumental conditioning. Consistent with this suggestion, he ﬁrst presented his innovative stimulus control (SC) insomnia treatment in the early 1970s (Bootzin, 1972). In his early reports, he demonstrated that a simple, straightforward operant conditioning approach involving standardization of the sleep-wake schedule, eliminating daytime napping, and discouraging sleep-incompatible behaviors in the bed and bedroom is particularly eﬀective for treating chronic primary insomnia. Perhaps both due to its practical appeal and its general eﬃcacy, SC quickly became one of the most widely used behavioral insomnia treatments (Lacks & Morin, 1992). In our early clinical work, we found stimulus control and relaxation therapies moderately eﬀective for treating the sleep problems of many of the primary insomnia patients we encountered. However, these treatments also appeared to have some limitations. Most notably, neither of these treatments included speciﬁc strategies for addressing patients’ unhelpful beliefs that served to support their sleep-related anxiety and promote many of their sleep-disruptive habits. In addition, many people with insomnia report that cognitive arousal is the most signiﬁcant factor in the maintenance of their sleep diﬃculty (Espie, Brooks, & Lindsay, 1989; Lichstein & Rosenthal, 1980). However, these treatments did not employ speciﬁc strategies shown to be eﬀective for decreasing pre-sleep arousal (Carney & Waters, 2006; Espie and Lindsay, 1987). Lastly, these
treatments did not speciﬁcally address the practice of spending excessive time in bed displayed by many of the patients with sleep maintenance complaints we encountered. Inasmuch as a case series study by Spielman, Saskin, and Thorpy (1987) showed that restricting time in bed led to sleep improvements in a small group of insomnia patients they treated, we thought a truly omnibus insomnia therapy should include such a strategy. Finally, we noted the need for speciﬁc strategies to enhance patients’ treatment adherence. In this regard we found that patients seemed more likely to adhere to treatment recommendations if they were ﬁrst provided some limited psychoeducational material designed to give them a basic understanding of what regulates the human sleep system and the types of habits that help and hinder the normal sleep process. Given these observations, the need for a multicomponent cognitivebehavioral therapy for insomnia became apparent. Thus, we constructed a treatment that included a number of components including (1) a cognitive module designed to provide psychoeducation about factors that regulate the human sleep system and to address unhelpful beliefs about sleep; (2) standard stimulus control instructions to address patients’ conditioned arousal and eliminate common sleep disruptive habits (daytime napping, maintaining an erratic sleep-wake schedule); and (3) a protocol for limiting each patient’s time in bed to an individually tailored time-in-bed prescription (discussed in detail in Chapter 3). To test this approach, we conducted two small case-series studies using multiple baseline designs. The ﬁrst of these studies (Hoelscher & Edinger, 1988), which included four primary insomnia patients, provided initial support for our multicomponent approach in that three of the four patients treated responded well once treatment was initiated. In our second case series study (Edinger et al., 1992), seven patients underwent baseline monitoring that varied from 2 to 4 weeks in length and then successively completed four weekly sessions of relaxation training followed by four sessions of our multicomponent treatment. Results of this latter trial again suggested that most patients showed marked improvements in key sleep measures and such improvements occurred only after our multicomponent Cognitive-Behavioral Therapy (CBT) was initiated. Shortly thereafter, Morin, Kowatch, et al. (1993) published the ﬁrst randomized clinical trial that showed a multicomponent CBT
similar to our approach was eﬀective (compared to a wait-list condition) for treating older adults with insomnia. Since the time of these early works, a number of larger randomized clinical trials have shown multicomponent CBT insomnia treatment is both eﬃcacious and clinically eﬀective for treating primary insomnia. In eﬃcacy studies (Edinger et al., 2001, 2007; Morin, 1999) conducted with intentionally recruited and thoroughly screened primary insomnia samples, CBT has proven superior to relaxation training, sham behavioral intervention, sleep medication (tamazepam), a medication placebo, and a no-treatment (wait-list) for treating insomnia complaints. In two large eﬀectiveness trials (Espie, 2001; Espie et al., 2007) conducted with patients who presented to primary care clinics with insomnia complaints, CBT proved more eﬀective than usual medical management strategies (medication and sleep advice) for producing sleep improvements. Moreover, a recent critical literature review (Morin et al., 2006) concluded that there have been a suﬃcient number of eﬃcacy and eﬀectiveness studies conducted to conclude that CBT for insomnia is a well-established and proven treatment approach particularly for those with primary insomnia. Thus, with reasonable conﬁdence we can oﬀer the treatment strategies outlined in this manual as a “Treatment That Works” for patients with this condition.
Theoretical Model for Cognitive-Behavioral Insomnia Therapy Spielman’s model presented in Figure 1.1 provides a conceptual framework for understanding the evolution of chronic primary insomnia and the role of CBT for managing this condition. According to this model, predisposing factors, precipitating events, and perpetuating mechanisms all contribute to the development of chronic primary sleep diﬃculties. Some individuals may be particularly vulnerable to sleep diﬃculties either by virtue of having a “weak,” “highly sensitive,” biological sleep system or personality traits that dispose them to poor sleep when confronted with stress. When such individuals are confronted with the proper precipitating circumstances (e.g., a stressful life event, sudden unexpected change in their sleep schedule), they tend to develop an acute sleep disturbance. This sleep problem, in
0 Premorbid Predisposing Acute Sub-Acute Chronic Perpetuating
Figure 1.1 Spielman’s model describing the evolution of chronic primary insomnia
turn, may then be perpetuated by a host of psychological and behavioral factors that emerge in reaction to such a sleep diﬃculty. Thus, although predisposing and precipitating factors contribute to the initial development of insomnia, the psychological and behavioral perpetuating factors that sustain it serve as the treatment targets for behavioral insomnia therapy. The cognitive behavior model posits that an interplay of cognitive and behavioral mechanisms act as the key perpetuating mechanisms for primary insomnia patients. Setting the stage for sustained sleep diﬃculty is a thinking style that can include misattributions about the causes of insomnia, attentional bias for sleep-related stimuli, worry and/or rumination about the consequences of poor sleep, and unhelpful beliefs about sleep promoting practices (Carney & Edinger, 2006; Carney et al., 2006; Edinger, et al., 2000; Espie, 2002; Harvey, 2002; Morin, 1993; Morin, Stone, Trinkle, Mercer, & Remsberg, 1993). These cognitions, in turn, support and sustain sleep-disruptive habits and conditioned emotional responses that either interfere with normal sleep drive or timing mechanisms or serve as environmental/behavioral inhibitors to sleep (Bootzin, 1977; Morin, 1993; Spielman, Saskin, & Thorpy, 1987; Webb, 1988). For example, daytime napping or spending extra time in bed in pursuit of elusive, unpredictable sleep may only serve to interfere with the body’s homeostatic mechanisms that operate automatically to increase sleep drive in the face of increasing periods of wakefulness (i.e., sleep debt). Alternately, the
habit of remaining in bed well beyond the normal rising time following a poor night’s sleep may disrupt the body’s circadian or “clock” mechanisms that control the timing of sleep and wakefulness in the 24-hour day. Additionally, the repeated association of the bed and bedroom with unsuccessful sleep attempts may eventually result in sleep-disruptive conditioned arousal in the home sleeping environment. Finally, failure to discontinue mentally demanding work and allot suﬃcient “wind-down” time before bed may serve as a signiﬁcant sleep inhibitor during the subsequent sleep period. In sum, all these factors may contribute to and perpetuate PI (Bootzin & Epstein, 2000; Edinger & Wohlgemuth, 1999; Hauri, 2000; Morin, Savard & Blias, 2000). As a result, our CBT approach is designed to modify the range of cognitions and sleep-related behaviors that ostensibly sustain or add to patients’ sleep problems.
Risks and Benefits of CBT for Insomnia Although systematic studies of CBT-related side eﬀects have not been conducted, the experience base with CBT-based insomnia interventions suggests this intervention is a safe and eﬀective treatment modality. This is not to say that side eﬀects do not occur, but those that do occur are generally transient and manageable with strategies outlined later in this manual. Perhaps the most common side eﬀect is enhanced daytime sleepiness during the initial stages of treatment resulting from restricting patients’ times spent in bed. In some patients the initial suggested restriction in time in bed results in mild partial sleep deprivation and, thus, elevated daytime sleepiness. This sleepiness is usually transient and corrected by gradual increases in time in bed. Some patients also show elevated anxiety about sleep when limits are placed on their times spent in bed and choices of rise times. This side eﬀect also is easily managed via some relaxation of the treatment protocol as discussed in more detail in Chapter 5. In contrast, there are many beneﬁts to this treatment program. As discussed, our CBT treatment is fashioned to address and eradicate the various cognitive and behavioral mechanisms that presumably sustain insomnia and, thus enhance chances for sustained improvements long after treatment ends. The fact that this actually occurs is supported by the long-term follow-up data reported in CBT trials
showing sustained treatment beneﬁts up to 24 months after active treatment (i.e., facilitator contact) concludes. As such, this treatment diﬀers from most pharmacological approaches (i.e., sleeping pills) that provide symptomatic relief but fail to address the cognitive and behavioral factors that sustain insomnia. Indeed, there are currently no data available to show that sleep improvements persist long after pharmacotherapy for insomnia is discontinued. In addition to this beneﬁt there are some data that indicate many patients may prefer CBT over medicinal approaches. For example, results of one study (Morin et al., 1999) showed patients were more satisﬁed with behavioral insomnia therapy and rated it as more eﬀective than sleep medication. Findings from another study (Morin et al., 1992) suggested that patients with chronic insomnia both preferred CBT to pharmacotherapy but also expected that CBT would produce greater improvements in daytime functioning, better long-term eﬀects, and fewer negative side eﬀects. Collectively, these data suggest that insomnia patients regard behavioral insomnia therapy as a viable and acceptable treatment for their sleep diﬃculties.
Alternative Treatments Various “stand-alone” behavioral strategies including relaxation therapies, stimulus control, sleep restriction, and paradoxical intention have proven eﬃcacy for management of insomnia and currently are regarded as “wellestablished” insomnia treatments (Morin et al., 2006). Each of these therapies addresses a speciﬁc subset of insomnia-perpetuating mechanisms. In addition to these therapies, cognitive therapy and sleep hygiene education are often employed in insomnia management but these therapies do not currently have empirical support as “stand-alone” interventions. Detailed descriptions of all of these treatments and their applications can be found in a number of sources (e.g., Morin et al., 2006; Edinger & Means, 2005; Edinger & Wohlgemuth, 1999). As noted previously, we have found our multicomponent therapy to be a more comprehensive and consistently eﬀective behavioral approach because it is designed to address the cognitive and behavioral mechanisms that perpetuate insomnia in the vast range of primary insomnia patients we encounter.
Other non-medicinal approaches for insomnia management have included forms of yoga and acupuncture. Both of these treatments have shown some eﬃcacy but neither treatment enjoys the sizable research support that the behavioral insomnia therapies have acquired. Moreover, access to these interventions as applied to insomnia may be much more limited than current access to the behavioral therapies. Recently, pre-market testing of several investigational devices for insomnia treatment has begun but such devices have not yet received FDA approval for insomnia management. Nonetheless, since it is likely devices may be available in the future, their eﬃcacy relative to current insomnia therapies will need to be evaluated.
Role of Medications The most commonly prescribed sleep medications are benzodiazepine receptor agonists (BzRA). These include several benzodiazepines (e.g., temazepam) as well as newer non-benzodiazepine agents (e.g., zolpidem, eszopiclone, zaleplon) that act at the same site on the GABAA receptor complex. In addition, sedating antidepressant drugs such as trazodone (TRZ) and various sedating tricyclic antidepressants (e.g., doxepin) have been widely used for insomnia management. Finally, the melatonin agonist ramelteon, has recently been approved for treatment of insomnia. The beneﬁt of medications and particularly the BzRAs is that they have immediate eﬀects on sleep. As such, sleep medications have their greatest advantage over CBT for managing acute and brief forms of insomnia. For example, sleep medications are well suited for treatment of insomnia arising from an abrupt sleep-wake schedule change (e.g., jet lag) or as a stress reaction (e.g., bereavement) to unfortunate life circumstances. In contrast, the role of medications in the management of chronic insomnia has been debated. Recently some studies (Krystal et al., 2003; Roth et al., 2005) have shown continued eﬃcacy of some medications when taken continuously for periods up to 12 months in duration. However, tolerance and consequent reduced eﬃcacy may emerge with continued use of some sleep medications, and all sleep medications hold the risk of psychological dependence when used over time. Furthermore, whereas medications may reduce sleep-related
anxiety for some patients, pharmacologic treatment, in general, is not designed to address the range of cognitive and behavioral insomniaperpetuating mechanisms mentioned previously. Of course, the relative value of BzRA and CBT therapies largely depends upon their comparative eﬃcacies for short- and long-term insomnia management of PI and CMI patients. Unfortunately, there are currently limited data that speak to the relative eﬃcacy of these two treatment modalities. One recent study (Sivertsen et al., 2006) compared CBT with the sleep medication zopiclone and showed CBT produced signiﬁcantly better short- and longer-term improvements on objective indices taken from electronic sleep recordings but not on subjective measures taken from sleep logs. Some other studies (e.g., Jacobs et al., 2004; Morin et al., 1999) that compared treatments consisting of a sleep medication alone, CBT alone, and a combined CBT and sleep medication therapy showed little diﬀerence in short-term outcomes, but superior longer-term outcomes with CBT alone compared to medication and combined treatment. However, all of these studies are limited by their small sample sizes, use of ﬁxed-dose, and ﬁxed-agent pharmacotherapy strategies that do not represent standard clinical practice. Thus, additional studies of the relative values of CBT and sleep medications would be useful.
Treatment Program Outline The treatment described in the manual should be preceded by a thorough insomnia assessment as described in Chapter 2. This assessment session should be conducted to ensure that the patient is suitable for CBT and to instruct the patient in collecting the baseline sleep log data needed in the initial stages of treatment. The subsequent treatment sessions are then employed to address a range of behavioral and cognitive treatment targets (perpetuating mechanisms). The following outline shows the organization and ﬂow of the overall assessment and CBT insomnia intervention. I. Pretreatment Assessment a. Assess nature of insomnia and appropriateness for CBT
b. Assign baseline (pre-therapy) sleep log monitoring
II. Presenting Primary Behavioral Treatment Components – Session 1 a. Present treatment rationale and sleep education module
b. Present sleep rules – behavioral insomnia regimen c. Calculate initial time in bed prescription
d. Assign homework III. Presenting Cognitive Therapy Strategies – Session 2 a. Review and comment on sleep log ﬁndings showing progress and adherence
b. Provide cognitive rationale to patient c. Discuss Constructive Worry technique
d. Discuss use of Thought Records e. Assign homework
IV. Follow-Up/Troubleshooting – Session 3 and Onward a. Adjusting time in bed recommendations
b. Review and reinforce treatment adherence c. Troubleshooting – behavioral component
d. Troubleshooting – cognitive component e. Consideration of therapy termination
Use of the Workbook A patient workbook has been prepared to accompany the treatment manual. This workbook includes much educational information designed to reinforce what is presented in the treatment sessions. The workbook also includes various blank forms such as the sleep log, constructive worry sheet, and thought record form that patients will use to complete their assigned therapy “homework” from week to week. Since reference will be made to sections of the workbook
during the course of therapy, it is recommended that the patient bring the workbook to each CBT session. However, in the event the patient fails to do so, it is suggested that the therapist have a workbook and blank copies of the various forms mentioned available to reference at each session.
There are various methods you can use to diagnose and assess Primary Insomnia (PI) as well as other forms of insomnia. The following sections brieﬂy discuss each method.
Clinical Interview The clinical interview is a particularly important component of an insomnia assessment because it provides the basis from which the clinician ascertains etiological factors and formulates a treatment plan. In addition to providing a comprehensive assessment of the individual’s speciﬁc insomnia complaint and sleep history, the clinical interview should include evaluation of medication and substance use as well as identiﬁcation of contributory medical and psychiatric conditions. Essential elements of an insomnia-focused clinical assessment are outlined in Table 2.1. As suggested by the information shown in the table, the insomnia-focused interview should provide a thorough descriptive and functional assessment of the sleep complaint, its history, and the psychological and behavioral factors that may sustain it. Moreover, the interview should provide a thorough assessment of the relationship, if any, between comorbid conditions (medical or psychiatric) and the insomnia complaint. To facilitate the insomnia assessment, the patient may be asked to complete a sleep history questionnaire like the one provided in the appendix prior to the interview. This sort of instrument is designed to gather the pertinent information needed for a thorough insomnia assessment. Clinicians may also choose to employ one of the available semi-structured interviews (Spielman & Anderson, 1999; Savard & Morin, 2002) designed speciﬁcally for insomnia to guide their inquiries. Whatever
method chosen for querying the insomnia suﬀerer, an interview with his or her bed partner about the patient’s sleep pattern and habits can reveal important diagnostic information such as symptoms of other sleep disorders.
Factors to Consider in Conducting a Clinical Interview for Insomnia
History, Symptoms, and Perpetuating Factors Nature of complaint (pattern, onset, history, course, duration, severity) Etiological factors Factors that exacerbate insomnia or improve sleep pattern Sleep schedule Daytime symptoms (fatigue, cognitive impairment, distress about sleep) Social/vocational impact Maladaptive conditioning to bedroom Physiological/cognitive arousal at bedtime Unhelpful sleep-related beliefs Symptoms of other sleep disorders Bedtime routines and sleep-incompatible behaviors in bed Lifestyle (daily activity, exercise pattern) Treatment history (self-help attempts, coping strategies, response to previous treatments) Treatment expectations
Medication and Substance Use
Sleep medication – prescription and over-the-counter remedies Other routine prescription and nonprescription medications Alcohol, tobacco, caﬀeine Illicit substances
Medical disorders associated with sleep disruption Chronic pain Menopausal status (women) Prostate disease (men) Any recent relevant laboratory test results (e.g., abnormal thyroid function)
Depression Anxiety Other mental disorders General day-to-day stress level
Sleep Logs Prior to providing any treatment instructions, it is useful to have the patient monitor his or her sleep pattern for a period of at least 2 weeks using a sleep log. Blank copies of the sleep log we use are provided for the patient in the corresponding workbook and a single blank copy of this log is shown in Figure 2.1. This instrument is a particularly valuable tool that allows for prospective monitoring of the patient’s sleep habits and pattern over time. The log is designed to solicit information relevant to each night’s sleep including whether any naps were taken the previous day, whether any medication or alcohol was ingested at bedtime to facilitate sleep, the time the patient entered bed, the time the lights were turned oﬀ and the patient attempted to fall asleep, the number of minutes it took to fall asleep, the number and length of awakenings during the night, the time of the ﬁnal morning awakening, and the time of actually arising from bed. The log also queries about the quality of each night’s sleep and how well rested the patient felt upon waking. As may be noted from Figure 2.1, the log is designed to allow entry of 1 week’s worth of sleep information on a single sheet. To ensure the greatest accuracy and usefulness of the data obtained, the patient should be encouraged to complete the sleep log each morning within the ﬁrst 30 minutes or so after arising. We ﬁnd the sleep log is the quintessential tool in our work with insomnia patients since it provides much useful assessment information and it guides the implementation of our cognitive and behavioral therapy strategies. As an insomnia assessment tool, the log provides important information about the patient’s sleep-disruptive habits as well as some insights into implicit cognitive treatment targets. In some instances, sleep log data may also be useful for identifying diagnostic subtypes who may not be good candidates for the treatment program described in this guide. To demonstrate the speciﬁc types of information that may be gleaned from the sleep log, the ensuing discussion provides a number of case examples.
