(Treatments That Work) Jack D. Edinger, Colleen E. Carney-Overcoming Insomnia A Cognitive-Behavioral Therapy Approach Therapist Guide-Oxford University Press, USA (2008)

Overcoming Insomnia
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
Overcoming
Insomnia
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
1
2008
1
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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
9
8
7
6
5
4
3
2
1
Printed in the United States of America on acid-free paper
About TreatmentsThatWork™
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.
v
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
References
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.
vi
Contents
Chapter 1
Introductory Information for Therapists
Chapter 2
Pretreatment Assessment
Chapter 3
Session 1: Psychoeducational and Behavioral Therapy
Components
31
Chapter 4
Session 2: Cognitive Therapy Components 49
Chapter 5
Follow-Up Sessions
Chapter 6
Considerations in CBT Delivery: Challenging Patients
and Treatment Settings
83
Appendix
Sleep History Questionnaire
References
1
15
69
97
109
About the Authors
117
vii
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Chapter 1
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
1
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 &
2
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
3
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-
4
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
5
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
6
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
7
100
Insomnia
Threshold
0
Premorbid
Predisposing
Acute
Sub-Acute
Precipitating
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
8
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
9
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.
10
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
11
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
12
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
13
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.
14
Chapter 2
Pretreatment Assessment
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
15
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.
Table 2.1
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 History/Exam
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)
Psychiatric Factors
Depression
Anxiety
Other mental disorders
General day-to-day stress level
16
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.
17
18
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
1 2
Fair
3
4
5
Excellent
6
7
8
9
10
11. How well rested did you feel upon arising today?
Not at All
1 2
Figure 2.1
Sleep Log
3
Somewhat
4 5 6
7
8
Well Rested
9 10
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.
19
20
Day of the Week
Mon
Tue
Wed
Thurs
Fri
Sat
Sun
Calendar Date
3/5
3/6
3/7
3/8
3/9
3/10
3/11
None
None
None
None
3:30–
3:35 PM
None
None
None
None
None
None
None
None
None
3. Last night I got in my bed at _____ (AM or PM?).
9:30 PM
10:00 PM
9:00 PM
9:15 PM
10:00 PM
9:45 PM
9:00 PM
4. Last night I turned off the lights and attempted
to fall asleep at _____ (AM or PM?).
11:00 PM
11:15 PM
10:45 PM
11:00 PM
11:30 PM
11:45 PM
10:45 PM
5. After turning off the lights it took me about _____ minutes to fall asleep. 25 min
20 min
15 min
45 min
20 min
15 min
30 min
6. I woke from sleep _____ times. (Do not count your final awakening here.) 2
3
2
3
2
1
2
7. My awakenings lasted _____ minutes. (List each awakening separately.)
20 min
60 min
15 min
45 min
30 min
15 min
75 min
15 min
15 min
30 min
15 min
15 min
25 min
15 min
60 min
6:00 AM
5:45 AM
5:00 AM
4:45 AM
6:00 AM
6:45 AM
5:50 AM
6:30 AM
6:35 AM
6:30 AM
6:00 AM
7:00 AM
7:30 AM
6:30 AM
5
3
2
2
6
7
4
5
4
1
2
6
7
4
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).
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
1 2
3
4
Fair
5 6
7
8
9
Excellent
10
11. How well rested did you feel upon arising today?
Not at All
1 2
3
Figure 2.2
Sleep Log Case #1
Somewhat
4 5 6
7
8
Well Rested
9 10
Day of the Week
Mon
Tue
Wed
Thurs
Fri
Sat
Sun
Calendar Date
1/15
1/16
1/17
1/18
1/19
1/19
1/21
1. Yesterday I napped from _____ to _____ (note time of all naps).
None
None
None
None
None
None
None
2. Last night I took _____ mg of _____ or _____ of alcohol as a sleep
None
None
None
None
None
None
None
3. Last night I got in my bed at _____ (AM or PM?).
11:00 PM
10:45 PM
10:30 PM
11:30 PM
11:20 PM
2:45 PM
9:30 PM
4. Last night I turned off the lights and attempted
to fall asleep at _____ (AM or PM?).