Day of the Week Calendar Date
1. Yesterday I napped from _____ to _____ (note time of all naps). 2. Last night I took _____ mg of _____ or _____ of alcohol as a sleep
aid (include all prescription and over-the-counter sleep aids).
3. Last night I got in my bed at _____ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at _____ (AM or PM?). 5. After turning oﬀ the lights it took me about _____ minutes to fall asleep. 6. I woke from sleep _____ times. (Do not count your ﬁnal awakening here.) 7. My awakenings lasted _____ minutes. (List each awakening separately.) 8. Today I woke up at _____ (AM or PM?). (NOTE: this is your ﬁnal
9. Today I got out of bed for the day at _____ (AM or PM?). 10. I would rate the quality of last night’s sleep as:
Very Poor 1 2 Not at All 1 2 Fair 3 4 5 6 7 8 Excellent 9 10 Well Rested 9 10
11. How well rested did you feel upon arising today?
3 Somewhat 4 5 6 7 8
Figure 2.1 Sleep Log
Case Example #1 Figure 2.2 shows one week of sleep log data for an individual who manifests a practice seen all too frequently among our insomnia patients. This individual shows a pattern of retiring to bed for the evening well in advance of the actual time chosen for beginning the night’s sleep. During review of the sleep log with the therapist, the patient noted a practice of watching television in bed for an hour or more before intending to fall asleep. This practice resulted in the patient spending 9 or more hours in bed many nights during the week and usually experiencing extended awakenings during the course of the night. Careful querying, however, led to the discovery that the patient often dozed oﬀ while watching TV in bed well before the designated “lights-out” time indicated on the sleep log. In such a patient, the excessive time spent in bed, using the bed for activities other than sleep, and the unrecorded “dozing” are important behavioral treatment “targets” uncovered by these sleep log data. The observed behavioral pattern also may herald underlying misconceptions the patient may have about sleep needs and sleep-promoting practices that should be addressed in treatment. Case Example #2 Figure 2.3 highlights another pattern commonly seen among insomnia patients. The most obvious problem shown by this log is the patient’s erratic sleep pattern. Indeed, the information recorded shows that the patient’s bedtimes varied by over 5 hours whereas the chosen rise times varied by over 3 hours during the week shown. The resulting sleep pattern shown accordingly is erratic and, from the patient’s perspective, highly unpredictable. Patients who show such patterns often stray from a routine sleep-wake schedule in an eﬀort to get what sleep they obtain, whenever they are able to obtain it. Hence, if they are able to sleep in an extra few hours following a disrupted night with extended waking periods, they do so to make up for the sleep they feel they lost during the night. Unfortunately, this practice only helps sustain the insomnia. As might be surmised from this discussion, both the noted erratic sleep pattern and the sleeprelated beliefs and anxiety that underlie this pattern are treatment targets that the sleep log has helped uncover.
Day of the Week
Mon 3/5 None
Tue 3/6 None
Wed 3/7 None
Thurs 3/8 None
Fri 3/9 3:30– 3:35 PM None 10:00 PM 11:30 PM 20 min 2 15 min 15 min 6:00 AM 7:00 AM 6
Sat 3/10 None
Sun 3/11 None
1. Yesterday I napped from _____to _____ (note time of all naps). 2. Last night I took _____ mg of _____ or _____ of alcohol as a sleep
aid (include all prescription and over-the-counter sleep aids).
None 9:30 PM 11:00 PM
None 10:00 PM 11:15 PM 20 min 3 15 min 45 min 30 min 5:45 AM 6:35 AM 3
None 9:00 PM 10:45 PM 15 min 2 15 min 75 min 5:00 AM 6:30 AM 2
None 9:15 PM 11:00 PM 45 min 3 15 min 15 min 30 min 4:45 AM 6:00 AM 2
None 9:45 PM 11:45 PM 15 min 1 25 min 6:45 AM 7:30 AM 7
None 9:00 PM 10:45 PM 30 min 2 15 min 60 min 5:50 AM 6:30 AM 4
3. Last night I got in my bed at _____ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at _____ (AM or PM?).
5. After turning oﬀ the lights it took me about _____ minutes to fall asleep. 25 min 6. I woke from sleep _____ times. (Do not count your ﬁnal awakening here.) 2 7. My awakenings lasted _____ minutes. (List each awakening separately.)
20 min 60 min 6:00 AM 6:30 AM 5
8. Today I woke up at _____ (AM or PM?). (NOTE: this is your ﬁnal
9. Today I got out of bed for the day at _____ (AM or PM?). 10. I would rate the quality of last night’s sleep as:
Very Poor 1 2 Not at All 1 2 3 4 Fair 5 6 7 8 9 Excellent 10
11. How well rested did you feel upon arising today?
3 Somewhat 4 5 6 7 8 Well Rested 9 10
Figure 2.2 Sleep Log Case #1
Day of the Week Calendar Date
1. Yesterday I napped from _____ to _____ (note time of all naps). 2. Last night I took _____ mg of _____ or _____ of alcohol as a sleep
aid (include all prescription and over-the-counter sleep aids).
Mon 1/15 None None 11:00 PM 11:00 PM
Tue 1/16 None None 10:45 PM 10:45 PM 45 min 2 25 min 25 min 8:30 AM 8:40 AM 7
Wed 1/17 None None 10:30 PM 10:30 PM 10 min 2 45 min 90 min 9:00 AM 9:05 AM 2
Thurs 1/18 None None 11:30 PM 11:30 PM 65 min 2 40 min 90 min 6:40 AM 7:30 AM 1
Fri 1/19 None None 11:20 PM 11:20 PM 35 min 1 55 min 5:15 AM 5:20 AM 4
Sat 1/19 None None 2:45 PM 2:45 PM 10 min 1 5 min 7:25 AM 7:30 AM 3
Sun 1/21 None None 9:30 PM 9:30 PM 120 min 2 80 min 60 min 7:20 AM 7:40 AM 2
3. Last night I got in my bed at _____ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at _____ (AM or PM?).
5. After turning oﬀ the lights it took me about _____ minutes to fall asleep. 20 min 6. I woke from sleep _____ times. (Do not count your ﬁnal awakening here.) 1 7. My awakenings lasted _____ minutes. (List each awakening separately.)
8. Today I woke up at _____ (AM or PM?). (NOTE: this is your ﬁnal
6:05 AM 6:30 AM 5
9. Today I got out of bed for the day at ____ (AM or PM?). 10. I would rate the quality of last night’s sleep as:
Very Poor 1 2 Not at All 1 2 3 4 Fair 5 6 7 8 Excellent 9 10
11. How well rested did you feel upon arising today?
3 Somewhat 4 5 6 7 8 Well Rested 9 10
Figure 2.3 Sleep Log Case #2
Case Example #3 Figure 2.4 highlights the diagnostic usefulness of sleep log data. These data were collected by a college student who presented to our clinic complaining about extreme diﬃculty falling asleep each night. This log clearly shows that the student has marked diﬃculty getting to sleep on most nights. Throughout the week, the student takes 2.5 to 3.5 hours to fall asleep despite the use of alcohol as a sleep aid on several nights. As a result, the usual sleep onset time on most weekday nights occurs between 2:30 and 3:30 AM. However, on weekend nights when the student chooses a bedtime more proximal to this usual sleep onset time, the sleep latency is markedly reduced. Moreover, the weekend rise times occur much later and aﬀord the student greater opportunity to obtain a full night’s sleep given the delayed time of sleep onset. All these indicators suggest the student likely suﬀers from delayed sleep phase syndrome, a circadian rhythm disorder wherein the endogenous sleep-wake rhythm is markedly phase delayed. As such, the student is biologically disposed to fall asleep in the early morning hours and sleep through much of the morning if allowed to do so. However, on weekdays the student is required to arise to attend morning classes, so the sleep period is artiﬁcially shortened on these days. Patients with this sort of sleep problem typically require treatments other than the one described in this guide, so data such as what is shown in Figure 2.4 are useful for identifying patients who are not good CBT candidates. As the treating clinician, you will likely ﬁnd these logs useful for identifying the most salient treatment targets in each of your insomnia patients. As described in greater detail in the ensuing chapter, you will use completed sleep logs to develop patient-speciﬁc Time in Bed Prescriptions (TIB) as part of your treatment recommendations (see Chapter 3 for more detail).
Insomnia Symptom Questionnaire The Insomnia Symptom Questionnaire (ISQ) developed by Spielman et al. (1987) is a 13-item self-report instrument designed to assess sleep (e.g., sleep onset diﬃculty, wakefulness during sleep) and waking (e.g., daytime fatigue, sleep worries) symptoms of insomnia. Each item
Day of the Week Calendar Date
1. Yesterday I napped from _____ to _____ (note time of all naps). 2. Last night I took _____ mg of _____ or _____ of alcohol as a sleep
aid (include all prescription and over-the-counter sleep aids).
Tue 4/2 None 4 oz wine 11:00 PM 11:00 PM
Wed 4/3 2:00– 4:00 PM None 12:30 PM 12:30 PM 3 hours 2 25 min 25 min 9:30 AM 9:40 AM 4
Thurs 4/4 5:00– 6:30 PM 2 beers 11:30 PM 11:30 PM 2.5 hours 2 40 min 30 min 9:00 AM 9:05 AM 4
Fri 4/5 None 1 beer 12:00 PM 12:00 PM 3.5 hours 1
Sat 4/6 None None 2:20 PM 2:20 PM 40 min 1
Sun 4/7 None None 2:45 PM 2:45 PM 30 min 1
Mon 4/8 None None 11:30 PM 11:30 PM 3 hours 1
3. Last night I got in my bed at _____ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at _____ (AM or PM?).
5. After turning oﬀ the lights it took me about _____ minutes to fall asleep. 3.5 hours 6. I woke from sleep _____ times. (Do not count your ﬁnal awakening
7. My awakenings lasted _____ minutes. (List each awakening separately.)
20 min 8:40 AM 8:45 AM 1
20 min 12:15 AM 12:20 AM 6
5 min 11:25 AM 11:30 AM 7
20 min 8:30 AM 8:40 AM 2
8. Today I woke up at _____(AM or PM?). (NOTE: this is your ﬁnal
8:05 AM 8:30 AM 4
9. Today I got out of bed for the day at _____ (AM or PM?). 10. I would rate the quality of last night’s sleep as:
Very Poor 1 2 Not at All 1 2 23 3 Fair 4 5 6 Somewhat 4 5 6 7 8 Excellent 9 10
11. How well rested did you feel upon arising today?
3 7 8 Well Rested 9 10
Figure 2.4 Sleep Log Case #3
is accompanied by a 100-mm visual-analog scale (i.e., horizontal line) that is labeled “not at all” at its left extreme and “always” at its right extreme. In responding to this instrument, respondents draw a vertical line through the point on each item’s analog scale (i.e., 100-mm line) to indicate their responses. The distance from the left end of the line to a subject’s response line serves as an analog measure of the degree to which the respondent has the symptom noted by the item. The mean score across all 13 items constitutes the measure to be used in this study. In our previous work (Edinger, et al., 2001; Edinger & Sampson, 2003), we have found the ISQ has acceptable internal consistency (Cronbach’s 0.73) and sensitivity to treatment-related sleep improvements. In our research we have used a total ISQ score 41 as the clinical cutoﬀ connoting insomnia remission given our early ﬁndings suggested this cutoﬀ has a 92% sensitivity and 64% speciﬁcity for discriminating normal sleepers from primary insomnia suﬀerers. However, in more recent unpublished work with a large validation sample, we have determined that an ISQ total score 36.5 may be a better benchmark since this cutoﬀ has an 89% sensitivity and 86.5% speciﬁcity for discriminating patients with primary insomnia from normal sleepers.
Insomnia Severity Index The Insomnia Severity Index (ISI: Morin, 1993) is a 7-item questionnaire that provides a global measure of perceived insomnia severity based on the following indicators: diﬃculty falling asleep, diﬃculty staying asleep, and early morning awakenings; satisfaction with sleep; degree of impairment with daytime functioning; degree to which impairments are noticeable; and distress or concern with insomnia symptoms. Each item is rated on a 5-point (0 to 4) Likert scale and the total score ranges from 0–28. The following guidelines are recommended for interpreting the total score: 0–7 (no clinical insomnia), 8–14 (sub-threshold insomnia), 15–21 (insomnia of moderate severity), and 22–28 (severe insomnia). The ISI has good internal consistency (Cronbach’s alpha 0.91) and testretest reliability (r 0.80). It has been validated against sleep logs and electronic sleep recordings (Bastien, Vallieres, & Morin, 2001) and has proven sensitive to therapeutic changes in several treatment studies of insomnia (Morin et al., 1999). In recent years, the ISI has become
increasingly popular in insomnia work and now is recommended as a standard assessment tool in insomnia research studies (Buysse et al., 2006). Since the ISI has the mentioned guidelines for score interpretation, this instrument can be used easily in clinical venues for judging initial insomnia severity and the clinical signiﬁcance of improvements achieved during insomnia treatment.
Pittsburgh Sleep Quality Index (PSQI: Buysse et al., 1989) This instrument, like the ISI, is a widely used and currently recommended (Buysse et al., 2006) tool for assessing sleep disturbance in insomnia patients as well as in patients with other types of sleep disorders. The PSQI is composed of four open-ended questions and 19 selfrated items (0–3 scale) assessing sleep quality and disturbances over the previous 1-month interval. Domains assessed include sleep onset latency, sleep duration, sleep eﬃciency (i.e., the proportion of time in bed that is actually spent asleep), sleep quality, disturbances to sleep, medication use, and daytime dysfunction. A summation of these seven component scores yields a global score of sleep quality, ranging from 0 to 21. Previous research (Buysse et al., 1989) has shown that a PSQI total score of 5 has good sensitivity (89.6%) and speciﬁcity (86.5%) in discriminating those with insomnia from good sleepers. As such, a posttreatment PSQI score 5 has been used in some studies as indicating insomnia remission. However, it should be noted that the PSQI provides a global sleep quality assessment and is not speciﬁcally or exclusively designed for insomnia assessment. Moreover, we (Carney et al., 2006) have found that elevated levels of anxiety may contribute to PSQI score elevations in some types of insomnia patients. Hence, the patient’s anxiety level at the time of PSQI administration should be considered when interpreting the summary score obtained.
Dysfunctional Beliefs and Attitudes About Sleep Questionnaire (DBAS) This instrument is a valuable tool for identifying unhelpful sleep-related beliefs and attitudes presumed to help perpetuate insomnia problems. Currently both the original parent version and an abbreviated version are
available for clinical and research use. The original DBAS-30 includes 30 items that comprise ﬁve subscales designed to assess (1) attributions about the eﬀects of insomnia (e.g., “I am concerned that chronic insomnia may have serious consequences on my physical health”); (2) perceptions of loss of control and unpredictability of sleep (e.g., “I am worried that I may lose control over my abilities to sleep”); (3) perceived sleep needs and sleep expectations (e.g., “Because I am getting older, I need less sleep”); (4) misattributions about causes of insomnia (e.g., “I feel insomnia is basically the result of aging and there isn’t much that can be done about this problem”); and (5) expectations about sleep-promoting habits (e.g., “When I don’t get the proper amount of sleep on a given night, I need to catch up the next day by napping or the next night by sleeping longer). A 100-millimeter (mm) analog scale (i.e., horizontal line) labeled “strongly disagree” at its far left extreme and “strongly agree” at its far right extreme accompanies each item and is used by respondents to indicate their degree of endorsement. When completing the DBAS-30, respondents are required to draw a vertical line through the point on the 100-mm scale to indicate their degree of agreement or disagreement with each item. The distance in mm between the far left extreme of the analog scale and the response line then is used as the item’s “score.” With one exception all items are structured so that higher scores (i.e., stronger item agreement) connote more dysfunctional beliefs. Recently an abbreviated 16-item version (DBAS-16) of the original DBAS-30 has become available. This abridged version is similar in format to the original instrument but it uses 10-point Likert scales superimposed on visual analog scales for indicating agreement/disagreement with the various items. For each of the 16 beliefs, the number corresponding to the degree of belief (e.g., 10 agree completely) is circled. A total score is calculated by summing the item scores and dividing the resultant sum by 16 (i.e., a mean item score). Both the DBAS-30 and DBAS-16 have shown acceptable levels of internal consistency values .80). Furthermore we recently have found (Cronbach’s DBAS-16 total scores 3.8 to be suggestive of the level of unhelpful beliefs common among individuals with clinically signiﬁcant insomnia problems. Both DBAS instruments can be used to identify speciﬁc problematic beliefs to target in treatment and to assess belief changes resulting from our cognitive-behavioral intervention.
Epworth Sleepiness Scale The Epworth Sleepiness Scale is an eight-item self-report questionnaire designed to assess daytime sleepiness in common day-to-day situations such as “Watching TV” or “Sitting and talking to someone.” Respondents are instructed to indicate how likely they are to fall asleep in each situation using a 4-point rating scale (0 “would never doze” to 3 “high chance of dozing”). The ESS score is obtained by summing all item responses so scores may range from 0 to 24 with higher scores suggesting greater daytime sleep tendency. A score of 10 or more is considered to indicate clinically signiﬁcant daytime sleepiness. A score of 18 or more connotes someone who is very sleepy. This instrument has shown very acceptable internal consistency (Cronbach’s 0.88) and test-retest reliability (r .82) within both non-complaining groups and in groups of clinical sleep-disordered patients (Johns, 1991; Johns, 1994) Additionally, Epworth ratings have been found to correlate signiﬁcantly (r .514, p .01) with objective tests of daytime sleepiness ( Johns, 1991). Whereas some insomnia patients will obtain scores in the “sleepy” range on this instrument, they commonly do not obtain scores indicating they are very sleepy. Overweight patients who report loud nocturnal snoring and who score above the clinical cutoﬀ are likely to suﬀer from sleep apnea and should be referred to a sleep specialist for thorough evaluation of this possibility.
Other Psychological Testing Because depressed mood and anxiety symptoms are common among insomnia patients, routine psychological screening is often recommended. Brief psychological questionnaires such as the current version of the Beck Depression Inventory (BDI-II), the Beck Anxiety Inventory, the Spielberger State-Trait Anxiety Inventories, and the Brief Symptom Inventory are all useful in this regard. Although they have limited value when used in isolation, these questionnaires may provide important supplemental information not apparent from the clinical interview.
In some cases, it may be necessary to conduct a more thorough psychological assessment. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is an extensive psychological questionnaire that produces personality proﬁles for a wide range of psychopathology. Validity scales provide information on response biases such as patients’ attempts to either deny or exaggerate psychopathological symptoms. Individuals with insomnia produce speciﬁc MMPI-2 proﬁles characterized by depression, anxiety, and somatization of emotional conﬂict. While some sleep disorders centers routinely administer the MMPI-2 to all patients as part of the intake evaluation, it may be considered too lengthy and time-consuming for some venues.
Actigraphy Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and onboard memory and can provide objective data on daytime activity. Computer software that accompanies most brands of actigraphs include scoring algorithms for estimating sleep and wake time for each night the actigraph is worn. Most such software also allows for outputting a day-to-day plot of the sleep-wake schedule when the patient is asked to wear the actigraph day and night for a series of days. Actigraphy is used to clinically evaluate insomnia, circadian rhythm sleep disorders, excessive sleepiness, and restless leg syndrome. It is also used in the assessment of the eﬀectiveness of treatments for these disorders, including behavioral therapy. Actigraphy has not traditionally been used in routine diagnosis of sleep disorders but is increasingly being employed in sleep clinics to replace full polysomnography. Its greatest value may be that of providing an object veriﬁcation of the patient’s sleep-wake schedule and adherence to recommended rising times and TIB prescriptions included in the treatment recommendation discussed in the next chapter.
Polysomnography Polysomnography is a diagnostic test during which a number of physiologic variables are measured and recorded during sleep. Physiologic sensor leads are placed on the patient in order to record the following: ■ Brain electrical activity ■ Eye and jaw muscle movement ■ Leg muscle movement ■ Airﬂow ■ Respiratory eﬀort (chest and abdominal excursion) ■ EKG ■ Oxygen saturation This test is typically conducted in a sleep disorders center but it can also be conducted in the patient’s home setting. In most cases, polysomnography is not necessary for diagnosing insomnia, although in some cases it is helpful in determining whether or not there is a medical reason for the patient’s sleep problems (e.g., sleep apnea or periodic limb movements during sleep).
Summary In summary, the evaluation of insomnia is a complex process that may include a variety of assessment procedures. In most cases of primary insomnia, the information needed for diagnosis and treatment decisionmaking can be gleaned from the clinical interview and sleep log. Indeed, these two sources usually provide suﬃcient information to identify pertinent cognitive and behavioral treatment targets in the insomnia patient. However, the additional assessment methods mentioned herein may provide much needed diagnostic and assessment information in selected cases of primary insomnia as well as with other insomnia patients who have underlying sleep disorders or complex comorbid disorders.
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Session 1: Psychoeducational and Behavioral Therapy Components
(Corresponds to chapter 2 of the workbook)
Materials Needed ■ Audiotape to record sleep education segment of session (optional) ■ Figure 3.1: Circadian Temperature Rhythm ■ Figure 3.2: Eﬀects of Jet Lag ■ Patient’s completed sleep logs (see Chapter 2)
Outline ■ Present rationale for treatment ■ Provide sleep education ■ Review “sleep rules” and provide brief summary of each ■ Make time in bed (TIB) recommendations ■ Assign homework
Treatment Rationale Use the information from Chapter 1 to present the client with a brief overview of Cognitive-Behavioral Therapy (CBT) for Primary Insomnia (PI). Review with the patient Spielman’s 3-P model of insomnia and how it suggests that predisposing factors (e.g., biological or personality traits) and precipitating events (events or circumstances that are stressful or otherwise disruptive to normal sleep-wake routines) can lead to the development of
sleep problems. These problems are then made worse by various perpetuating mechanisms including unhelpful misconceptions about sleep, anxiety about sleeping poorly, conditioned arousal to the bed and bedroom, and various sleep disruptive habits (e.g., daytime napping, spending excessive time in bed). Explain that this treatment program is designed to correct those unhelpful sleep-related beliefs and anxiety as well as common sleepdisruptive habits that maintain or contribute to insomnia. You may use the following sample dialogue: We have conducted a thorough evaluation of your sleep problem, and based on our ﬁndings we believe you will beneﬁt from some information about sleep and some recommendations designed to help you change your sleep habits. When sleep problems linger on, as they have in your case, usually unhelpful sleep-related beliefs and habits develop and add to the sleep problem. The treatment you receive will educate you about your sleep problem and help you correct those unhelpful beliefs and habits you have so that you can again develop a more normal sleep pattern. Then, move on to providing the patient with information about sleep.
Sleep Education The sleep education provided to patients during CBT has two primary functions. First, it helps patients overcome their misconceptions and anxiety-provoking beliefs about sleep so that they may develop realistic sleep expectations. Also, it enables patients to better understand the rationale for the behavioral regimen used in this treatment. This understanding, in turn, increases the likelihood that patients will adhere to treatment recommendations. During this ﬁrst session of treatment, provide the patient with information on sleep norms, circadian rhythms, the eﬀects of aging on sleep, and sleep deprivation. If you wish, you may audiotape this part of the session and give a copy of the tape to the patient to review at home. This information also appears in the corresponding patient workbook. You may use the following sample dialogue:
This treatment will require you to make some major changes in your sleep habits so you can improve your sleep. However, before you learn these new habits, it is important that you have a better understanding of your sleep needs and what controls the amount and quality of sleep you obtain. The information I’m about to give you will help you understand how your body’s sleep system works and prepare you for the speciﬁc treatment suggestions you will be given. Before you make any changes in your sleep habits, it is important that you ask the question, “How much sleep do I need each night?” Generally speaking, there is no one amount of sleep that “ﬁts” everyone. Most normal adults sleep 6 to 8 hours per night. However, some people need only 3 or 4 hours of sleep each night, whereas others require 10 to 12 hours of sleep on a nightly basis. At this point, it is important to set aside any previous notions or beliefs you might have about your sleep needs. These beliefs may be wrong and may hinder your progress. The treatment we give you will help you discover the amount of sleep that satisﬁes your needs and lets you feel alert and energetic during the day. In addition to getting rid of any old ideas you have about your sleep needs, it is important that you learn some things about how your body’s sleep system works. People, like many animals, have powerful internal “clocks” that aﬀect their behavior and bodily functioning. The “body clock” works in roughly a 24-hour period and produces 24-hour cycles in such things as digestion, body temperature, and the sleep-wake pattern. For example, if we record a person’s body temperature for several days in a row, we will see a consistent up and down pattern or rhythm in temperature across each 24-hour day. The temperature will be at its lowest point around 3 or 4 AM, will rise throughout the morning and early afternoon, and will hit its peak around 3 or 4 PM. Then, once again the temperature will begin to fall until it hits its low point in the early morning hours. The inﬂuence of the internal circadian clock on the sleep-wake cycle is apparent if one studies the relationship between the body’s 24-hour temperature rhythm and the timing of the sleep period. Suppose a person is placed in a place like a cave, away from daylight, external clocks, and all other time-of-day indicators. In this situation, the person will continue to show a consistent temperature rhythm and sleep-wake pattern that complete a full cycle about every 24 hours. In most people, there is
a close relationship between the temperature cycle and the sleep-wake pattern they show. This relationship is shown in the Circadian Temperature Rhythm graph included in your workbook. (Direct the patient to the graph in the workbook or show him Figure 3.1.) As shown by this graph, the main sleep period begins when the body temperature is falling and later ends after the body temperature begins rising again. Hence, although the 24-hour temperature cycle shown does not control the human sleep-wake pattern, the temperature rhythm reﬂects the working of the body clock and can be used to predict when sleep is likely to occur in the 24-hour day. In the real world, work schedules, meal times, and other activities work together with our body clocks to help us keep a stable sleep-wake pattern. However, signiﬁcant changes in our sleep-wake schedule can interfere with our ability to sleep normally. This may be caused by what is often called “jet lag.” If, for example, a man who lives in New York ﬂies to Los Angeles, he initially is likely to have some diﬃculty with his sleep and to experience some daytime fatigue once he arrives in California. This occurs because the 3-hour time-zone change places his new desired sleep-wake schedule at odds with his “body clock” that is “stuck” in his old time zone. This situation is shown in the second graph included in your workbook. (Direct the patient to the graph in Chapter 2 of the workbook or show him Figure 3.2.) The man’s body clock remains on New York time and initially lags behind the real-world clock time in California. This traveler is likely to become sleepy 3 hours earlier than he wishes and to wake up 3 hours before he prefers on the initial days of his trip. Fortunately, with repeated exposure to the light-dark pattern in the new time zone, the body clock resets and allows the traveler to “get in sync” with the new time zone. However, this traveler is again likely to experience temporary problems with his sleep and daytime fatigue when he ﬁrst returns to New York. In addition to our body clock, getting older usually leads to changes in our sleep. As we age, we tend to spend more time
Circadian Temperature Variation 12:00 AM
Figure 3.1 Circadian Temperature Rhythm
Circadian Temperature Rhythm
Biological Wake Time
Circadian Variation 12:00 AM
Circadian Temperature Rhythm
12:00 PM 6:00 PM 12:00 AM 6:00 AM 12:00 PM 6:00 PM 12:00 AM
Figure 3.2 Eﬀects of Jet Lag
Desired Sleep/Wake Schedule
awake in bed and less time in the deepest parts of sleep. Because sleep becomes more “shallow” and broken as we age, we may notice a decrease in the quality of our sleep as we grow older. Although these changes set the stage for the development of sleep problems, they do not guarantee such problems. However, because of these changes, it is probably unrealistic to expect that you will again have the type of sleep you enjoyed at a much younger age than you are now. Finally, before attempting to change your sleep habits, it is important that you understand the eﬀects of sleep loss on you. This understanding is important because many who have sleep problems make these problems worse by what they do to make up for lost sleep. For example, people may take daytime naps, go to bed too early, or “sleep in” following a poor night’s sleep in order to avoid or recover lost sleep. Although these habits seem logical and sensible, they all may serve to continue the sleep problems. In fact, these habits are usually the opposite of what needs to be done to improve sleep. In some respects, losing sleep one night may lead to getting more or better sleep the following night. In fact, the drive to sleep gets stronger the longer one is awake before attempting to sleep again. For example, a person is much more likely to sleep for a long time after being awake for 16 hours in a row than after being awake for only 2 hours. It is important to remain awake through each day in order to build up enough sleep drive to produce a full night’s sleep. Extended periods of sleep loss, of course, may have some bad eﬀects as well. If people are totally deprived of a night’s sleep, they usually become very sleepy, have some trouble concentrating, and generally feel somewhat irritable. However, they typically can continue most normal daytime activities even after a night without any sleep at all. When allowed to sleep after a longer than normal period of being awake, most people will tend to sleep longer and more deeply than they typically do on a normal night. Although people tend not to recover all of the sleep time they lost, they do typically recover the deep sleep they lost during longer than usual periods without sleep. Hence, your body’s sleep system has some ability to make up for times when you don’t get the amount of sleep you need.
Since you have kept a sleep log for a couple of weeks, you have probably noticed that you occasionally had a relatively good night’s sleep after one or several nights of poor sleep. Such a pattern suggests that your body’s sleep system has an ability to make up for some of the sleep loss you experience over time. Although your sleep is not normal, you can take some comfort in this observation. The important point to remember is that you do not need to worry a great deal about lost sleep nor should you actively try to recover lost sleep. Needless worry and attempts to recover lost sleep will only worsen your sleep problem. This information is not intended to “make light” of your sleep problem. You do indeed have a sleep problem that needs to be treated. This discussion is intended to help you to understand your problem. With this knowledge you should now understand the purpose for the treatment recommendations I’m making. Do you have any questions about what you have just heard ?
Behavioral Treatment Regimen The behavioral treatment regimen uses stimulus control and sleep restriction strategies to standardize the patient’s sleep-wake schedule, eliminate sleep-incompatible behaviors that occur in the bed and bedroom, and restrict time in bed (TIB) in an eﬀort to force the development of an eﬃcient, consolidated sleep pattern. The majority of behavioral recommendations included in this regimen are standard for all patients. However, the TIB prescriptions provided are based on a pretreatment estimate (derived from sleep logs) of each patient’s sleep requirement. Since TIB prescriptions may vary from patient to patient, these prescriptions allow for the tailoring of this regimen to ﬁt each patient’s speciﬁc sleep needs. Refer the patient to the sleep improvement guidelines in Chapter 2 of the workbook and provide a brief justiﬁcation for each behavioral recommendation included in the regimen. The workbook provides a list of “rules” to follow and also includes space for the patient to note his or her standard wake-up time and suggested earliest bedtime. You may use the following sample dialogues as you review each sleep rule with the patient.
Rule 1: Select a Standard Wake-Up Time Emphasize the importance of choosing a standard wake-up time and sticking to it every day regardless of how much sleep the patient actually gets on any given night. This practice will help the patient develop a more stable sleep pattern. As discussed earlier in the session, changes in your sleep-wake schedule can disturb your sleep. In fact, you can create the type of sleep problem that occurs in jet lag by varying your wake-up time from day to day. If you stick to a standard wake-up time, you will soon notice that you usually will become sleepy at about the right time each evening to allow you to get the sleep you need.
Rule 2: Use the Bed Only for Sleeping Explain to the patient why it is critical that the bed be used only for sleeping and sexual activity. While in bed, you should avoid doing things that you do when you are awake. Do not read, watch TV, eat, study, use the phone, or do other things that require you to be awake while you are in bed. If you frequently use your bed for activities other than sleep, you are unintentionally training yourself to stay awake in bed. If you avoid these activities while in bed, your bed will eventually become a place where it is easy to go to sleep and stay asleep. Sexual activity is the only exception to this rule.
Rule 3: Get Up When You Can’t Sleep Many people linger in bed for minutes, or even hours, when they can’t fall asleep. Lying in bed awake and trying harder and harder to go to sleep only increases anxiety and frustration which make the sleeping problem worse. Never stay in bed, either at the beginning of the night or during the middle of the night, for extended periods without being asleep. Long periods of being awake in bed usually lead to tossing and turning,
becoming frustrated, or worrying about not sleeping. These reactions, in turn, make it more diﬃcult to fall asleep. Also, if you lie in bed awake for long periods, you are training yourself to be awake in bed. When sleep does not come on or return quickly, it is best to get up, go to another room, and return to bed only when you feel sleepy enough to fall asleep quickly. Generally speaking, you should get up if you ﬁnd yourself awake for 20 minutes or so and you do not feel as though you are about to go to sleep.
Rule 4: Don’t Worry, Plan, etc., in Bed Bedtime is not the time to attempt problem solving or to engage in thinking or worrying. Engaging in these sorts of activities only serves to keep the mind awake, making it extremely diﬃcult to fall asleep. Do not worry, mull over your problems, plan future events, or do other thinking while in bed. These activities are bad mental habits. If your mind seems to be racing or you can’t seem to shut oﬀ your thoughts, get up and go to another room until you can return to bed without this thinking interrupting your sleep. If this disruptive thinking occurs frequently, you may ﬁnd it helpful to routinely set aside a time early each evening to do the thinking, problem solving, and planning you need to do. If you start this practice you probably will have fewer intrusive thoughts while you are in bed.
Rule 5: Avoid Daytime Napping Strongly recommend to the patient that he refrain from taking daytime naps. If the patient absolutely must take a daytime nap, instruct him to keep it to less than an hour and to complete it before 3:00 PM. However, the patient should do all that he can to avoid taking naps, regardless of how tired he may be. You should avoid all daytime napping. Sleeping during the day partially satisﬁes your sleep needs and, thus, will weaken your sleep drive at night.
Rule 6: Go to Bed When You Are Sleepy, but Not Before the Time Suggested Advise the patient to attempt sleep only when he is feeling sleepy. In general, you should go to bed when you feel sleepy. However, you should not go to bed so early that you ﬁnd yourself spending far more time in bed each night than you need for sleep. Spending too much time in bed results in a very broken night’s sleep. If you spend too much time in bed, you may actually make your sleep problem worse. I will help you to decide the amount of time to spend in bed and what times you should go to bed at night and get out of bed in the morning.
Determining Time in Bed Prescriptions As brieﬂy discussed in Chapter 2, you will use the patient’s pretreatment sleep logs to determine how much time he or she should stay in bed. First, calculate the average total sleep time (ATST) displayed by the patient as shown on his completed sleep logs. Then, use the following formula to make a recommendation of how long the patient should remain in bed each night.
Time in Bed (TIB)
Average Total Sleep Time (ATST)
Remember to add 30 minutes, which accounts for the time it takes to fall asleep as well as a few normal, brief nocturnal arousals. To illustrate how a TIB prescription is determined, consider the sleep log data shown in Figure 3.3. This log presents 6 days worth of data as well as calculations of the average total sleep time (ATST) and average time in bed across this 6-day period. Note in this example the patient slept 400 minutes per night, on average, but had an average time in bed of 540 minutes (i.e., 9 hours) per night. The ATST falls between 61⁄2 and 7 hours and, as such, does not seem at all abnormal. However, there is a marked discrepancy between the average time slept and the average time in bed. Given the data shown, the TIB prescription derived using the above formula would be 430 minutes, or 7 hours and 10 minutes. Hence, that TIB prescription
would be used as the initial time allotment for the nocturnal sleep period. Of course, patient preferences should be considered when establishing the initial TIB allotment, and it is perfectly acceptable to round the TIB prescription identiﬁed in this example to either 7 hours or 71⁄4 hours if such rounding helps with the patient’s sleep scheduling. It should be noted that in practice it is preferable to derive the initial TIB prescription from sleep log data collected for 2 or more weeks so that a more stable estimate of ATST can be made. Once the initial TIB prescription is determined, it is important to help the patient choose a standard wake-up time and earliest bedtime so that the prescription can be followed. In doing so, it is important to have the patient consider both “ends” of the night. A patient may initially decide that 7:00 AM is a desirable wake-up time. That choice may seem reasonable to the patient with the TIB prescription derived in the preceding example. However, if the initial TIB prescription is much shorter, say 6 hours, this wake-up time would result in an earliest bedtime of 1:00 AM. Upon discovering this fact, the patient may wish to select an earlier wake-up time so that bedtime can be earlier during the night. Whatever wake-up and bedtimes are chosen, it is important to involve the patient in this decision-making process. Adherence to the TIB prescription will usually be best when the patient takes an active role in selecting his own bed and wake-up times.