11:00 PM
10:45 PM
10:30 PM
11:30 PM
11:20 PM
2:45 PM
9:30 PM
5. After turning off the lights it took me about _____ minutes to fall asleep. 20 min
45 min
10 min
65 min
35 min
10 min
120 min
6. I woke from sleep _____ times. (Do not count your final awakening here.) 1
2
2
2
1
1
2
7. My awakenings lasted _____ minutes. (List each awakening separately.)
50 min
25 min
25 min
45 min
90 min
40 min
90 min
55 min
5 min
80 min
60 min
6:05 AM
8:30 AM
9:00 AM
6:40 AM
5:15 AM
7:25 AM
7:20 AM
6:30 AM
8:40 AM
9:05 AM
7:30 AM
5:20 AM
7:30 AM
7:40 AM
5
7
2
1
4
3
2
5
6
3
1
4
3
1
aid (include all prescription and over-the-counter sleep aids).
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
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
1 2
3
21
Figure 2.3
Sleep Log Case #2
Somewhat
4 5 6
7
8
Well Rested
9 10
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
22
Day of the Week
Tue
Wed
Thurs
Fri
Sat
Sun
Mon
Calendar Date
4/2
4/3
4/4
4/5
4/6
4/7
4/8
1. Yesterday I napped from _____ to _____ (note time of all naps).
None
2:00–
4:00 PM
5:00–
6:30 PM
None
None
None
None
2. Last night I took _____ mg of _____ or _____ of alcohol as a sleep
4 oz
wine
None
2 beers
1 beer
None
None
None
3. Last night I got in my bed at _____ (AM or PM?).
11:00 PM
12:30 PM
11:30 PM
12:00 PM
2:20 PM
2:45 PM
11:30 PM
4. Last night I turned off the lights and attempted
to fall asleep at _____ (AM or PM?).
11:00 PM
12:30 PM
11:30 PM
12:00 PM
2:20 PM
2:45 PM
11:30 PM
5. After turning off the lights it took me about _____ minutes to fall asleep. 3.5 hours
3 hours
2.5 hours
3.5 hours
40 min
30 min
3 hours
6. I woke from sleep _____ times. (Do not count your final awakening
1
2
2
1
1
1
1
10 min
25 min
25 min
40 min
30 min
20 min
20 min
5 min
20 min
8:05 AM
9:30 AM
9:00 AM
8:40 AM
12:15 AM
11:25 AM
8:30 AM
8:30 AM
9:40 AM
9:05 AM
8:45 AM
12:20 AM
11:30 AM
8:40 AM
4
4
4
1
6
7
2
4
3
3
1
7
7
1
aid (include all prescription and over-the-counter sleep aids).
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
1 2
3
Fair
4 5 6
7
8
Excellent
9 10
11. How well rested did you feel upon arising today?
Not at All
1 2
3
23
Figure 2.4
Sleep Log Case #3
Somewhat
4 5 6
7
8
Well Rested
9 10
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
24
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 ⱕ 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
25
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
(Cronbach’s ␣ values ⬎ .80). Furthermore we recently have found
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.
26
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.
27
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.
28
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.
29
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Chapter 3
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
31
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:
32
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
33
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
34
35
Figure 3.1
Circadian Temperature Rhythm
Biological Bedtime
12:00 AM
6:00 PM
12:00 PM
6:00 AM
Sleep
12:00 AM
6:00 PM
12:00 PM
6:00 AM
12:00 AM
6:00 PM
12:00 PM
6:00 AM
12:00 AM
Circadian Temperature Variation
Circadian Temperature Rhythm
Biological Wake Time
Sleep
Figure 3.2
Effects of Jet Lag
Biological Bedtime
12:00 AM
6:00 PM
12:00 PM
6:00 AM
12:00 AM
6:00 PM
12:00 PM
6:00 AM
12:00 AM
6:00 PM
12:00 PM
6:00 AM
12:00 AM
Circadian Variation
36
Circadian Temperature Rhythm
Desired Sleep/Wake Schedule
Desired Bedtime
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.
37
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.
38
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,
39
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.