Managing Patients’ Expectations and Treatment Adherence Once the treatment regimen has been explained and an agreed upon sleep schedule has been established, it is helpful to provide the patient some additional information about the likely course of treatment and the importance of treatment adherence. Most treatment-seeking insomnia patients are notably distressed by their sleep-wake disturbances and desire rapid relief from such symptoms. However, as is the case with most psychological and behavioral interventions, the current treatment produces improvements gradually and requires consistent treatment adherence on the patient’s part to achieve optimal results. In our experience, most patients who show consistent adherence to the behavioral strategies described earlier show marked reductions in their wake time during the night within the ﬁrst 2 to 3 weeks
Day of the Week Calendar Date
1. Yesterday I napped from _____ to _____ (note time of all naps). 2. Last night I took ______ mg of _____ or _____ of alcohol as a sleep aid (include all prescription and over-the-counter sleep aids). 3. Last night I got in my bed at ______ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at ______ (AM or PM?). 5. After turning oﬀ the lights it took me about _____ minutes to fall asleep. 6. I woke from sleep ______ times. (Do not count your ﬁnal awakening here.) 7. My awakenings lasted _______ minutes. (List each awakening separately.) 8. Today I woke up at _______ (AM or PM?). (NOTE: this is your ﬁnal awakening.) 9. Today I got out of bed for the day at ____ (AM or PM?). 10. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent 1 2 3 4 5 6 7 8 9 10 11. How well rested did you feel upon arising today? Not at All Somewhat Well Rested 1 2 3 4 5 6 7 8 9 10
Mon 3/5 None None
Tue 3/6 None None
Wed 3/ 7 None None
Thurs 3/8 None None
Fri 3/9 None None
Sat 3/10 None None
11:00 PM 11:30 PM 11:15 PM 10:30 PM 11:15 PM 10:30 PM 11:30 PM 11:30 PM 11:15 PM 11:00 PM 11:15 PM 10:50 PM 20 min 2 35 min 1 75 min 3 10 min 25 min 30 min 7:15 AM 45 min 2 15 min 1 20 min 2
25 min 15 min 6:30 AM 7:00 AM 2
60min 7:00 AM 7:30 AM 3
60 min 40 min 7:30 AM
30 min 45 min
7:00 AM 7:15 AM 7:15 AM 7:30 AM 2 3
7:30 AM 7:45 AM 2 3
AVERAGE Total Sleep Time Time in Bed 360 min 480 min 415 min 540 min 400 min 555 min 425 min 615 min 390 min 510 min 410 min 540 min 400 min 540 min 43
Figure 3.3 Calculating a Time in Bed (TIB) Prescription
of treatment implementation. Improvements (increases) in average sleep time at night are less dramatic and occur much more gradually during treatment. However, many patients continue to appreciate some sleep time improvements even after formal treatment (therapist contact) ends. Of course, patients who do not adhere well to the treatment recommendations may improve more slowly or not at all. Thus, encouraging consistent treatment adherence is highly important to the treatment process and outcome overall. You may wish to use the following sort of dialogue to emphasize these points to the patient: Now that we have discussed what you are to do to improve your sleep, you should understand that it is important to follow all the recommendations we have discussed consistently each and every day of the week. If you are able to do that, you likely will start to see some improvements in your sleep within the next 2 to 3 weeks. You are likely to notice ﬁrst that the time you take to get to sleep and the amount of time you spend awake during the night will decrease signiﬁcantly. Although you may not see large changes in the amount of time you sleep each night during this time period, your sleep should start to become more solid and restorative. However, if you do not follow the recommendations we have discussed consistently, your progress will likely be much slower or you may not see any signiﬁcant changes in your sleep. Thus, it is important that you follow the treatment recommendations we discussed consistently so that you obtain the types of results you are seeking. As you begin this treatment at home, it is also important for you to understand that the sleep schedule we agreed upon for you today may leave you feeling a little sleepy in the daytime, particularly during the ﬁrst week as you get adjusted to this new schedule. If you notice an increase in sleepiness, avoid activities wherein your sleepiness might be dangerous to you such as driving long distances or operating hazardous machinery. If you continue to feel sleepy in the daytime beyond the ﬁrst week, that usually means we have limited your time in bed at night too much and you would beneﬁt by increasing this time somewhat. If this is the case when you return for your next session, we will review your sleep logs and make the needed adjustments in your nightly sleep schedule to
address this problem. Moreover, we can continue to make such adjustments from session to session until we arrive at the schedule that works best for you. It is important that you follow the treatment recommendations consistently from week to week and chart your progress on the sleep logs in your workbook. This will allow us to assess your progress and determine what, if any, changes in your schedule might be needed.
Managing Patients Unable to Attend Routine Follow-Up Sessions It is desirable to provide patients one or more return visits to encourage and reinforce treatment adherence, resolve diﬃculties they are having with treatment enactment, and assist them in making TIB adjustments. However, we encounter some patients who live a great distance from our clinic or for other reasons are not able to return for follow-up sessions. Both our clinical experiences and our recent research ﬁndings (Edinger et al., 2007) suggest that some patients are able to achieve signiﬁcant sleep improvements over time following only one session wherein the information covered in this chapter is presented. However, in such cases, it is useful to give the patient instructions that will enable him to make needed TIB alterations to establish an optimal sleep wake pattern. For such individuals, you may use the following sample dialogue: You should try this sleep-wake schedule for at least two weeks and determine how well you sleep at night and how tired or alert you feel in the daytime. If you sleep well most nights and are as alert as you would like to be in the daytime, then you probably should make no changes in your time in bed each night. If, however, you ﬁnd you are sleeping well at night, but you feel tired most days, you should try increasing your time in bed at night by 15 minutes. If, for example, you begin with 7 hours in bed per night the ﬁrst week and ﬁnd that you are tired in the daytime despite sleeping soundly at night, you should try spending 7 hours and 15 minutes in bed each night during the second week. If, with this amount of time in bed, you continue to sleep soundly at night but still feel tired in the daytime, you can add another 15 minutes to the time in bed during the third week and so on.
However, when you notice an increase in the amount of time you are awake in bed each night, you will know that you are spending too much time in bed at night. If this occurs, you should decrease your time in bed by 15 minutes per week until you ﬁnd the amount of time that enables you to sleep soundly through the night and feel reasonably alert in the daytime. You should also decrease your time in bed after the ﬁrst 2 weeks if the initial amount of time in bed we choose together today does not reduce your time awake in bed each night. To help you make decisions about changing your time in bed, it may be helpful to consider some simple guidelines. If you routinely take more than 30 minutes to fall asleep or you are routinely awake for more than 30 minutes during the night, you probably should reduce the amount of time you spend in bed each night. You also should consider decreasing your time in bed if you ﬁnd that you routinely awaken more than 30 minutes before you plan to. Of course, the key word here is “routinely.” Occasional nights during which you have a somewhat delayed start to your sleep or you have more wakefulness than usual once you get to sleep, should not be viewed as reasons for changing your sleep schedule. Only when such occurrences are frequent or routine should you try a somewhat shorter time in bed. In the end, the best guideline to use is how you feel each day. If you are satisﬁed with how you generally feel in the daytime, you can assume that the sleep you are obtaining at night is suﬃcient.
Providing Basic Sleep Hygiene Education In addition to providing the sleep improvement guidelines mentioned earlier, the patient should be given some standard sleep hygiene education and instructions to encourage lifestyle practices that promote sleep quality and daytime alertness. These recommendations are a common component of behavioral insomnia therapy, have good “face validity,” and are easily understood by the majority of patients. They are also included in Chapter 2 of the workbook. To facilitate the patient’s acceptance of and
adherence to these recommendations, the following rationale should ﬁrst be provided to the patient. The sorts of daytime activities in which you engage, the foods and beverages you consume, and the surroundings in which you sleep may all inﬂuence how well you sleep at night and how you feel in the daytime. Thus, in addition to making the speciﬁc changes to your sleep habits we have discussed, you also may beneﬁt from making some changes to your lifestyle and bedroom to promote a more normal sleep-wake pattern. Once this general rationale has been presented, the patient should be given the speciﬁc sleep hygiene recommendations described in the following instructions: Recommendation 1: Limit your use of caﬀeinated foods and beverages such as coﬀee, tea, soft drinks with added caﬀeine, or chocolates. Caﬀeine is a stimulant that may make it harder for you to sleep well at night. You should also know that caﬀeine stays in your system for several hours after you consume it. Therefore, we recommend that you limit your caﬀeine to the equivalent of no more than three cups of coﬀee per day and that you not consume caﬀeine in the late afternoon or evening hours. Recommendation 2: Limit your use of alcohol. Alcoholic beverages may make you drowsy and fall asleep more easily. However, alcohol also usually causes sleep to be much more broken and far less refreshing than normal. Therefore, we recommend against using much alcohol in the evening or using alcohol as a sleep aid. Recommendation 3: Try some regular moderate exercise such as walking, swimming, or bike riding. Generally, such exercise performed in the late afternoon or early evening leads to deeper sleep at night. Also improving your ﬁtness level, no matter when you choose to exercise, will likely improve the quality of your sleep. However, avoid exercise right before bedtime because it may make it harder to get to sleep quickly. Recommendation 4: Try a light bedtime snack that includes such items as cheese, milk, or peanut butter. These foods contain chemicals that your body uses to produce sleep. As a result, this type of bedtime snack may actually bring on drowsiness.
Recommendation 5: Make sure that your bedroom is quiet and dark. Noise and even dim light may interrupt or shorten your sleep. You can block out unwanted noise by wearing earplugs, running a fan, or using a so-called “white noise” machine that is speciﬁcally designed to screen sleep-disruptive noise. Also, if possible, eliminate the use of night-lights and consider using dark shades in your bedroom so that unwanted light does not awaken you too early in the morning. Recommendation 6: Make sure the temperature in your bedroom is comfortable. Generally speaking, temperatures much above 75 degrees Fahrenheit cause unwanted wake-ups from sleep. Thus, during hot weather, we suggest you use an air conditioner to control the temperature in your bedroom. Before closing the session and assigning homework, review the patient’s expectations for treatment and encourage consistent treatment adherence. Also ask the patient if he has any questions about today’s session.
✎ Instruct the patient to review the sleep education material in the workbook (or listen to the audiotape recording if one was made), as well as the sleep rules and recommendations outlined
✎ Instruct the patient to continue recording his sleep habits using the
sleep logs provided in the workbook
✎ For patients who cannot return for routine follow-up, review methods
for adjusting TIB prescriptions if necessary, based on the information provided in today’s session
Session 2: Cognitive Therapy Components
(Corresponds to chapter 3 of the workbook)
Materials Needed ■ Patient’s completed sleep logs ■ Audiotape to record cognitive education segment of session (optional) ■ Constructive Worry Worksheet and instructions for completion ■ Thought Record and instructions for completion
Outline ■ Review and comment on sleep log ﬁndings showing progress and treatment adherence ■ Provide cognitive rationale to patient ■ Discuss Constructive Worry technique ■ Discuss use of Thought Records ■ Assign homework
Review Homework and Treatment Adherence Speciﬁcally targeting cognitive change may be important for increased adherence to behavioral recommendations, as well as eliminating sleepinterfering thoughts. As a result, Session 2 is devoted to restructuring
cognitions and outlining strategies for mental overactivity. You may use the following sample dialogue to begin the session: Today we will be focusing on the role of thoughts in insomnia, but before we do, I’d like to check in on your experience with some of the recommendations from last session. Review the patient’s completed sleep logs and check in on the recommendations by asking how each one went. Be sure to praise all instances of adherence. In areas of non-adherence, try to frame it positively: I can see that you had some trouble getting out of bed in the morning, but I also notice that you were able to do this on two of the mornings. That’s great. Let’s return to this issue at the end of this session and see if we can ﬁgure out a way to increase this to 7 days a week.
Cognitive Rationale for Patient Begin a discussion about the role of cognitions in the maintenance of insomnia. You may use the following sample dialogue: Last week we focused on changing behaviors that had negative eﬀects on sleep. Today, we will discuss the role of your thoughts in insomnia and give you strategies to help with any problems you may be having in this regard. Speciﬁcally, we will focus on how thoughts and beliefs can cause insomnia or at least make it worse. What role do thoughts play in insomnia? Some people don’t even consider that how we think and how we feel can have a huge impact on how we sleep. It turns out that what and how we think aﬀects how we sleep, how we feel, and how we deal with periods of sleep loss. Lots of research and conversations with insomnia patients have led us to conclude that there is a particular way of thinking associated with insomnia. We call it the “Insomnia Brain” because most people tell us that this way of thinking is not typical of how they normally think, but since they have had insomnia, their type of thinking has changed and the way they view sleep has changed too. The Insomnia Brain tends to be very “noisy” and very focused on the eﬀects of not sleeping. Let’s take a few minutes to examine the Insomnia Brain and we’ll oﬀer some strategies for managing this unhelpful state of mind.
Negative thoughts in the insomnia brain spread like wildﬁre. All the thoughts are negative and they are usually related in some way. Positive thoughts don’t make it in. Most people with insomnia tell us, “I don’t understand it, I am not usually a worrier, but once I get into bed I think about the weirdest things and I have no control.” This is the Insomnia Brain—and it can seem unrelenting. Do you have diﬃculty shutting your mind oﬀ at night? The problem is that we cannot sleep when our brain is alert. Moreover, the more this happens in your bed on a nightly basis, the more likely it is to continue to happen. This is because it becomes an unintentional and unwanted habit. The good news is that all habits can be broken if you have a good strategy. Do you tend to get upset about not sleeping or worry about whether or not you will be able to manage during the day? Many people with insomnia will say, “I wasn’t worried at all today but as soon as my head hit the pillow, it was like a switch went oﬀ.” Does this ever happen to you? It means that your bed has become a signal for worry and upset. There are ways to change this signal. Remember your homework from last session? You were to leave the room when you were unable to sleep. One of the most eﬀective strategies for quieting an active mind is to leave the bedroom when your mind starts to take over. This will break the habit. It may take several attempts at ﬁrst but your brain will eventually get the picture that your bed is not the place for it to be active. This practice may have other beneﬁts too. Taking the Insomnia Brain out of bed results in becoming more clearheaded and being better able to switch oﬀ your troublesome thinking. Most people tell us that the worry they could not switch oﬀ in the bedroom became a nonworry in the living room. So, do yourself a favor and get out of the domain of the Insomnia Brain temporarily. You can return to the bed when you are no longer worrying or problem solving. Some people are concerned that getting out of bed will limit their opportunity for sleep, but the chance of you sleeping while your brain is active is limited. Getting this type of mental activity under control by spending a few minutes out of bed will increase your chances of being able to sleep.
Assess if the patient has any questions and whether any of this discussion seems to be personally applicable. Reinforce the patient’s identiﬁcation with the problem. For example, if the patient says, “I deﬁnitely worry in bed about every little thing.” Be sure to say, “Okay, then it’s going to be important for us to focus on this and for you to complete some additional homework over the next 2 weeks.”
Constructive Worry Many people with insomnia complain of “unﬁnished business” following them into the bedroom and creating arousal/distress in bed. Indeed, problem solving in the presleep period has been implicated as one of the strongest predictors of diﬃculties falling asleep (Wicklow & Espie, 2000). Espie and Lindsay (1987) were among the ﬁrst to report positive results for an early evening procedure that targeted presleep worry. Similarly, Carney and Waters (2006) demonstrated that a single night of using an early evening procedure called Constructive Worry results in decreased presleep arousal. As a result, providing a tool to manage nocturnal worry is often helpful. If nighttime worry is a signiﬁcant issue, it is important to pair this procedure with stimulus control (i.e., the instruction to leave the bedroom when problem solving or worrying) and other stress management techniques such as relaxation and/or time management techniques. Introduce the exercise with a rationale such as the following: While most people ﬁnd that getting out of the bed is enough to address their nighttime worry problem, some continue to worry. Some bedtime worries are a result of keeping so busy during the day that no time is available to deal with the worries. Sleep is the ﬁrst opportunity that is quiet enough for your brain to try to complete its unﬁnished business. Does this sound like it applies to you? The Constructive Worry Worksheet is taken from Carney & Waters (2006) and copies for the patient’s use are provided in the workbook. A sample, completed worksheet is shown in Figure 4.1. The following instructions also appear in the workbook and should be used as a guide when completing the worksheet with the patient in session.
Write down the problems facing you that have the greatest chances of keeping you awake at bedtime, and list them in the “Concerns” column. Then, for each problem you list, think of the next step you might take to help ﬁx it. Write it down in the “Solutions” column. This need not be the ﬁnal solution to the problem, since most problems have to be solved by taking a series of steps anyway, and you will be doing this problem-solving task again tomorrow night and the night after until you ﬁnally get to the best solution. ■ If you know how to ﬁx the problem completely, then write that down. ■ If you decide that this is not really a big problem, and you will just deal with it when the time comes, then write that down. ■ If you decide that you simply do not know what to do about it, and need to ask someone to help you, write that down. ■ If you decide that it is a problem, but there seems to be no good solution at all, and that you will just have to live with it, write that down, with a note to yourself that maybe sometime soon you or someone you know will give you a clue that will lead you to a solution.
Repeat this for any other concerns you may have.
4. Fold the Constructive Worry Worksheet in half and place it on the nightstand next to your bed and forget about it until bedtime. 5. At bedtime, if you begin to worry, actually tell yourself that you have dealt with your problems already in the best way you know how, and when you were at your problem-solving best. Remind yourself that you will be working on them again tomorrow evening and that nothing you can do while you are so tired can help you any more than what you have already done; more eﬀort will only make matters worse.
Review the Constructive Worry Worksheet with the patient and ask him or her to try to ﬁll it out each evening. If the patient has diﬃculty thinking of any worries on a particular night, instruct the patient to write
CONCERNS 1. The air conditioning isn’t working in the car 1.
SOLUTIONS Could ask my wife if she has time to take it in 2. Could call tomorrow for a Saturday appointment
1. Will make an appointment with our financial planner tomorrow 2 Will agree to that project for extra income
3. Will cut out my latte over the next month 4. I will wait until my credit card is due to pay it
Figure 4.1 Example of completed Completed Constructive Worry Worksheet
down “No Concerns.” Also, be sure to ask the patient if she foresees any barriers to completing this exercise. Finally, engage in problem solving with the patient to reduce such barriers to adherence.
Thought Records Cognitive restructuring is most often associated with the seminal text Cognitive Therapy of Depression by Aaron Beck and colleagues (Beck, Rush, Shaw, & Emery, 1979). Beck et al. wrote about fears of becoming ill as a result of insomnia and the discrepancy between objective and subjective sleep time estimation in people with Major Depression. These observations are common features of people with insomnia irrespective of whether they have Major Depressive Disorder. Beck’s early writings were applied to insomnia by Morin (1993), who developed a cognitive therapy component for insomnia.
Morin suggested the use of the Thought Record to restructure some unhelpful or inﬂexible thoughts and beliefs about insomnia (Morin, 1993). In line with these works, we have found the following instructions to be useful. In addition to nighttime worry, sometimes we have thoughts or beliefs about sleep that can actually make sleep worse. Most beliefs about sleep boil down to a fear about whether we will be able to cope with the insomnia. It is common for people with insomnia to worry about whether they will lose control over their abilities to sleep, whether they will become sick as a result of the insomnia, and even whether they may “go crazy” if their insomnia persists. These worries can be very frightening, so it is often helpful to take a more critical look at the types of beliefs that lead to such distress. The Thought Record is a very simple tool, yet we ﬁnd that it is a very powerful instrument. It’s powerful because it curbs the Insomnia Brain’s tendency to be negative and consider only the worst case scenarios of sleep loss. Balanced thoughts also challenge those beliefs that generate anxiety. Lastly, we ﬁnd that this tool helps people see that they are not powerless; their eﬀorts toward changing their sleep habits produce improvements in their sleep and in their daytime fatigue and mood. It is important to complete a Thought Record in session so that the patient understands it well enough to complete it between sessions. A sample, completed record is shown in Figure 4.2. A sample for the patient to use as a model, as well as blank copies for the patient to ﬁll out, is also included in the workbook. You may use the following suggested dialogue to help the patient complete a blank Thought Record during the session. Let’s walk through an example of a Thought Record to help with troubling thoughts or beliefs about sleep. Think of a time, perhaps even last night when you had strong feelings or upsetting thoughts related to your insomnia. What were you doing or where were you when you had these feelings or thoughts? Write them down in the Situation column. What kind of mood or feelings were you experiencing? Write down feelings in the Mood column. What are you thinking or what were you thinking when you began to feel this way?