40
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) ⫹ 30 minutes
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
41
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
42
Day of the Week
Mon
Tue
Wed
Thurs
Fri
Sat
Calendar Date
3/5
3/6
3/ 7
3/8
3/9
3/10
1. Yesterday I napped from _____ to _____ (note time of all naps).
None
None
None
None
None
None
2. Last night I took ______ mg of _____ or _____ of alcohol as a
sleep aid (include all prescription and over-the-counter sleep aids).
None
None
None
None
None
None
3. Last night I got in my bed at ______ (AM or PM?).
11:00 PM 11:30 PM 11:15 PM 10:30 PM 11:15 PM 10:30 PM
4. Last night I turned off the lights and attempted
to fall asleep at ______ (AM or PM?).
11:30 PM 11:30 PM 11:15 PM 11:00 PM 11:15 PM 10:50 PM
5. After turning off the lights it took me about _____ minutes to
fall asleep.
20 min
35 min
75 min
45 min
15 min
20 min
6. I woke from sleep ______ times. (Do not count your
final awakening here.)
2
1
3
2
1
2
25 min
15 min
60min
10 min
25 min
30 min
60 min
40 min
90 min
30 min
45 min
8. Today I woke up at _______ (AM or PM?). (NOTE: this is
your final awakening.)
6:30 AM
7:00 AM
7:15 AM
7:30 AM
7:00 AM 7:15 AM
9. Today I got out of bed for the day at ____ (AM or PM?).
7:00 AM
7:30 AM
7:30 AM 7:45 AM
7:15 AM 7:30 AM
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
2
3
2
3
2
3
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
1
4
2
5
1
3
7. My awakenings lasted _______ minutes. (List each awakening
separately.)
AVERAGE
43
Total Sleep Time
360 min
415 min
400 min
425 min
390 min
410 min
400 min
Time in Bed
480 min
540 min
555 min
615 min
510 min
540 min
540 min
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
44
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.
45
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
46
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.
47
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.
Homework
✎ 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
48
Chapter 4
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
49
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.
50
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.
51
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.
52
1.
Write down the problems facing you that have the greatest
chances of keeping you awake at bedtime, and list them in the
“Concerns” column.
2.
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.
3.
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
53
CONCERNS
SOLUTIONS
1. The air conditioning isn’t working
in the car
1.
Could ask my wife if she has time to
take it in
2. Could call tomorrow for a Saturday
appointment
2. Money!
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.
54
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?
55
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.
56
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
Last week I
made a mistake
on my report
I’m going to
mess up
I’ve already
stopped
exercising
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?
57
Figure 4.2
Example of completed Thought Record
Evidence for the
thought
I’m starting
to feel
less like
doing things
Evidence against
the thought
Adaptive/Coping
statement
I’ve made
mistakes at work
when I have
had a good
night’s sleep
I don’t feel my
best, but the
truth is, I always
make it
through (70%)
I’ve had insomnia
for over a year
and haven’t
been sick
Just because I
don’t feel
at my best,
doesn’t mean
that anything bad
is going to
happen (75%)
I notice I feel a
little better
after lunch
I always seem to
have an ok
day despite
my insomnia
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%)
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
58
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.
59
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?
60
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
61
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?
62
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.
63
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
64
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
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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?
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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.
Homework
✎ Instruct the patient to continue recording her sleep habits using the
sleep logs provided in the workbook
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✎ 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
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Chapter 5
Follow-Up Sessions
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
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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. ■
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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.
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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
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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
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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
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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
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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,
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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
77
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.”
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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
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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
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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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Chapter 6
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,
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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
84
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.
85
86
Day of the Week
Thurs
Fri
Sat
Sun
Mon
Tues
Wed
Calendar Date
10/19
10/20
10/21
10/22
10/23
10/24
10/25
1. Yesterday I napped from _____ to _____ (note time of all naps).
None
None
None
None
None
None
None
2. Last night I took ______ mg of ______ or ______ of alcohol as a
sleep aid (include all prescription and over-the-counter sleep aids).
1 mg
Lorazepam
10 mg
Zolpidem
1 mg
Lorazepam
10 mg
Zolpidem
1 mg
Lorazepam
10 mg
Zolpidem
1 mg
Lorazepam
10 mg
Zolpidem
1 mg
Lorazepam
10 mg
Zolpidem
1 mg
Lorazepam
10 mg
Zolpidem
1 mg
Lorazepam
10 mg
Zolpidem
3. Last night I got in my bed at ______ (AM or PM?).
11:30 AM
12:00 AM 1:00 AM 2:30 AM
12:30 AM
1:30 AM
12:30 AM
4. Last night I turned off the lights and attempted to fall asleep at ______
(AM or PM?).
11:30 AM
12:00 AM 1:00 AM 2:30 AM
12:30 AM
1:30 AM
12:30 AM
5. After turning off the lights it took me about _____ minutes to fall asleep. 105
5
5
1
90
5
30
6. I woke from sleep ______ times. (Do not count your final
awakening here.)
2
3
1
Don’t
remember
2
3
3
7. My awakenings lasted _______ minutes. (List each a wakening
separately.)
5
5
5
?
5
5
5
5
5
5
5
5
5
5
8. Today I woke up at _______ (AM or PM?). (NOTE: this is your final
awakening.)
9:30 AM
7:15 AM
8:45 AM 10:30 AM 10:00 AM 8:00 AM 7.15 AM
9. Today I got out of bed for the day at ____ (AM or PM?).
9:30 AM
8:00 AM
8:45 AM 10:45 AM 10:10 AM
8:15 AM 7:45 AM
10. I would rate the quality of last night’s sleep as:
6
4
8
8
6
4
6
1
1
6
10
6
6
4
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
5
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
87
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.
88
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
89
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.
90
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
91
92
Day of the Week
Sat
Sun
Mon
Tue
Wed
Thurs
Fri
Calendar Date
9/21
9/22
9/23
9/24
9/25
9/26
9/27
1. Yesterday I napped from _______ to _______ (note time of all naps).
None
None
None
None
None
None
2. Last night I took _______ mg of _______ or _______ of alcohol as a
sleep aid (include all prescription and over-the-counter sleep aids).
None
None
None
None
None
None
3. Last night I got in my bed at _______ (AM or PM?).
10.30 PM
11:30 PM
8:20 PM
9:35 PM
8:20 PM
10:40 PM 10:35 PM
4. Last night I turned off the lights and attempted to fall asleep at _______ 10.30 PM
(AM or PM?).
11:30 PM
8:20 PM
9:35 PM
8:20 PM
10:40 PM 10:35 PM
5. After turning off the lights it took me about _______ minutes to fall asleep. 90
35
60
90
70
45
60
6. I woke from sleep _______ times. (Do not count your final
awakening here.)
1
3
2
1
2
1
25
20
40
20
20
25
25
40
45
15
20
60
8. Today I woke up at _______ (AM or PM?). (NOTE: this is your final
awakening.)
5:30 AM
5:15 AM
6:00 AM
6:15 AM
7:00 AM
6:35 AM
5:30 AM
9. Today I got out of bed for the day at _______ (AM or PM?).
8:15 AM
8:30 AM
7:10 AM
6:45 AM
7:25 AM
7:05 AM
8:15 AM
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
7
5
7
7
5
7
7
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
6
7
7
6
7
7
6
7. My awakenings lasted _______ minutes. (List each awakening
separately.)
Figure 6.2
Sleep Log: Baseline
2
None
Day of the Week
Tue
Wed
Thurs
Fri
Sat
Sun
Mon
Calendar Date
12/17
12/18
12/19
12/20
12/21
12/22
12/23
1. Yesterday I napped from _______ to _______ (note time of all naps).
None
None
None
None
None
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).
None
None
None
None
None
None
3. Last night I got in my bed at _______ (AM or PM?).
11:45 PM
11:35 PM 12:00 AM
12:10 AM 11:40 PM 11:30 PM 11:40 PM
4. Last night I turned off the lights and attempted to fall asleep at
_______ (AM or PM?).
11:45 PM
11:35 PM 12:00 AM
12:10 AM 11:40 PM 11:30 PM 11:40 PM
5. After turning off the lights it took me about _______ minutes to fall
asleep.
15
15
15
15
20
15
15
6. I woke from sleep _______ times. (Do not count your final
awakening here.)
1
1
1
1
1
1
1
7. My awakenings lasted _______ minutes. (List each awakening
separately.)