Are you concerned about how you will deal with another day with this insomnia? Are you predicting that you’ll never sleep? Write these down in the Thoughts column. Even if some of your thoughts seem to be untrue or silly, it is important to write them down. There are no wrong thoughts to write down. The next step is to look at why this thought may seem true. What’s the evidence for this thought? Write this down in the Evidence for the Thought column. Most people can remember a time when they had diﬃculty dealing with their insomnia. The Insomnia Brain remembers this as “evidence” that you can’t deal with insomnia. But this is probably not the whole story. It is important to look more critically at these beliefs, and one way to do this is to think about whether this thought is true 100% of the time. For example, we may focus on the one instance in which we performed poorly at work and discount the thousands of times we have performed ﬁne even though it was diﬃcult. Or we overlook that there are small things that don’t support the thought. For example, we may forget that there have been times when we have felt good after a poor night’s sleep; or when we felt poorly after a good night’s sleep; or we jump to conclusions or focus on the worst possible outcome. Write all this evidence down in the Evidence against the Thought column. Examining the evidence against the belief forces the Insomnia Brain to focus on thoughts that are less anxiety-provoking or less frustrating. The last step in this process is to consider both the evidence for and against the belief and think of a thought that lies somewhere in the middle. This thought should consider that there may be some part of the evidence for the belief that may be true, but it should take into consideration that there is plenty of evidence against the belief. For example, a balanced alternative to the thought, “I’m never going to make it through tomorrow” is: “I sometimes feel groggy at work after a poor night, but not always, and I always seem to cope pretty well with it.” Write this new thought down in the Adaptive/Coping Statement column. Most people tend to feel a little better after completing this exercise. Try it over the next week or two until our next visit and we’ll review it then.
Situation Sitting at my desk thinking how sluggish I feel
Mood (Intensity 0–100%) Down (75%) Frustrated (100%) Worried (80%) Tired (100%)
Thoughts I’m never going to get through today I’m going to mess up I need to get some sleep I can’t concentrate I’m going to get sick if I keep going like this I can’t keep going on like this What’s wrong with me?
Evidence for the thought Last week I made a mistake on my report I’ve already stopped exercising I’m starting to feel less like doing things
Evidence against the thought I’ve made mistakes at work when I have had a good night’s sleep I’ve had insomnia for over a year and haven’t been sick I notice I feel a little better after lunch I always seem to have an ok day despite my insomnia
Adaptive/Coping statement I don’t feel my best, but the truth is, I always make it through (70%) Just because I don’t feel at my best, doesn’t mean that anything bad is going to happen (75%) I’ve noticed there are things I can do to cope with the fatigue, so it is not hopeless (80%)
Do you feel any differently? Down (30%) Frustrated (60%) Worried (10%) Tired (70%)
Figure 4.2 Example of completed Thought Record
In reviewing the Thought Record with the patient, it is important to indicate that the patient’s thoughts and feelings are valid. It is also important to acknowledge that you know it may seem diﬃcult to the patient to change her thoughts given how automatic they are. Ask the patient to explore whether there may be costs to having such strong conviction in these thoughts and whether these thoughts may be adding to the problem (i.e., emotional reasoning). This may be done by highlighting what Greenberger and Padesky (1995) call the Thought-Mood connection. For example, if the patient is having the thought, “I’m never going to get to sleep,” ask them how they feel when they think they are never going to get to sleep. Hopeful or hopeless? Is it setting up a self-fulﬁlling prophecy? It is also important to recognize that patients may present many types of “cognitive errors” (Beck et al., 1979) during both the in-session exercise and when using the Thought Record at home. It is very important to review such “errors” when patients present them, although it is not helpful to label them as “errors.” It is more helpful to explore them without labeling, and instead talk about particular “thinking styles” or “thought patterns” that occur when people’s moods are disturbed. The following are the most common unhelpful “thinking styles” or “thought patterns” we encounter in our insomnia patients when using Thought Records with them. Misattribution: people with insomnia tend to attribute any cognitive troubles or negative mood to poor sleep, and they discount several other factors. For example, it is normal to experience some grogginess for the ﬁrst 30–60 minutes upon awakening. It is called sleep inertia. Many people with insomnia who experience this on awakening believe that this is evidence that they had a poor night’s sleep and predict they consequently will have a bad day. Similarly, it is normal to experience an increase in sleepiness and a decline in mental and emotional functioning in the early afternoon. This is a normal phenomenon called the “post-lunch dip.” It corresponds to a “dip” in one’s body temperature after lunch. This is often the time when people with insomnia nap, cancel appointments, or leave work. They believe that this dip is evidence that they cannot function. Providing education on this phenomenon and focusing on coping strategies to ride out sleep inertia or the circadian dip (e.g., exposure to fresh air, activity, coping
statements such as “this is just temporary”) will be helpful for patients. Emotional Reasoning: Some patients focus on their feelings as facts. For example, they believe that the presence of anxious feelings is evidence that they will not sleep. Such a belief will lead to further anxiety when sleep does not come quickly. All-or-none thinking: “I didn’t sleep last night.” Explore with your patient the cost of thinking “I don’t sleep.” Is it increased anxiety? It is often helpful to train patients to “ﬁnd the missing sleep” in their sleep logs and to “catch themselves asleep.” Did they miss parts of the plot of the television program they were watching? When patients report that they have been awake “all night long,” ask what they were doing. It is highly unlikely that they were lying motionless in their bed for 8 hours without sleeping. Some patients have diﬃculty with sleep perception because their brain activity is “noisier” than most people when they sleep (Krystal et al., 2002). Some people need the reassurance that their body is “sleeping” from an objective standpoint and is thus restoring and protecting itself; however, it feels like very poor or “no” sleep because of the mental activity. Self-fulﬁlling prophecy: People with insomnia often predict that their day will be terrible because they had poor sleep—is it possible that they approach their day in a way that ensures this will be true? It has been said, “Whether you think you can or you cannot, you are right either way.” There is tremendous power in the mind’s ability to create a reality consistent with its beliefs. As a result, it is important to give the patient the option of creating a self-eﬃcacious, coping reality instead of a bleak one. Catastrophizing: “I’m going to go crazy.” The fear of serious mental or physical illness as a consequence of the insomnia is a common fear for insomnia suﬀerers. It is important to follow their fears to their most catastrophic conclusion to understand someone’s fear of insomnia. This has been described elsewhere (Burns, 1980) as the “downward arrow” method, which is illustrated in the following case vignette. In this dialogue, T represents the therapist and P represents the patient.
Case Vignette T: You told me that you start to worry as soon as you notice that you have been in bed an hour without sleeping. Can you tell me a little about the thoughts or images you experience when you notice the clock? P: I think, “Oh God, I have a big day at work tomorrow. If I don’t get to sleep, I’ll be useless at work.” T: You’re worried you’ll be useless at work, what would that mean? P: I could get into trouble. T: And then what? What would be the worst case scenario? P: Well, I’d get ﬁred, I guess. Well I probably wouldn’t get ﬁred, but that’s what I am worried about. T: Well let’s stay with this fear for a moment. Can you get a picture of getting ﬁred because of your insomnia? P: Yes, I’ve pictured it many times. My boss is telling me my work has been slipping and I look like I’m sleepwalking, so he’s going to let me go. T: And then what? P: Well, I could never do well on a job interview feeling the way I do, so I don’t think I could get another job. Well, maybe I could . . . T: Let’s stay with this a moment if you can. So you might not be able to ﬁnd another job? P: Well, yeah, and then I can’t pay my bills and then I’m homeless. T: So you’re homeless and then what? P: Well, that’s it. I’m homeless. I can’t take care of myself and I’ll be like that forever I guess. T: Wow, it sounds like there’s a lot riding on whether you get to sleep tonight. Maybe by looking at this chain of events operating below the surface we can understand why you become so anxious when you can’t sleep. Losing an hour of sleep triggers a chain of thoughts that leads to you becoming homeless forever. No wonder you are so upset when you get into bed. Do you think we could take a closer look at this belief?
Exploring this fear and empathizing that it’s no wonder the patient is worried about sleep when the stakes seem so high (i.e., it feels as though they may become ill), is a good starting point for modiﬁcation of this belief. Many patients are surprised that they have such catastrophic beliefs lurking beneath the surface. Mind reading: Some people with insomnia believe that others are “noticing” their poor performance. They may worry about this out of a fear of negative evaluation from others. This belief is often untrue because most people with insomnia function quite well. What tends to be diﬀerent after a poor night’s sleep is the amount of extra eﬀort required to do regular tasks (Espie and Lindsay, 1987). Even if the following belief is true, “People notice that I am incompetent at work because of my insomnia,” exploring whether it is true 100% of the time and exploring the consequences of holding such a belief can be helpful. For example, if there are fears of negative evaluation, believing that this is true will result in increased anxiety in performance situations. We know that anxiety can interfere with performance; thus, fears of poor performance will result in poorer performance. It is helpful to explore whether this formulation may apply to the patient and whether it would be useful to modify this belief. Overgeneralization: Overfocusing on a single instance (i.e., I had trouble completing my crossword puzzle this morning . . .) as proof that their beliefs are true (“ . . . so, I am mentally useless at work today.”) Encourage patients to see the range of evidence because people with insomnia tend to cope extraordinarily well 90% of the time. Discounting the positive/Focusing exclusively on the negatives: There are often hundreds of instances of coping and good functioning within the day that are discounted in lieu of one instance wherein functioning was lower (e.g., the patient forgets about one appointment). There are likely times when the patient may have had a poor night and still managed to have a good day. Similarly, there are often instances in which the patient may have voluntarily had a night with no sleep (e.g., stayed out late with friends) and had a good day afterwards. Lastly, many patients discount that there are days in which they had a good night’s sleep and did not have a good day. Explore all of these scenarios with your patient. Although we have focused on cognitive “errors” is it important to keep in mind that it is the “adaptiveness” of the beliefs that is important to
explore, not whether or not they are “true.” In other words, it is important to explore the consequences of the belief (i.e., does the belief increase anxiety?), because some beliefs are true to some extent. When beliefs become so rigid that they cause emotional arousal, it may be important to modify them. The goal is to give patients choices when their thoughts are activated. We want them to get into the habit of forcing themselves to consider alternative thoughts in addition to their negative thoughts. If it becomes a habit, they will have a choice. If their current pattern continues, it allows the Insomnia Brain to focus only on conﬁrmatory evidence (i.e., that they can’t cope, things are hopeless, etc.). Forcing the Insomnia Brain to consider other evidence will be uncomfortable at ﬁrst, but soon it will become a habit and these thoughts will lose their negative potency. In working through the Thought Record in session, you may note some patients have diﬃculties completing one or more of the columns. Some people mistake moods and thoughts, some people think that they have no thoughts (i.e., their mind is blank), some have trouble generating evidence, and others have diﬃculty integrating the evidence into a balanced thought. Greenberger and Padesky (1995) have many suggestions for helping patients who have these diﬃculties. The Situation column can be completed by asking the patient: “Who was with you when you started feeling bad? What were you doing? Where were you? When did it happen?” For example, a patient may tell you about a situation in which she started worrying about her ability to sleep that night. When probed with these questions, the patient can usually ﬁll in the blanks, and tell you she was in the living room with her spouse watching television after dinner. Moods are best described using one word. When patients need multiple words to describe a mood, they are most likely describing a thought instead. The Thoughts column can be challenging for some patients. You want to elicit what was going through the patient’s mind during the upsetting situation. Ask the patient to focus on the emotions as clues to what she was thinking. For example, if the mood is anxious, ask the patient if she can identify what caused the anxiety. It is then often helpful to have the patient consider the most extreme scenario by asking a series of questions: “You said you were anxious about waking up in the morning. What is the worst possible thing about waking up in the morning?
What is the worst case scenario?” Also, ask the patient if this situation reminds her of other similar situations. This usually results in generating some thoughts or images. If the patient had diﬃculty naming a mood and was instead listing “thoughts,” be sure to make note of these thoughts so you can present them for inclusion in the Thoughts column later. You can give patients the following hint to help identify thoughts in the future: “The next time you are experiencing a strong emotion, ask yourself to notice what is going through your mind.” Most automatic thoughts in insomnia patients relate to a fear that something is very wrong with them and that they are helpless to change it. Eliciting catastrophic statements from the patient’s thoughts is helpful to get at the core beliefs. For example, a patient is afraid of setting the alarm and reports the thought, “If I set the alarm then I know I will only have 7 hours to sleep, and every hour that goes by I’ll be thinking that I have to get up.” Ask the patient why having only 6 hours, or 5 hours, of sleep is distressing, and what is the worst case scenario imagined for that situation. Then, take the worst case scenario (e.g., getting ﬁred from a job because sleep loss is causing unacceptably poor work performance) and reﬂect it back to the patient such as: “Gosh, if you think you are going to get ﬁred because of your insomnia, it sounds as though there really is so much riding on you getting to sleep each night.” This will either elicit more catastrophic statements or the patient may engage in reporting evidence against the thought because the catastrophic nature of the thought is disconcerting. When generating automatic thoughts, it is usually important to generate several thoughts and not stop at one. One technique for facilitating the recording of multiple thoughts is to lead the patient to the next thought by repeating how she was thinking and feeling and ask what happened next: “So you were feeling anxious and thinking, ‘I’m going to have to call in sick.’ And then what?” Most patients do not have diﬃculty generating evidence for the thought in the Evidence for the Thought column, because the thoughts are seen as very compelling. One common problem is the tendency to rush through the evidence and say, “Yeah, but I know that’s not really true.” It’s important to spend some time on the evidence for the belief and reﬂect that the patient isn’t “crazy” so there must be a good reason to have this belief. Exploring the kernel of truth in the evidence for the belief is really important.
Generating items for the Evidence against the Thought column can be challenging for some patients. Keep track in earlier sessions of any evidence the patient cited that is contrary to the belief. For example, the patient may talk about a horrible day in which nothing catastrophic happened. Or the most feared situation (e.g., “going crazy”) has not occurred despite the fact that the patient had suﬀered from years of insomnia. Focusing on evidence of the patient’s eﬀective coping can also help here. The following questions may also help: ■ “If someone you cared about thought their insomnia problem was hopeless, would you tell them, ‘Yeah, you’re right, it is hopeless.’ Why not? Why wouldn’t this be helpful?” ■ “Are you discounting your strong coping skills? I’m impressed by the tremendous coping resources you seem to have.” ■ “Has there been a time in the past when you had very little sleep and functioned well?” ■ “Have there been times in the past when you had lots of sleep and felt poorly during the day?” ■ “Have there been situations when this thought is not true 100% of the time? For example, you say you get headaches when you have insomnia; do you have headaches every single day?” The “cognitive errors” discussed earlier may also help patients with this column. Generating an Adaptive/Coping Statement can be diﬃcult for patients. Some patients will focus on the evidence for the belief and have diﬃculty incorporating the evidence against the belief. Others will want to focus exclusively on the evidence against the thought, which is equally problematic. One of the easiest formulas to derive a coping statement is to start with a statement from the evidence for the belief column, and follow it with a “BUT,” and then a statement from the evidence against the belief column. For example, “I sometimes forget things at work, BUT, sometimes I forget things even if I had a decent night’s sleep.” Encourage the patient to modify this statement until it seems believable and it is something that can be remembered. Positively reinforce even tiny improvements in mood, as this is evidence that there has been some
input into the Insomnia Brain. For example, “Okay, so you are 5% less anxious? That’s still an improvement from 5 minutes ago. Small victories are important in this process, so good for you.” Patients will generally report that their mood is less negative following the exercise. If there has not been a mood improvement, see Chapter 5 for some troubleshooting tips. After jointly completing a Thought Record, ask if the patient has any questions and instruct her to complete a Thought Record whenever a negative sleep-related shift in thoughts or mood occurs. If patients initially have diﬃculty noticing this shift, get them to practice by retrospectively completing one Thought Record per day. The practice of recording the situation, moods, and thoughts components of the Thought Record will typically improve their ability to notice shifts in their mood or thinking, or at least recognize patterns in the types of situations that generally produce sleep-related thoughts or feelings. Remember, the goal in therapy is for the therapist to be replaced by the patient’s mastery of this new skill (i.e., the Thought Record). To gain mastery over the technique requires successful in-session exploration of records, as well as much between-session practice. Given the brevity of this treatment, there will likely be one or two opportunities to go through a Thought Record in-session. Be sure to make the most of these few opportunities and troubleshoot any problems with the technique.
Dealing With Resistance The best way to manage resistance is to reduce the likelihood that it will occur. It is important for the therapist not to directly challenge beliefs; rather, encourage the patient to scrutinize the belief. Patients who are directly challenged on a belief may be more likely to respond with reactance (Brehm & Cohen, 1962). That is, they are more likely to argue on behalf of the unhelpful belief. Collective empiricism (Beck et al., 1979) is the cornerstone of Cognitive Therapy. Eﬀective therapists help patients to explore the utility of holding the belief so strongly. Socratic questioning is often helpful in this regard. Socratic questioning is achieved by leading a patient through a series of questions designed to create uncertainty about the unhelpful belief. It is important to be eﬃcient in your questioning because a
long, unfocused series of questions can make the session feel like an interview. This is best done by having a clear idea of the conclusion you wish for the patient to reach. In the example that follows, the therapist wants the patient to consider stress as an additional explanation for her headaches and to focus on ways to manage the headaches.
Case Vignette T: So, you’re afraid that you are going to become seriously ill because of your insomnia? P: Deﬁnitely. I feel horrible, and I’m starting to get these really bad headaches. T: And the headaches are evidence that you may be getting sick? P: Yeah. My doctor ran some tests and said it was stress but I’m sure there is something else wrong. T: That must be scary to think that you have an undetected illness. I’m relieved that the tests haven’t revealed a serious illness. Wouldn’t it be good news if it were stress related? P: I guess. I don’t see how it could be stress. T: How much do you know about the kind of body changes stress produces? P: Not much. I guess it makes you tense. Are the headaches because of the tension? T: I’m not sure. Do you think they could be? P: I don’t know. I can’t believe it’s stress. T: Isn’t having insomnia stressful? P: It deﬁnitely is. T: Maybe we could spend a few minutes talking about stress symptoms and how to manage them?
One ﬁnal issue that may surface in therapy is when thoughts are related to believing that CBT will not work. It is important to explore resistance to therapy in a nonjudgmental, curious way. Many patients have tried several treatments and are understandably frustrated and scared that they are losing control over their ability to sleep. Highlighting the ambivalence is often important in this regard.
Case Vignette P: I have insomnia because of my Chronic Fatigue Syndrome, not because I have bad sleep habits. T: You may be right. But if we could improve your sleep, wouldn’t you like to try? P: I’ve tried a dozen pills and nothing works. I’ll never sleep better until they ﬁnd a cure for Chronic Fatigue Syndrome. T: It must be frustrating to have tried so many treatments in the past and nothing works. To try so many medications in the past makes me think that you would really like to improve your sleep. Would you like to try a new approach over the next couple of weeks? Would it hurt to try something that may help you sleep better? P: Well yeah, it may hurt. If something else doesn’t work, things will seem hopeless. T: Sounds like you’ve been feeling hopeless about your sleep. Is this something worth talking about? This brief interchange highlights how a patient’s initial resistance to CBT might be addressed.
✎ Instruct the patient to continue recording her sleep habits using the
sleep logs provided in the workbook
✎ Ask the patient to ﬁll out the Constructive Worry Worksheet in the
early evenings and bring completed forms to the follow-up session, if applicable
✎ Ask patients to also complete Thought Records whenever they notice a
sleep-related bothersome thought or feeling (e.g., usually at least one daily), and to bring these records to the follow-up session, if applicable
Once patients are provided the behavioral and cognitive strategies discussed in the previous two chapters, they usually beneﬁt from one or more follow-up sessions to (1) assist them in making needed adjustments in their TIB prescriptions, (2) encourage and reinforce their adherence to treatment recommendations, and (3) “troubleshoot” the problems they may be having with the behavioral or cognitive techniques they have been taught. There are no new materials needed during these follow-up sessions. The therapist should be guided by the patient’s self-report of progress as well as by a review of completed sleep logs, Constructive Worry Worksheets, and Thought Records. You should review all of these “homework” materials that the patient brings to the session and provide guidance as needed using the information that follows.
Adjusting Time in Bed Recommendations The method for making adjustments in TIB prescriptions was discussed in Chapter 3. Review the patient’s completed sleep logs each week and determine his average sleep eﬃciency during the week prior to the current session. Sleep eﬃciency is calculated by dividing the patient’s average total sleep time (ATST) over the time period since the previous session by the average time spent in bed (ATIB) and then multiplying the result by 100% (Sleep Eﬃciency (ATST/ATIB) 100%). If the patient’s sleep eﬃciency is 85% and the patient has noted daytime sleepiness with the current TIB prescription, suggest a 15-minute increase in TIB. Suggest a 15-minute decrease in TIB if the patient’s sleep eﬃciency is 80%. If the
patient is sleeping soundly most nights and feeling alert in the daytime, then no TIB adjustment is needed. At times patients will develop problems with excessive sleepiness as a result of restricting their TIB to the initially prescribed amount. This problem may occur in some insomnia patients who markedly underestimate their sleep time on their pre-therapy sleep logs. Other patients may experience increased anxiety when limits are placed on the times they allot for sleep. The following two case examples demonstrate the types of adjustments that can be made to address these diﬃculties. Case Example #1 ■ Ms. T. was a 72-year-old retired schoolteacher who presented with primary sleep maintenance insomnia. Initial evaluation showed that she manifested many sleep-disruptive habits such as frequent napping while watching the evening news and remaining in bed as much as 10 hours on some of her more diﬃcult nights. Given these ﬁndings, CBT was initiated. Pretreatment sleep logs had shown Ms. T.’s average sleep time at night to be approximately 6.5 hours, so she was initially restricted to 7 hours in bed each night at the start of treatment. Five days after her ﬁrst appointment she phoned the therapist with concerns about markedly increased daytime sleepiness. In fact, she noted that she had fallen asleep in her car after having stopped for a traﬃc light. Because of this, she had become concerned about driving her car and wondered what she should do. Questioning of the patient indicated that she had adhered to the TIB restriction very strictly and she was sleeping very soundly on most nights. However, she continued to feel sleepy in the daytime and had to constantly ﬁght oﬀ naps. Hence, the therapist suggested she increase her time in bed by 30 minutes per night to try to reduce this sleepiness. He also suggested that she ask her husband to take over all driving responsibilities until she returned to the clinic for follow-up 1 week later. Upon her presentation for her ensuing appointment, she reported reduced daytime sleepiness with the increased time in bed. Her sleep logs showed she was sleeping fairly well at night with very few extended awakenings. As she continued to report some mild sleepiness, the therapist suggested she add another 15 minutes to her TIB each night. After trying this new TIB prescription, she reported an elimination of her daytime sleepiness and a continuation of improved sleep at night. ■
Case Example #2 ■ Ms. C. was a 66-year-old retired female who presented with severe sleep-maintenance insomnia that developed after her retirement. Following an assessment that suggested a diagnosis of primary insomnia, she was begun on a course of CBT. After 2 weeks of following this regimen she returned to the clinic anxiously explaining that her sleep had gotten worse. Furthermore, she reported that the strict behavioral regimen made her very anxious and she felt under too much pressure to sleep. To address this problem, a more lenient TIB prescription was established and the patient was allowed to take a brief (30 min) daytime nap each day if she felt the need to do so. With these changes, the patient was able to relax and gradually showed nocturnal sleep improvements over the ensuing month of treatment. ■
Reviewing and Reinforcing Treatment Adherence In addition to assisting patients with setting their sleep and wake times, use the follow-up sessions to reinforce the patient’s adherence to the prescribed CBT regimen and completion of the Constructive Worry Worksheet and Thought Records. Assess patient adherence by reviewing the sleep rules and recommendations integral to this program (see Chapter 3 for list of sleep rules) and asking the patient about his adherence to each one. You should freely compliment the patient who closely follows all treatment recommendations and completes the cognitive homework exercises. In doing so, however, it is particularly useful to point out the relationship between the patient’s treatment adherence and improvement noted by his sleep logs or other outcome measure being used (see Chapter 2 for a list of measures and self-reports). For example, you may make comments such as, “You have done an excellent job following through on the strategies we discussed last time. As you can see, your eﬀorts have paid oﬀ. Your logs show that you are now sleeping much better. Keep up the good work!” In providing such comments it is important to remain genuine and avoid patronizing the patient. Thus, language that feels comfortable and consistent with the therapist’s usual interactional style should be used in reinforcing adherence.
Troubleshooting: Behavioral Component To a great extent, troubleshooting consists of assessing patient adherence to the sleep improvement guidelines and sleep hygiene recommendations. Often a lack of treatment response is traceable to the patient’s misunderstanding of, or non-adherence to, treatment recommendations. By far, the most common adherence problems are patients’ failures to adhere to a standard wake-up time, to get out of bed during the night when they are unable to sleep, and to refrain from unintentional sleeping during the daytime. A careful review of sleep logs should be employed to identify nonadherence with prescribed wake-up times. Also, speciﬁc questioning of the patient to determine the occurrence of daytime napping episodes and extended periods of wakefulness spent in bed should be conducted. When such problems are identiﬁed, review the behavioral regimen with the patient and talk about methods the patient can use to avoid these practices in the future. The following series of case examples demonstrate how patients’ diﬃculties enacting the sleep improvement guidelines and sleep hygiene recommendations may be managed during follow-up sessions. Case Example #3 ■ Mr. X. was a 61-year-old patient who presented to our sleep center with a complaint of sleep-maintenance insomnia. Evaluation of this patient suggested that he suﬀered from primary insomnia and warranted a trial of behavioral therapy. He was provided our CBT treatment as described in this manual. After 1 week of treatment, he reported back to our center noting little improvement. From a review of his sleep logs and a discussion with him, it was discovered that he failed to adhere to a standard wake-up time as instructed. In fact, on three of the nights during the ﬁrst week of treatment, he stayed in bed over 2 hours beyond his prescribed wake-up time reportedly to compensate for periods of wakefulness during the night. Also, he admitted to failing to get out of bed during extended periods of wakefulness because he thought that if he would lie in bed long enough he would eventually go to sleep. Although he adamantly denied daytime napping, he did admit to some unintentional dozing around 7:00 PM each evening while he was reclining on the couch watching TV. To correct the patient’s sleep problem, the therapist ﬁrst explained the deleterious eﬀect the noted nonadherence would continue to have on
Mr. X.’s sleep. Subsequently, the patient and therapist jointly decided that the patient would place his alarm clock in a location far from his bed so that he could not reach it without getting up. This measure was used to force the patient to get out of bed at the selected wake-up time. In addition, the therapist helped the patient decide what activities he might do instead of lying in bed when he experienced extended nocturnal awakenings. Speciﬁcally, the patient was instructed to consider watching TV, reading magazine articles, or listening to music. Finally, the patient was encouraged to refrain from reclining while watching TV in the evening and to have his wife help him remain awake during the early evening hours. At a follow-up session 1 week later, the patient showed markedly improved adherence and a reduction in his sleep maintenance diﬃculty. ■ Case Example #4 ■ Mr. M. was a 52-year-old college professor who presented with sleep onset and maintenance diﬃculties. After a thorough assessment it was determined that he suﬀered from primary insomnia and would beneﬁt from CBT. After 2 weeks of this treatment, Mr. M. returned to the sleep clinic noting marked improvement in his sleep-onset problem but continued intermittent diﬃculties maintaining sleep. Upon questioning by the therapist it was discovered that Mr. M. followed the recommendation of getting out of bed in the middle of the night when he could not sleep. However, on such occasions, he typically watched a late-night talk show on television and found he did not want to return to bed before he saw the ending to this show. Since Mr. M.’s TV watching seemed to be extending his middle-of-the-night awakenings, he was discouraged from continuing this practice and was encouraged to engage in light, recreational reading instead. The patient subsequently complied with this recommendation and soon became able to sleep through most nights. ■ Case Example #5 ■ Mr. R. was a 47-year-old professional who presented with an 11-year history of diﬃculty initiating and maintaining sleep. The initial evaluation suggested a history of sleep diﬃculties that reportedly were sometimes caused by conﬂicts with coworkers and supervisors. Nonetheless, the patient appeared to often allot 9 or more hours for sleep at night and he reported he preferred to keep his bedroom TV playing so he would have
something to distract him if he did awaken during the night. When the CBT regimen was introduced, he appeared somewhat skeptical, particularly when it was suggested that he stop watching TV in his bedroom and that he reduce his time in bed. Although the patient stated he would try the regimen, he showed evidence of only marginal adherence when he returned for his subsequent treatment session. Speciﬁcally, he continued his former practice of keeping the TV on all night and he often stayed in bed at least 1 hour more than recommended. Although Mr. R. continued to voice skepticism, he eventually did agree to conduct a series of “clinical experiments” on himself to see the eﬀects of each of the disputed CBT suggestions. Hence, during the subsequent 2 weeks he agreed to remove himself from his bedroom when he couldn’t sleep instead of watching TV in bed. When, on a subsequent visit, he reported being surprised that this strategy did lead to gradual sleep improvement, he agreed to reduce his time in bed to an amount that closely approximated the therapist’s suggestions. Upon his subsequent return, he again agreed the clinical experiment had beneﬁted him. Although the patient noted that he would not agree to avoid sleeping in on weekend mornings, he did agree to stay in bed no longer than 1 hour beyond his weekday rising time. Since the patient had made reasonable progress and seemed very resistant to further changes, the therapist chose to commend him on his accomplishments and refrained from attempts at additional interventions that very likely would have been met with excessive resistance. ■ Case Example #6 ■ Ms. Q. was a 45-year-old employed woman with diﬃculty initiating sleep and subsequent daytime fatigue. She readily accepted the sleep hygiene recommendation to exercise regularly as she indicated she believed that exercise would help her sleep more soundly at night and give her more pep in the daytime. However, 4 weeks into treatment, she had failed to establish any regular exercise program. She complained that she had diﬃculty ﬁnding time for exercise due to her ongoing work and family responsibilities. The therapist suggested that she try to integrate some exercise by using stairs instead of the elevator whenever possible at her work site and taking a brisk 20-minute walk around the parking deck at work during her lunch break at least three times per week. Ms. Q. found these suggestions helpful and subsequently was able to initiate this plan over the subsequent several
weeks. By the conclusion of treatment she reported that she was beginning to see the beneﬁts of her exercise on her sleep and daytime energy level. ■ Case Example #7 ■ Mr. J. was a 51-year-old, divorced man who lived alone. He had long had problems sleeping and had developed the habit of having 1–2 shots of bourbon in the evening shortly before bedtime. Typically the patient had little diﬃculty falling asleep but he often awakened and could not return to sleep easily. Whereas the patient’s enactment of most treatment recommendations was very acceptable, his sleep logs showed he continued to consume alcohol close to bedtime several nights per week. Often when he did so his subsequent sleep was rather fragmented. To address this problem the therapist used the patient’s sleep log data to highlight the association between his bedtime alcohol consumption and subsequent poor sleep. The therapist also suggested the patient move his alcohol consumption to an early time so that it did not interfere with his sleep. In response to this suggestion the patient reduced his use of alcohol and generally refrained from alcohol consumption after his evening meal. Subsequent to these changes the patient’s nighttime awakening problem diminished. ■
Troubleshooting: Cognitive Component Constructive Worry: The most common problem reported with this procedure tends to be allotting insuﬀicient time to complete it. Troubleshooting this problem requires encouraging patients to examine their schedules and prioritize a 15-minute block in which to complete the Constructive Worry Worksheet. It may also help to check with the patient’s understanding of the rationale. If the rationale is not understood, it will be less likely that patients will make the scheduling of this activity a priority. Sometimes patients become so activated that they have trouble completing this activity. In such cases it is important to complete one example in the follow-up session to ensure that the patient has the ability to complete such an exercise and to reduce the likelihood of becoming too aroused to successfully complete it on their own. Cognitive Restructuring: There are a number of potential problems that can occur with patients completing a Thought Record. Such barriers
include diﬃculty remembering to complete one, diﬃculty with completing one or more of the columns, a denial that thoughts are contributing to the problem, predicting that it will not be helpful, and no mood change following the exercise. Such problems can usually be worked through in session. For example, the problem of not remembering to complete a Thought Record can be addressed by scheduling a Thought Record around the same time each day. Problems completing one or more columns are best solved by completing a number of Thought Records in session. The questions you ask to direct a patient through the Thought Record should be written down, so the patient can refer to these questions when completing one on his own. Those patients who regularly use the Thought Record typically report that they are extremely helpful in making a cognitive shift. Patients who present doubts about the usefulness of Thought Records may be encouraged to try using this instrument as a behavioral experiment. For example, you can ask the patient to complete the Thought Record for 2 weeks and “suspend judgment” about whether it is helpful until then. Agreeing to evaluate the eﬀectiveness at a later date is often satisfactory to the patient. When reviewing whether the Thought Records were helpful, look at all the available data including any possible mood improvements in the ﬁnal column (i.e., “Do you feel any diﬀerently?”), or possible improvements in sleep. Often, the problem to “troubleshoot” in regard to Thought Records is that the patient resisted the assignment and did not complete one. It is important to assess reasons for non-completion in an open and nonjudgmental fashion. Are they convinced it will not be helpful? Some ﬁnd it contrived, and will say, “I know my thoughts are irrational, but that’s what I feel.” It is important to validate that the patient’s thoughts and feelings are valid. It is also important to validate that it must seem as though it would be diﬀicult to change given how automatic these thoughts are. Ask to explore whether there may be costs to having such strong conviction in these thoughts and whether these thoughts may be adding to the problem (i.e., emotional reasoning). In addressing such thinking it is useful to consider the methods for managing patients’ cognitive errors discussed in the previous chapter. All of the previously mentioned troubleshooting advice should address the common problem that the patient’s mood does not improve after completing the Thought Record. When there is no mood improvement,
it typically means that one of the columns was not completed correctly. For example, the thoughts recorded are not related to the mood (e.g., the thought that is most strongly connected to the mood is not recorded). In this case, go through a series of questions to elicit more thoughts. If some thoughts are related to one mood and other thoughts are related to a diﬀerent mood, complete separate Thought Records to deal with each mood state or emotionally charged thought. For example, if anger and fear are recorded and the thoughts seem to relate to either one or the other mood state, complete one Thought Record for the anger-related thoughts and one for the anxiety-related thoughts. Also, spend more time in the Evidence against the Thought column to ensure that adequate attention is paid to disconﬁrming evidence. Lastly, generate more “believable” Adaptive/Coping Statements. These statements should be rated for believability. If they are not believed strongly, it will be necessary to rewrite them in a way that is more believable.
Case Example #8 ■ Ms. S. was a 33-year-old female who presented with sleep onset insomnia. She reported prominent worries about sleep and nightly dependence on sleep medications. She had a history of problems with anxiety. An examination of her sleep logs revealed excessive time-in-bed and variable bedtimes and rise times. CBT recommendations included psychoeducation about sleep need, instructions to reduce her time in bed to match her sleep production (e.g., 7 hours), establishing a regular bedtime and rise time, and to get out of bed when unable to sleep (i.e., stimulus control). Ms. S. returned to the clinic 2 weeks later and reported almost no adherence to the sleep schedule or stimulus control instructions. She explained that she could not adhere to the treatment because she needed 8 hours to function. The next two sessions were devoted to restructuring the belief that she could not function without 8 hours of sleep. Her Thought Records revealed a core belief of helplessness. She believed that she had limited coping abilities and that she was “always one crisis away from becoming permanently disabled.” She had images of herself in a wheelchair in a “mental institution.” These beliefs were formed many years prior when she suﬀered from debilitating panic attacks. Focusing on the positive instances of coping, which included her gaining mastery over her panic attacks, allowed her to modify her helplessness beliefs. This cognitive shift resulted in almost total adherence to the behavioral recommendations
and a mean posttreatment sleep onset latency in the normal range (posttreatment SOL 21 minutes, instead of the pretreatment sleep onset latency of 184 minutes). ■
Tracking Down “Missing” Sleep It is not uncommon for some patients to present with a complaint that they “do not sleep” for days, weeks, or even months on end. Patients with this complaint will often produce sleep logs that show very limited amounts or no sleep on many nights each week. Such cases may require use of special cognitive strategies to conduct some “detective work” to uncover the sleep that is “missing.” There are good reasons to do a little detective work in such cases. First, human beings are often unsuccessful with attempts to stay awake for more than a couple of days. “Trying” to stay awake is very diﬀicult, as the body ﬁnds a way to produce short or brief unplanned bouts of sleep when confronted with long periods of wakefulness. Sleep-deprivation experiments often must resort to using high degrees of stimulation (i.e., noise and light in a laboratory setting) and experimenter intervention (i.e., talking to the patient) in order to successfully keep someone awake. What makes the report of no sleep in a person with insomnia even more incredible is that they report not falling asleep under conditions of almost no stimulation at all. For example, they report that they lay awake in bed, in the dark, with no noise, all night long. Also, there are plenty of data to document a discrepancy between objective indices of sleep (i.e., brain wave activity on a polysomnogram or activity monitoring on an actigraph) and subjective reports (i.e., sleep log) of “I don’t sleep.” There is controversy as to what accounts for the discrepancy, as some other physiological measures (i.e., spectral analysis) have shown increased high frequency activity in the brain of those with a so-called subjective-objective discrepancy. One common cognitive error in such insomnia suﬀerers is dichotomous thinking. Large amounts of time spent awake is viewed as “no sleep.” There may be a “cost” to believing that one does not sleep (irrespective of whether there is objective data to the contrary). The cost to believing “I don’t sleep” is increased anxiety, and anxiety increases the likelihood of sleep disruption. Following is an example of some “detective work” in investigating the report of “no sleep.”
Case Vignette T: I see on your Thought Record that your thoughts have included “I can’t believe I went another night without sleeping.” “I haven’t slept in over 2 weeks.” and “Can you die from not sleeping?” I also notice that you have rated frustration and anxiety at 100%. P: You’d be anxious and frustrated if you didn’t sleep either. T: I would like us to examine whether there may be a connection between some of these thoughts and your mood. Is there any possible connection between the thought, “I haven’t slept in over 2 weeks” and anxiety or frustration? P: Of course. It’s scary to not sleep. T: I can see how thinking you haven’t slept in 2 weeks would be scary. I wanted to make sure that I understand this; you have not slept even 1 minute in 2 weeks? P: Well, very little anyway. T: Oh okay, there has been some sleep, but very little? P: Almost none. T: I can see how it would be upsetting to have very little sleep, but I could see how it would be even more upsetting if there was absolutely zero sleep. In fact, I have never had a case with no sleep for 2 weeks so I am relieved to hear there has been at least a little bit of sleep. Can you estimate how much sleep is a “little bit of sleep” over the last 2 weeks? P: I don’t know, maybe a few minutes. T: Okay, a few minutes. I remember you told me that you were irritated when your husband woke you to tell you that you were snoring. Was this the few minutes we are talking about? P: I guess. I was so irritated because I felt as though I was just about to fall asleep and then he nudged me. It didn’t seem like I was sleeping but I guess I must have been. You can’t snore when you’re awake, right? Also, I looked in the mirror yesterday and saw the imprint of
my keyboard on the side of my face. So I know I fell asleep yesterday at the computer but I don’t really remember it. So that’s a little more time. T: This is good. We also need to remember that you recorded two daytime naps over the last week. It is important for us to “ﬁnd forgotten sleep,” especially since you have said that thinking you don’t sleep at all increases your anxiety. When you are more anxious, are you more likely to have worse sleep? P: Well, yes. T: Then it would be important for us to make sure you are not telling yourself something that makes you more anxious, right? P: I guess. Although I don’t think I am sleeping that much, I don’t usually remember seeing the clock or getting up between 2–6 AM, so it’s possible that I am sleeping a little during that time. T: So we have a few minutes during the day, a few minutes in the ﬁrst half of the night, and about a 4-hour window in the second half of the night when there is an undetermined amount of sleep. It looks like your body is really working to give you bits of sleep here and there, even if you are not always aware of it, and even if it doesn’t always feel like it. Does this help at all with the thought that you might die from not sleeping? P: Well, I’m probably not going to die. It was just scary to think I wasn’t sleeping at all. I guess I’m sleeping a little. T: Do you think that being less anxious about this may allow you to get even more sleep? P: I hope so!