15
15
30
25
25
25
35
8. Today I woke up at _______ (AM or PM?). (NOTE: this is your final 5:31 AM
awakening.)
5:40 AM
5:50 AM
6:20 AM
5:50AM
6:00 AM 6:50 AM
9. Today I got out of bed for the day at _______ (AM or PM?).
5:35 AM
6:55 AM
6:50 AM
6:20 AM
6:00 AM 6:00 AM 6:50 AM
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
9
8
8
9
8
8
8
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
9
8
8
9
8
8
8
93
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,
94
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
95
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.
96
Appendix
97
Sleep History Questionnaire
Sleep Disorders Center
Duke University Medical Center
Part I:
General Information
Name: _____________________________
Date: _________________________
Address: ____________________________
Phone: ________________________
___________________________________
Age: _____________
Sex: F M (circle one)
Education (years of school): _____________
Occupation: _________________________
Marital Status: _______________________
Children: ___________________________
98
Years: ________________
Part II:
Sleep History
A.
Nighttime Sleep
1.
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).________________________________________
——————————————————————————————————––
99
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 ⫽ would never doze
1 ⫽ slight chance of dozing
2 ⫽ moderate chance of dozing
3 ⫽ high chance of dozing
100
Situation
Chance of dozing
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
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
1 ⫽ Feeling active and vital; wide awake
2 ⫽ Functioning at a high level, but not at peak; able to concentrate
3 ⫽ Relaxed, awake; not full alertness; responsive
4 ⫽ A little foggy; not at peak; let down
5 ⫽ Fogginess; beginning to lose interest in remaining awake; slowed down
6 ⫽ Sleepiness; prefer to be lying down; fighting sleep; woozy
7 ⫽ 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? _________
C.
Bedtime Characteristics:
1.
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)
101
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:
_____________ times per week
B. Watch TV in bed:
_____________ times per week
C. Eat in bed:
_____________ times per week
D. Work in bed:
_____________ times per week
E. Argue in bed:
_____________ times per week
F. Worry in bed:
_____________ 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
102
2
some difficulty
3
4
5
6
great difficulty
7
8
9
10
D.
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
_________ times per month
b) Notice a deep, creeping sensation
inside your calves or thighs during
the night
_________ times per month
c) Wake up confused and wander
during the night
_________ times per month
d) Have nightmares
_________ times per month
e) Have fearful thoughts or images
as you are falling asleep
_________ times per month
103
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.
________________________________________________________________
________________________________________________________________
104
F.
Sleep Expectancy:
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.
兹
General Medical History
Please check (兹) in the boxes beside those medical problems you have now or
have had in the past.
Problem
兹
Problem
兹
Problem
Arthritis
Asthma
Chronic pain
Depression
Diabetes
Memory/Concentration Problems
Emphysema
Epilepsy
Headaches
Heartburn/Ulcers
High Blood Pressure
Hallucinations/Delusions
Kidney Problems
Hiatal Hernia
Childhood Hyperactivity
Panic Attacks
Nose/Throat Problems
Alcohol/Drug Problems
Sexual Problems
Anxiety/Nervousness
Loss of Sex Drive
Stroke
Suicide Attempts
Swelling Ankles
Thyroid Problems
Cold/Heat Intolerance
Trouble Breathing at Night
Changes in Hair or Skin
Please describe other problems not listed above:
105
2. What is (or was) your body weight?
A. Now
_________ (lbs)
B. 6 months ago
_________ (lbs)
C. When age 20
_________ (lbs)
D. When heaviest ever
_________ (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)
——————–————–————–————–—
106
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.
——————–——————–—————————–——–——–——–——–
——————–————–————–——————–——–——––——–——–
——————–—————–——————–———–——–——–——–——–
——————–————–—–—————————–——–——–——–——–
——————–————–——–————————–——–——–——–——–
Part IV:
Other Information
In the spaces provided below, please add any information that you feel is important.
——————–————–————–————————–——–——–——–——–
——————–————–————————————–——–——–——–——––
——————–————–—–———————————–——–——–——–——–
——————–—————–———————————–——–——–——–——––
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
——————–————–———————————–——–——–——–—–––—–
107
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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.
117