Summary Although we have no hard and fast rule about the number of follow-up sessions to provide patients, most of our primary insomnia patients respond to treatment in 3–4 sessions total. Of course, there are those who
respond more gradually but do achieve a satisfactory outcome. In the end, therapy should be guided by the patient’s sleep performance reﬂected by sleep log data and by the patient’s subjective appraisal. Optimal sleep performance is characterized by sleeping soundly at night and having no daytime symptoms (e.g., fatigue, impaired concentration, distress about sleep) of insomnia. In this case, sleep logs would show the patient has a regular sleep-wake schedule and typically has little diﬀiculty falling asleep or staying asleep through the night. Along with this observation, the logs and the patient’s self-report should indicate that the ﬁnal morning awakening typically occurs slightly before the alarm clock sounds. If the patient sleeps soundly but most often is awakened by the alarm, it is likely that the patient could and would sleep a little longer each night had the alarm not be set. In such cases, it is usually useful to expand the TIB window somewhat until the sleep pattern described emerges. However, once the patient achieves a sound sleep pattern at night and is satisﬁed with his daytime function, therapy termination may be considered. When therapy termination is discussed with patients, it is important to review all of the new sleep and insomnia management skills they have learned during the treatment. In this regard, it is important to emphasize that they now have the “tools” they need to manage their sleep problems and combat any future bouts of insomnia they may confront. It is also useful to emphasize that future nights of poor sleep are not only possible but also are very likely to occur from time to time. However, it is important to emphasize to that patient that he now is well equipped to manage such episodes eﬀectively so that they do not persist. In addition to this information, we have found it helpful to give the patient “permission” to schedule any future “refresher sessions” he feels are necessary to reinforce what he has learned and to help the patient through more diﬃcult episodes. Through use of such strategies we have found a large percentage of those patients we treat are able to continue the treatment on their own with minimal or no further assistance from our clinic.
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Considerations in CBT Delivery: Challenging Patients and Treatment Settings
Overview of the Treatment Challenges Thus far, the discussion in this manual has summarized strategies to employ during individual therapy sessions with unmedicated primary insomnia patients. Of course, many patients who present for treatment do so in the context of ongoing use of sleep medications. Many other treatment-seeking patients have concurrent comorbid medical or psychiatric conditions that contribute signiﬁcantly to their persistent sleep diﬃculties. Furthermore, not all patients who seek insomnia treatment present to psychologists or other providers who have training and skills in Cognitive-Behavioral Therapy techniques. In fact, the majority of treatment-seeking insomnia patients present to primary care or other types of medical venues where individualized one-on-one sessions with a CBT therapist are either unavailable or not practical. The various types of patients with insomnia as well as the varied settings in which they present for treatment present special challenges to those wishing to implement the CBT procedures described herein. The discussion in this chapter considers how CBT may be disseminated to the types of patients and settings mentioned.
CBT With Hypnotic-Dependent Insomnia Patients As noted in Chapter 1, various medications are commonly employed for insomnia management. Included among these are various types of benzodiazepine receptor agonists (BZRAs) that have been well tested and have FDA approval for insomnia treatment. At times, other BZRAs that have FDA approval for treating anxiety, but not insomnia,
are prescribed alone or in addition to the approved medications to treat sleep diﬃculties. In addition, a variety of other medications including antidepressants such as the sedating tricyclics (e.g., doxepine) and trazodone, and the atypical antipsychotic, quetiapine, are often used to manage patients’ sleep complaints. These latter medications lack FDA approval and are used “oﬀ-label” for treating insomnia. Finally, various over-the-counter medications are available and are used frequently by insomnia patients in their eﬀorts at self-management. Over the years, concerns have been raised about protracted use of medications to address chronic primary insomnia. Although there is considerable “clinical lore” supporting the prescription medications used “oﬀ-label” for sleep, currently there are few data to support their safety and eﬃcacy for long-term treatment of primary insomnia. Likewise, there are extremely limited data concerning the safety and eﬃcacy of those sleep medications available without prescription. With some of the ﬁrst generation FDAapproved BZRA hypnotics, medication tolerance develops with continued use such that patients experience reduced eﬃcacy while being maintained on stable therapeutic doses for extended periods of time. Abrupt withdrawal of such medications often results in a transient, albeit distressing, worsening of sleep that convinces many patients to quickly resume their medication use. In contrast, some of the longer acting BZRAs may result in unwanted next-day eﬀects such as sluggishness or “hangover.” Fortunately the newer generation BZRAs (e.g., zolpidem, eszopiclone, zaleplon) have far less pronounced unwanted properties such as these, and some such agents have proven safe and eﬀective over extended periods of continued use. Nonetheless, as displayed by the following case description, long-term use of hypnotics can be problematic to some patients for reasons other than those mentioned thus far.
Case Example: Insomnia and Medication Dependence ■ Ms. R. was a middle-aged married woman who presented to our clinic with insomnia complaints. At the time of her presentation, she reported a history of sleep diﬃculties dating back about 10 years to a time when she was having ongoing medical problems. She noted that at that time she had undergone surgery on her left leg and the surgical wound did not heal properly. She noted pain, immobility and general distress over her condition. In
that context, she experienced the onset of her sleep diﬃculties. Shortly after her sleep problem began, she obtained a prescription for lorazepam to treat her sleep diﬃculty, and she had taken that medication almost nightly since that time. She also subsequently received an additional prescription for zolpidem, 10 mg, to help her sleep. Hence, when she presented for treatment, she was taking 10 mg of zolpidem along with .5 to 1 mg of lorazepam on a nightly basis as sleep aids. Her stated goal for treatment was to learn how to sleep without sleep medications. However, she noted that she became very anxious and unable to sleep without lorazepam and she admitted she thought she would be unable to initiate and maintain sleep unless she took both of her sleep medications. In support of this, she noted that her eﬀorts to stop these medications had been met with her experiencing elevated anxiety about sleep and pronounced wakefulness during the subsequent night. With her medications, she indicated that she was able to function in the daytime without severe daytime sleepiness (Epworth Sleepiness Scale 9). However, she did indicate that her sleep still was not ideal and she experienced a signiﬁcant level of fatigue many days each week despite her nightly use of medicinal sleep aids. Her sleep log shows her sleep pattern at the time of her initial clinic visit (see Figure 6.1). Despite her nightly medication use, she still showed diﬃculty initiating sleep on two nights and relatively poor quality sleep on several nights. This log also showed the erratic sleep scheduling common to insomnia patients in general. ■ Ms. R.’s case highlights many of the characteristics commonly presented by those insomnia patients who use sleep medications on a chronic basis. As her history demonstrates, her sleep medication use began for good reason during a time she was recovering from a painful medical condition that disrupted her sleep. However, she was initially prescribed a BZRA medication for sleep that has FDA approval for anxiety management but not insomnia. While continued on this medication, she was given an FDA-approved hypnotic as an additional sleep aid. Her history suggests that, over time, she developed a psychological dependence on such medications as sleep aids. Indeed, her eﬀorts to stop these medications were met with increased sleep-focused anxiety and marked sleep disruption. When patients like Ms. R. are interviewed thoroughly, they often report a general lack of self-eﬃcacy in regard to their ability to obtain adequate sleep. In a sense, they have lost faith in themselves as sleepers. As a consequence, they come to rely on sleep medication(s) to obtain the sleep they need.
Day of the Week Calendar Date
1. Yesterday I napped from _____ to _____ (note time of all naps). 2. Last night I took ______ mg of ______ or ______ of alcohol as a sleep aid (include all prescription and over-the-counter sleep aids). 86
Thurs 10/19 None 1 mg Lorazepam 10 mg Zolpidem 11:30 AM 11:30 AM
Fri 10/20 None 1 mg Lorazepam 10 mg Zolpidem
Sat 10/21 None 1 mg Lorazepam 10 mg Zolpidem
Sun 10/22 None 1 mg Lorazepam 10 mg Zolpidem
Mon 10/23 None 1 mg Lorazepam 10 mg Zolpidem 12:30 AM 12:30 AM 90 2 5
Tues 10/24 None 1 mg Lorazepam 10 mg Zolpidem 1:30 AM 1:30 AM 5 3 5 5 5
Wed 10/25 None 1 mg Lorazepam 10 mg Zolpidem 12:30 AM 12:30 AM 30 3 5 5 5
3. Last night I got in my bed at ______ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at ______ (AM or PM?).
12:00 AM 1:00 AM 2:30 AM 12:00 AM 1:00 AM 2:30 AM 5 3 5 5 5 7:15 AM 8:00 AM 4 5 1 1 Don’t remember ?
5. After turning oﬀ the lights it took me about _____ minutes to fall asleep. 105 6. I woke from sleep ______ times. (Do not count your ﬁnal awakening here.) 7. My awakenings lasted _______ minutes. (List each a wakening separately.) 8. Today I woke up at _______ (AM or PM?). (NOTE: this is your ﬁnal awakening.) 9. Today I got out of bed for the day at ____ (AM or PM?). 2 5 5 9:30 AM 9:30 AM 6
8:45 AM 10:30 AM 10:00 AM 8:00 AM 7.15 AM 8:45 AM 10:45 AM 10:10 AM 8 8 6 8:15 AM 7:45 AM 4 6
10. I would rate the quality of last night’s sleep as:
Very Poor 1 2 3 4 Fair 5 6 7 8 Excellent 9 10 11. How well rested did you feel upon arising today? Not at All Somewhat Well Rested 1 2 3 4 5 6 7 8 9 10
Figure 6.1 Sleep Log: Sleep Medication User
Insomnia patients who use hypnotics chronically present with many of the cognitive and behavioral treatment “targets” discussed in previous chapters. Speciﬁcally, they have catastrophic beliefs about the daytime eﬀects of their sleep diﬃculties as well as a misunderstanding of how their sleep habits may contribute to their insomnia. Accordingly they demonstrate many of the common sleep disruptive compensatory practices (e.g., daytime napping, erratic sleep schedules, extended waking periods spent in bed) seen in medication-free primary insomnia patients. However, they also present a unique set of cognitions and behaviors that require treatment attention. Commonly such patients have strong beliefs that their insomnia is “due to a chemical imbalance” so they conclude that they are unable to sleep without a medication. Many appear rather conﬂicted, on the one hand believing that long-term sleep medication use is harmful, while on the other hand feeling helpless to sleep without some sort of sleep aid. Some patients who are concerned about their medication use cut their sleeping pills in half and surprisingly sleep well on subtherapeutic doses yet are unable to wean themselves completely from such medications without a marked worsening of sleep. Others will intermittently try going to bed without their usual medication to “see how they do” without it. Of course, this latter strategy usually tends to increase sleep vigilance, which, in turn, makes sleeping more diﬃcult. Thus, chronic medication users present additional cognitive and behavioral targets that merit the therapist’s attention. Since many chronic hypnotic users present with the desire to discontinue their sleep medications, it is important to implement a treatment plan that enables them to do so yet maintain or reestablish a satisfactory medication-free sleep pattern. Current evidence (Morin et al., 2005; Belleville et al., 2007; Soeffing et al., 2007) suggests a therapy that combines CBT techniques with a structured medication-tapering program produces optimal results with medication-dependent patients. Typically it is helpful to initially have the patient continue on her usual medication, and to plan to take this medication routinely, as prescribed, prior to going to bed each night. While the medication regimen remains stable, treatment should commence by initiating the CBT strategies described in detail in the preceding three chapters. While patients receive CBT instructions, they should be dissuaded from making any changes in their sleep medication practices. Speciﬁcally, they should be
discouraged from changing their medication dosages or experimenting with medication-free nights. During the course of this treatment it may be helpful to identify some unhelpful beliefs about sleep medications and have patients complete Thought Records (see Chapter 4) as “homework” to address such beliefs. It is also important to have patients adhere strictly to the behavior strategies discussed in Chapter 3 to produce a consolidated and consistent sleep pattern while they are still taking their medications. Encouraging implementation and adherence to these strategies often results in improved sleep patterns and enhances chances for success in the subsequent medication taper process. Once the patient successfully implements the CBT strategies discussed in the previous chapters and shows a stable sleep pattern for at least 2 consecutive weeks, a medication-tapering strategy can be introduced. From a safety viewpoint, most prescription and over-the-counter medications taken for sleep can be discontinued fairly rapidly without untoward medical concerns. However, patients who are dependent on sleep medications usually are more successful discontinuing such medications if allowed to taper them more slowly and deliberately. In this regard, strategies discussed elsewhere (Belleville et al., 2007, Soeffing et al., 2007) have proven eﬃcacious for such patients. These approaches allow a slow, graded, “stepdown” approach to tapering that oﬀers the patient a gentle pace at fading the medication while allowing some sense of gradually increasing selfeﬃcacy in regard to the discontinuation process. For example, the approach described recently by Morin et al. involves the following sequence of steps: (1) setting a goal for medication use/reduction each week; (2) when more than one medication is being used, reduction to a single medication at a stable dose is set as the ﬁrst goal; (3) the initial dosage of the medication is reduced by 25% every 2 weeks until the lowest available (therapeutic) dosage is reached; (4) drug-free nights are gradually introduced with drug-free nights being planned in advance; and (5) the number of drug-free nights per week is gradually increased until the patient is medication free. While instituting this sort of withdrawal plan it is important to have the patient continue monitoring her sleep with the sleep log and to continue with the cognitive tools (Thought Records, Constructive Worry Worksheets) as needed. It is also important to monitor CBT adherence using the techniques outlined in Chapter 5.
Whereas this combined approach tends to produce the best results, patients may vary in the success they achieve. Some show a good response and become able to sleep medication free. Others experience setbacks along the way due to unexpected stressors or other factors. Some patients may view such setbacks as indications of treatment failure, so it is helpful to assist such patients in reframing such occurrences in constructive manners. Again, use of Thought Records may help with this problem. However, some patients may not succeed with medication discontinuation due to ongoing stressors or other life circumstances that demand their attention. Like other problem areas that merit a certain degree of readiness on the part of the patient to change, discontinuation of hypnotic medication requires a level of readiness and commitment to the treatment processes discussed herein. Hence, a thorough assessment to determine the patient’s readiness for the strategies described may be useful prior to initiation of this approach.
Treating Insomnia Patients With Comorbid Disorders Whereas many insomnia patients encountered clinically suﬀer from primary insomnia, a far greater proportion of all treatment-seeking insomnia patients present with complex comorbid conditions. A variety of medical conditions, and particularly those that result in chronic pain, breathing diﬃculties, or immobility, can give rise to insomnia problems. Likewise, a large proportion of psychiatric conditions have insomnia as a primary presenting symptom. Furthermore, many medications prescribed for the treatment of medical and psychiatric conditions may have insomnia as a common side eﬀect. Finally, excessive use of alcohol, caﬀeine, and various illicit substances may cause or add to insomnia problems. In a sizable proportion of patients, a mixture of medical, psychiatric, and substance-related causes of insomnia coexist and complicate insomnia management. In cases of comorbid insomnia, it is always helpful to optimize management of the comorbid medical or psychiatric conditions to optimize insomnia treatment outcomes. In some cases, successful treatment of the comorbid disorder(s) results in insomnia remission. However, frequently this is not the case since factors in addition to or other than the
comorbid condition may sustain insomnia over time. Although the onset of insomnia may relate to endogenous physiological changes or acute stress reactions to the onset of a comorbid illness, a host of cognitive and behavioral factors may perpetuate insomnia over time. Even among individuals whose sleep disturbance initially emerged as a symptom of the comorbid condition, the nightly experience of unsuccessful sleep attempts can result in conditioned arousal and subsequent eﬀorts to make up for lost sleep by spending excessive time in bed each night or napping during the day. These practices can result in prolonged sleep diﬃculties because they adversely aﬀect homeostatic and circadian mechanisms that control the normal sleep-wake rhythm. Since such sleep-disruptive cognitions and habits may play important roles perpetuating insomnia in comorbid patients, CBT strategies may be useful as primary or adjunctive insomnia treatment for these individuals. To date, a relatively limited number of randomized clinical trials have investigated the eﬃcacy of CBT for treating insomnia patients with various types of comorbid conditions. The more convincing studies have focused on medical disorders and have suggested that CBT is eﬃcacious for treating insomnia in patients with chronic pain (Currie et al., 2000), ﬁbromyalgia (Edinger et al., 2005), mixed older medical patients (Rybarczyk et al., 2002) and cancer survivors (Savard et al., 2005). Wellconducted randomized trials of CBT for insomnia treatment in psychiatric samples have generally been lacking. However, a few clinical case series studies (Morawetz, 2003; Kuo, et al., 2001) have suggested that CBT does seem eﬀective for treatment of insomnia in patients with comorbid depression. Whereas these ﬁndings are encouraging, additional randomized trials are needed to conﬁrm the usefulness of CBT with psychiatric patients. Nonetheless, it is useful to consider CBT insomnia treatment for those psychiatric patients who present obvious cognitive and behavioral treatment targets discussed in the previous chapters. The following case example shows the potential usefulness of CBT strategies with a psychiatric patient. The patient described here suﬀered chronic insomnia comorbid to a serious anxiety disorder.
Case Example: Insomnia and Comorbid Anxiety Disorder ■ The patient was a 56-year-old married man who participated in a CBT insomnia treatment study at a VA hospital. The patient has been seen for treatment at the hospital for a number of years in relation to the combat-related posttraumatic stress disorder he developed as a result of his service experience during the Vietnam War. At the time the patient presented for the study, he reported a 15-year history of chronic insomnia problems. Speciﬁcally he reported that he would typically sleep soundly for only about 2.5 hours per night and then he would toss and turn the remainder of the night. He reported he was receiving ongoing pharmacotherapy (Citalopram) for his PTSD, and his symptoms other than his sleep diﬃculty were relatively well controlled. As part of his initial evaluation for the treatment study, he underwent diagnostic sleep monitoring (polysomnography) in order to rule out sleep disorders not detectable from interview (e.g., sleep apnea). Results showed no evidence of sleep apnea or other medically based primary sleep disorders. However, the recording showed very poor sleep with a sleep onset latency of 63 minutes, 90 minutes of wakefulness during the middle of the night, and a total sleep time of only 4 hours. A sleep log maintained by the patient for several weeks prior to treatment corroborated the ﬁndings from his sleep recording. Speciﬁcally this sleep log showed an average sleep onset latency of 82 minutes, an average wake time during the night of 165 minutes, and an average sleep time of only 4 hours and 25 minutes per night. The patient’s sleep log for the ﬁrst week of this monitoring period, which captures this general pattern of sleep diﬃculty, is shown in Figure 6.2. This log shows the patient’s variable sleep schedule as well as his penchant to allot excessive times each night for sleep. To treat this condition the patient received four biweekly 30- to 60-minute sessions that included the psychoeducational information and sleep improvement recommendations presented in Chapter 3. During this time period, no changes were made in his pharmacological treatment for his PTSD condition. Over the course of the CBT treatment, the patient’s sleep improved markedly. Sleep logs maintained by the patient immediately following treatment showed an average sleep onset latency of 15 minutes per night, an average wake time during the night of slightly less than 31 minutes, and an average total sleep time of 5 hours and 45 minutes. Figure 6.3
Day of the Week Calendar Date
1. Yesterday I napped from _______ to _______ (note time of all naps). 2. Last night I took _______ mg of _______ or _______ of alcohol as a sleep aid (include all prescription and over-the-counter sleep aids). 3. Last night I got in my bed at _______ (AM or PM?).
Sat 9/21 None None 10.30 PM
Sun 9/22 None None 11:30 PM 11:30 PM 35 1
Mon 9/23 None None 8:20 PM 8:20 PM 60 3 20 20 25 6:00 AM 7:10 AM 7
Tue 9/24 None None 9:35 PM 9:35 PM 90 2
Wed 9/25 None None 8:20 PM 8:20 PM 70 1
Thurs 9/26 None None
Fri 9/27 None
10:40 PM 10:35 PM 10:40 PM 10:35 PM 45 2 60 1
4. Last night I turned oﬀ the lights and attempted to fall asleep at _______ 10.30 PM (AM or PM?). 5. After turning oﬀ the lights it took me about _______ minutes to fall asleep. 90 6. I woke from sleep _______ times. (Do not count your ﬁnal awakening here.) 7. My awakenings lasted _______ minutes. (List each awakening separately.) 8. Today I woke up at _______ (AM or PM?). (NOTE: this is your ﬁnal awakening.) 9. Today I got out of bed for the day at _______ (AM or PM?). 10. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent 1 2 3 4 5 6 7 8 9 10 11. How well rested did you feel upon arising today? Not at All Somewhat Well Rested 1 2 3 4 5 6 7 8 9 10 2
25 20 5:30 AM 8:15 AM 7
40 5:15 AM 8:30 AM 5
25 40 6:15 AM 6:45 AM 7
45 7:00 AM 7:25 AM 5
15 20 6:35 AM 7:05 AM 7
60 5:30 AM 8:15 AM 7
Figure 6.2 Sleep Log: Baseline
Day of the Week Calendar Date
1. Yesterday I napped from _______ to _______ (note time of all naps).
Tue 12/17 None
Wed 12/18 None None
Thurs 12/19 None None
Fri 12/20 None None
Sat 12/21 None None
Sun 12/22 None None
Mon 12/23 None None
2. Last night I took _______ mg of _______ or _______ of alcohol as a None sleep aid (include all prescription and over-the-counter sleep aids). 3. Last night I got in my bed at _______ (AM or PM?). 4. Last night I turned oﬀ the lights and attempted to fall asleep at _______ (AM or PM?). 5. After turning oﬀ the lights it took me about _______ minutes to fall asleep. 6. I woke from sleep _______ times. (Do not count your ﬁnal awakening here.) 7. My awakenings lasted _______ minutes. (List each awakening separately.) 11:45 PM 11:45 PM 15 1 15
11:35 PM 12:00 AM 11:35 PM 12:00 AM 15 1 15 5:40 AM 6:55 AM 8 15 1 30 5:50 AM 6:50 AM 8
12:10 AM 11:40 PM 11:30 PM 11:40 PM 12:10 AM 11:40 PM 11:30 PM 11:40 PM 15 1 25 6:20 AM 6:20 AM 9 20 1 25 5:50AM 15 1 25 15 1 35
8. Today I woke up at _______ (AM or PM?). (NOTE: this is your ﬁnal 5:31 AM awakening.) 9. Today I got out of bed for the day at _______ (AM or PM?). 10. I would rate the quality of last night’s sleep as: Very Poor Fair Excellent 1 2 3 4 5 6 7 8 9 10 11. How well rested did you feel upon arising today? Not at All Somewhat Well Rested 1 2 3 4 5 6 7 8 9 10 93 5:35 AM 9
6:00 AM 6:50 AM
6:00 AM 6:00 AM 6:50 AM 8 8 8
Figure 6.3 Sleep Log: Post-CBT
shows the ﬁrst week of these sleep log data collected by the patient following treatment. This log shows the marked improvements in the patient’s sleep pattern as well as greater stability in his chosen sleep schedule. When a follow-up of this patient was conducted 6 months after he completed treatment, his sleep pattern continued to show the improvement displayed immediately after treatment with virtually no change in his sleep or wake time measures. ■ Whereas treatment results like these suggest that the CBT strategies are well suited for treating those with comorbid insomnia, there is still need for some caution when employing these techniques with such patients. Admittedly, given the limited data suggesting the eﬃcacy of CBT with comorbid patients, there is much to be learned about optimizing outcomes with these individuals. Indeed, there are many questions yet to be answered. Among the more pertinent are (1) How can we best combine CBT with pharmacotherapy and other medical management of the existing comorbid disorder? (2) Do the speciﬁc sleep-focused CBT techniques need to be altered or augmented in any way to maximize outcomes with comorbid insomnia? (3) Should CBT for insomnia be incorporated into more global cognitive-behavioral protocols that exist for various comorbid conditions (e.g., depression, anxiety disorders, etc.)? and (4) Does CBT for insomnia in comorbid patients require more extended therapy and follow-up than commonly required for primary insomnia? These, among many other questions, need to be addressed before this treatment can be conﬁdently extended to various other comorbid groups. For a more thorough discussion of this topic, the reader is referred to the recent excellent review article by Smith et al. (2005). Nonetheless, the research conducted to date as well as with results with cases such as the one presented here encourage further applications of this modality for addressing comorbid insomnia problems.
Dissemination of CBT Across Settings Whereas CBT has proven eﬃcacy for primary insomnia and holds much promise for treating those with various comorbidities, it is currently challenging to make this therapy available to all who may beneﬁt from it. Whereas 10% to 15% of the population has chronic insomnia,
there are currently a paucity of trained providers who oﬀer the treatment described in this manual. Furthermore, those who are trained and skilled in these techniques tend to be found in larger medical centers or specialty sleep centers and not in the general medical practice settings where most treatment-seeking insomnia patients present for their care. Thus, expanding the provider pool and exporting this treatment to the venues wherein most insomnia patients receive their initial treatment remain as challenges to this therapeutic modality. In eﬀorts to facilitate dissemination of CBT for insomnia, some investigators have tested treatment models suitable for medical practice settings or the public at large. Given that insomnia suﬀerers typically present ﬁrst in primary care settings, it seems reasonable to consider providing CBT training to those health care professionals (e.g., nurses, general practitioners) commonly found in such settings. Two studies designed to test the eﬃcacy of such an approach have demonstrated that both family physicians (Baillargeon et al., 1998) and oﬃce-practice nurses (Espie et al., 2001; Espie et al., 2007) can eﬀectively administer CBT components in general medical practice settings. In contrast, Oosterhuis and Klip (1997) reported delivery of behavioral insomnia therapy via a series of eight, 15-minute educational programs broadcast on radio and television in the Netherlands. Over 23,000 people ordered the accompanying course material, and data from a random subset of these showed that sleep improvements and reductions in hypnotic use, medical visits, and physical complaints were achieved by this educational program. Thus, it appears that behavioral insomnia treatments can be eﬀectively delivered by various providers and delivery of such treatment even via mass media outlets may provide beneﬁts to some insomnia suﬀerers. Of course, the relative eﬃcacy of these alternate modes of treatment delivery vis-à-vis more traditional treatment with experienced CBT therapists is yet to be determined. Other eﬀorts aimed at treatment dissemination have tested treatment protocols that can be self-administered outside the clinic setting. Mimeault and Morin (1999), for example, tested a self-help CBT bookbased treatment (i.e., bibliotherapy) with and without supportive phone consultations against a wait-list control. Compared to the control condition, those treated with the bibliotherapy showed substantially greater sleep improvements, and these improvements were maintained at a
3-month follow-up. The addition of phone consultations with a therapist provided some advantage over bibliotherapy alone at least in the short term. Recently, Strom et al. (2004) tested a 5-week self-help interactive CBT program delivered to insomnia patients via the Internet. Although those receiving CBT showed no greater improvement than a wait-list control group, this study does demonstrate that treatments such as CBT can be disseminated widely via the Internet. However, how to ensure the value and eﬃcacy of such applications remains a current challenge. Nonetheless, these studies provide some initial ideas for wider dissemination of CBT strategies. Such eﬀorts may be useful to ﬁll the void until a suﬃcient number of traditional providers are trained in these strategies and the more challenging insomnia patients will be able to access the comprehensive CBT they ultimately may need.
Sleep History Questionnaire
Sleep Disorders Center Duke University Medical Center
General Information Date: _________________________ Phone: ________________________ Age: ____________ _
Name: _____________________________ Address: ___________________________ _ _______________________________ ____ Sex: F M (circle one) Education (years of school): ___________ _ _ Occupation: ________________________ _ Marital Status: ______________________ _ Children: __________________________ _
Years: _______________ _
Nighttime Sleep Please describe your sleep disturbance. ————————————————————– —– —– —– —– —– —– —– – – – – – – – ————————————————————– —– —– —– —– —– —– —– – – – – – – – – ————————————————————– —– —– —– —– —– —– ––– – – – – – – –
2. Estimate how many hours of sleep you get . . . a) on a good night ______ 3. b) on a bad night ______
How long does it take you to fall asleep . . . a) on a good night? ______ b) on a bad night? ______
4. How many times do you wake up during the night . . . a) on a good night? ______ b) on a bad night? ______ 5. How long are you awake during the night after initially falling asleep . . . a) on a good night? ______ b) on a bad night? ______ 6. How long have you had this problem? ______ Has it increased in severity, and if so, over what period of time? ______ 7. What do you feel is the major cause(s) of your sleep problem? ———————————–––———————–——–——–——–——–—— ———————————————————––——–——–——–——–—— ——————–—————————————–——–——–——–——–—— 8. Did you have sleep problems as a child? Yes No (circle one)
Please describe the problem(s).________________________________________ —————————————————— ——— ——— ——— ——— ——— – —–
B. Daytime Functioning: 1. Do you have a problem with severe sleepiness (feeling very sleepy or struggling to stay awake during the daytime? Yes No (circle one) If yes, how many days during the average week? ________________________ 2. Do you often have a problem with your performance at work because of sleepiness? Yes No (circle one) 3. Have you ever had car accidents because of sleepiness (not due to alcohol or drugs)? Yes No (circle one) 4. Have you ever had near car accidents (for example, driving oﬀ the road) because of sleepiness (not due to alcohol or drugs)? Yes No (circle one) 5. Do you fall asleep without meaning to during the day? Yes No (circle one)
If yes, how many times during the average week? _________________________ 6. How likely are you to doze oﬀ or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have aﬀected you. Use the following scale to choose the most appropriate number for each situation: 0 1 2 3 would never doze slight chance of dozing moderate chance of dozing high chance of dozing Chance of dozing _________________ _________________ _________________ _________________
Situation Sitting and reading Watching TV Sitting inactive in a public place (e.g., a theater or a meeting) As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in the traﬃc
_________________ _________________ _________________ _______________ ___
7. On the graph below, indicate how sleepy you generally feel at the times indicated by choosing the most appropriate corresponding number from the scale below and circling that number on the graph. 9:00 AM Noon 6:00 PM 9:00 PM 1 2 3 4 5 6 7 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7
Feeling active and vital; wide awake Functioning at a high level, but not at peak; able to concentrate Relaxed, awake; not full alertness; responsive A little foggy; not at peak; let down Fogginess; beginning to lose interest in remaining awake; slowed down Sleepiness; prefer to be lying down; ﬁghting sleep; woozy Almost in reverie; sleep onset soon; lost struggle to stay awake
8. How many naps do you take during the average week? _________ How long is your average nap? _________
Bedtime Characteristics: a) On average, what is your normal bedtime? _________ b) On average, what time do you get out of bed in the morning? _________
2. Do you have a standard wake-up time that you use . . . a) 7 days per week? Yes No b) 5 days per week? Yes No 3. Does your job require that you change shifts? Yes No (circle one)
4. How often do you travel across time zones? _________ times per month 5. Do you have a bed partner? Yes No (circle one) If yes, are you and your bed partner having any problems that might be interfering with your sleep? Yes No (circle one) If yes, please describe: ______________________________________________ _______________________________________________________________ _ 6. How often do you do the following activities in bed during the average week? A. Read in bed: B. Watch TV in bed: C. Eat in bed: D. Work in bed: E. Argue in bed: F. Worry in bed: _____________ times per week _____________ times per week _____________ times per week _____________ times per week _____________ times per week _____________ times per week
7. How many nights during the average week do you lie in bed for at least 30 minutes either trying to fall asleep or trying to return to sleep? _________ nights per week. 8. How many mornings during the average week do you wake up at least 1 hour before your normal wake-up time and cannot return to sleep? _________ mornings per week. 9. Please circle a number from 1 to 10 to indicate how much diﬃculty you have relaxing your body at bedtime. no diﬃculty some diﬃculty great diﬃculty 1 2 3 4 5 6 7 8 9 10
10. Please circle a number from 1 to 10 to indicate how much diﬃculty you have “slowing down” or “turning oﬀ” your mind while trying to sleep. no diﬃculty 1 2 3 some diﬃculty 4 5 6 great diﬃculty 7 8 9 10
Additional Sleep Complaints:
If you have a bed partner, ask him/her to assist you in answering the next three questions about your sleep. 1. Has anyone ever told you that you snore loudly? Yes No (circle one) If yes, has your snoring caused people to refuse to sleep in the same room with you? Yes No
2. Has anyone ever told you that you seem to stop breathing while you sleep, or that you wake up gasping for breath? Yes No (circle one) If yes, how often has this been noted? __________ If yes, how long is the time that you stop breathing? __________ 3. Has anyone ever noticed your legs periodically twitching during the night? Yes No 4. Have you ever been unable to move when falling asleep or immediately upon waking? Yes No (circle one) 5. Have you ever had episodes of sudden muscular weakness (paralysis or inability to move) when laughing, angry, or in other emotional situations? Yes No If yes, how often has this happened? 6. Indicate how many times per month you have noticed that you . . . a) Wake up with a morning headache b) Notice a deep, creeping sensation inside your calves or thighs during the night c) Wake up confused and wander during the night d) Have nightmares e) Have fearful thoughts or images as you are falling asleep _________ times per month
_________ times per month _________ times per month _________ times per month _________ times per month
E. Medication History: 1. Currently, how many times during the month do you use medications to help you sleep? ____________________ times per month _ 2. Currently, how much alcohol do you use to help you sleep? _________________ times per month ________________ amount per night _________________ how long 3. Please list all medications, prescribed and over-the-counter, you are presently taking or have recently stopped taking and the reason for taking these medications. Medication Dosage/times per day Reason Current?
4. How much of the following do you consume during the average day? Alcohol __________________________ _ _ Coﬀee (with caffeine) ________________ _ Tea (with caffeine) ___________________ Soft drink (with caffeine) _____________ _ Cigarettes ________________________ __ Other tobacco products _______________ 5. Describe any other treatments you have had to help your sleep and how well the previous treatments worked. ________________________________________________________________ ________________________________________________________________
I believe a normal person my age without a sleep problem should . . . get about _________ hours of sleep per night. take about _________ minutes to fall asleep at the beginning of the night. wake up about _________ times per night. spend about _________ minutes awake in bed during the night.
Part III: 1.
General Medical History
Please check ( ) in the boxes beside those medical problems you have now or have had in the past.
Problem Arthritis Depression Emphysema Heartburn/Ulcers Kidney Problems Panic Attacks Sexual Problems Stroke Thyroid Problems Changes in Hair or Skin Problem Asthma Diabetes Epilepsy High Blood Pressure Hiatal Hernia Nose/Throat Problems Anxiety/Nervousness Suicide Attempts Cold/Heat Intolerance Problem Chronic pain Memory/Concentration Problems Headaches Hallucinations/Delusions Childhood Hyperactivity Alcohol/Drug Problems Loss of Sex Drive Swelling Ankles Trouble Breathing at Night
Please describe other problems not listed above:
2. What is (or was) your body weight? A. Now B. 6 months ago C. When age 20 D. When heaviest ever _________ (lbs) _________ (lbs) _________ (lbs) _________ (lbs)
3. What is your height? _________ feet _________ inches 4. Allergies __________________________________________________________ _________________________________________________________________ 5. Have you ever been treated by a psychiatrist, psychologist, or other mental health professional? Yes No (circle one) If yes, please indicate when you were treated and for what reason. ————–————–——————–——————–——–——–——–——–– –————–————–——————–———–——–——–——–——–——–– 6. Has anyone in your family ever had any of the following problems? A. Depression: Yes No (circle one) If yes, list relationship to you (for example, grandfather, sister, etc.) ————–————–————–————–————–———– B. Alcohol or drug problems: If yes, list relationship. Yes No (circle one)
——————–————–————–————–— C. Suicide or suicide attempts: Yes No (circle one)
——————–————–————–————–— D. Sleep problems: Yes No (circle one)
7. Have you or anyone in your family ever had your sleep recorded in a sleep laboratory? Yes No (circle one) If yes, please give details and describe the results of the recording(s) if you are aware of them. ——————–——————–—————————–——–——–——–——– ——————–————–————–——————–——–——––——–——– ——————–—————–——————–———–——–——–——–——– ——————–————–—–—————————–——–——–——–——– ——————–————–——–————————–——–——–——–——–
In the spaces provided below, please add any information that you feel is important. ——————–————–————–————————–——–——–——–——– ——————–————–————————————–——–——–——–——–– ——————–————–—–———————————–——–——–——–——– ——————–—————–———————————–——–——–——–——–– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—– ——————–————–———————————–——–——–——–—–––—–
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About the Authors
Jack D. Edinger, PhD, is Clinical Professor in the Department of Psychiatry and Behavioral Sciences at Duke University, as well as Senior Psychologist at the VA Medical Center in Durham, North Carolina. He is certified in behavioral sleep medicine by the American Academy of Sleep Medicine, and has over 25 years of clinical and research experience with insomnia and other sleep-disordered patients. He has numerous publications in the form of journal articles, abstracts, and book chapters devoted to the topic of insomnia assessment and treatment. Dr. Edinger has received funding from NIH and the Department of Veterans Affairs to support his ongoing research concerning insomnia. Colleen E. Carney received her PhD in Clinical Psychology from Louisiana State University in 2003. She is currently an Assistant Clinical Professor of Psychiatry at Duke University Medical Center. Dr. Carney specializes in the assessment and treatment of insomnia in comorbid emotional disorders as part of the Duke Insomnia Sleep Research Program. Her research has focused on cognitive factors in insomnia and depression. Dr. Carney is the President of the Insomnia and Other Sleep Disorders Special Interest Group of the Association for Behavioral and Cognitive Therapies. She has published numerous journal articles, abstracts, and book chapters on insomnia and depression. Dr. Carney’s research is currently funded by the National Institutes of Health.
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