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

OvercomingInsomniaA Cognitive-Behavioral Therapy Approach

T h e r a p i s t G u i d e

Jack D. Edinger Colleen E. Carney

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. InsomniaTreatmentPopular works. 2. Cognitive therapy. I. Carney, Colleen.

II. Title. III. Series: Treatments that work. [DNLM: 1. Sleep Initiation and Maintenance Disorderstherapy. 2. Cognitive Therapymethods. WM 188 E23o 2008]RC548.E35 2008616.8498206dc22

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

1

vAbout 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

benet, but perhaps, inducing harm. Other strategies have been

proven eective using the best current standards of evidence, result-

ing 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, gov-

ernments 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 publics 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 inter-

ventions. 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 communicat-

ing these exciting new interventions to clinicians on the front lines of

practice.

The manuals and workbooks in this series contain step-by-step detailed

procedures for assessing and treating specic 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 practi-

tioners in the implementation of these procedures in their practice.

In our emerging health care system, the growing consensus is that evidence-

based practice oers 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 expe-

riences insomnia at least intermittently and 1 to 2% of the general pop-

ulation suers 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 signicant side eects.

Unlike pharmacological approaches, CBT insomnia intervention has been

shown to yield long-term improvements. This guide outlines a safe and

eective treatment that targets the behavioral and cognitive components

of insomnia. It includes detailed instructions for assessment and trou-

bleshooting. The corresponding client workbook provides educational

information and homework forms. Together, they form a complete insom-

nia treatment package for a variety of client needs. Clinicians will nd 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, 59,869878.

Institute of Medicine. (2001). Crossing the quality chasm: A new healthsystem for the 21st century. Washington, DC: National Academy Press.

vi

vii

Contents

Chapter 1 Introductory Information for Therapists 1

Chapter 2 Pretreatment Assessment 15

Chapter 3 Session 1: Psychoeducational and Behavioral Therapy

Components 31

Chapter 4 Session 2: Cognitive Therapy Components 49

Chapter 5 Follow-Up Sessions 69

Chapter 6 Considerations in CBT Delivery: Challenging Patients

and Treatment Settings 83

Appendix Sleep History Questionnaire 97

References 109

About the Authors 117

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1Chapter 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 rst authors ( 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 investiga-

tors and clinicians an understanding of CBT as well as step-by-step

instructions for replicating treatment procedures.

The specic 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 rst generation

behavioral treatment strategies that have proven reasonably eective 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 specic treatment needs

of the insomnia patients we encounter. This CBT protocol was developed

from the rst authors 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

2Morin (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. Specic

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 rst 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 diculties initiating,

sustaining, or obtaining qualitatively satisfying sleep that occur

despite adequate sleep opportunities/circumstances and result in

notable waking decits (Edinger et al., 2004). Over one third of

the adult population experiences insomnia at least intermittently,

whereas 10% to 15% suer chronic, unrelenting sleep diculties.

Insomnia may result from various medical disorders, psychiatric con-

ditions, substance abuse, and other primary sleep disorders (e.g., sleep

apnea). However, 1% to 2% of the general population suers 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 develop-

ing this condition remains relatively stable across the life span.

Although many insomnia suerers go undetected (Ancoli-Israel &

Roth, 1999), primary insomnia is common in primary care settings

and accounts for over 20% of all insomnia suerers who present to

specialty sleep disorders centers (Coleman et al., 1982; Simon &

VonKor, 1997). Thus, primary insomnia appears suciently preva-

lent 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 aected

individuals (Ozminkowski, Wang, & Walsh, 2007; Simon & VonKor,

1997; Weissman, Greenwald, Nino-Murcia, & Dement, 1997). Also, sev-

eral studies have shown that primary insomnia dramatically increases

subsequent risk for developing a depressive illness, serious anxiety disor-

der, or substance abuse problem even after other signicant 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, acci-

dents 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, eective, and enduring treatment.

Diagnostic Criteria for Primary Insomnia Disorder

Primary Insomnia is a diagnosis specic to the American Psychiatric

Associations sleep disorder classication system outlined in recent versions

of its Diagnostic and Statistical Manual of Mental Disorders. This diagnosis

rst appeared in the revised, third edition of the Associations Diagnostic

and Statistical Manual (American Psychiatric Association, 1987) and has

3

been maintained through subsequent revisions of this text (DSM-IV-TR,

American Psychiatric Association, 1994, 2000). Primary insomnias diag-

nostic criteria listed in Table 1.1 highlight the primary or central role that

sleep-wake disturbance serves in dening 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 med-

ical disorder or substance use/abuse. As such, primary insomnia is perhaps

best conceptualized as a diagnosis established by exclusion of other pri-

mary 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., follow-

ing a routine sleep-wake schedule; avoiding daytime napping, etc.) and

relaxing before bedtime facilitates nocturnal sleep. As such, it seems rea-

sonable to speculate that psychological and behavioral strategies

designed to improve sleep habits and reduce bedtime arousal may be use-

ful for treating insomnia. However, not until the late 1950s did the use-

4

Table 1.1 Diagnostic Criteria for Primary Insomnia

A. The predominant complaint is diculty initiating or maintaining sleep, or nonrestorative sleep, forat least 1 month.

B. The sleep disturbance (or associated daytime fatigue) causes clinically signicant distress or impair-ment in social, occupational, or other important areas of functioning.

C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-RelatedSleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia.

D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., MajorDepressive Disorder, Generalized Anxiety Disorder, delirium).

E. The disturbance is not due to the direct physiologic eects 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)

fulness of behavioral interventions receive attention in the scientic

literature. In 1959, Schultz and Luthe were the rst 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 rst randomized clinical trials conducted to document the

ecacy of RTs (Borkovec & Fowles, 1973; Nicassio & Bootzin, 1974).

Although limited in number, these early reports were sucient 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 Bootzins (1972) observation concerning the

important role of behavioral conditioning in disrupting or promoting

sleep. Indeed, Bootzin was the rst to suggest that sleep, like other overt

behaviors, should respond to instrumental conditioning. Consistent

with this suggestion, he rst 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 condi-

tioning approach involving standardization of the sleep-wake schedule,

eliminating daytime napping, and discouraging sleep-incompatible

behaviors in the bed and bedroom is particularly eective for treating

chronic primary insomnia. Perhaps both due to its practical appeal and

its general ecacy, 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 eective for treating the sleep problems of many of

the primary insomnia patients we encountered. However, these treat-

ments also appeared to have some limitations. Most notably, neither of

these treatments included specic 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 signicant factor

in the maintenance of their sleep diculty (Espie, Brooks, & Lindsay,

1989; Lichstein & Rosenthal, 1980). However, these treatments did not

employ specic strategies shown to be eective for decreasing pre-sleep

arousal (Carney & Waters, 2006; Espie and Lindsay, 1987). Lastly, these

5

treatments did not specically 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 specic strategies to enhance

patients treatment adherence. In this regard we found that patients

seemed more likely to adhere to treatment recommendations if they were

rst 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 cognitive-

behavioral therapy for insomnia became apparent. Thus, we con-

structed 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 patients 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 rst of these studies (Hoelscher &

Edinger, 1988), which included four primary insomnia patients, pro-

vided 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 under-

went 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 rst randomized clinical trial that showed a multicomponent CBT

6

similar to our approach was eective (compared to a wait-list condition)

for treating older adults with insomnia.

Since the time of these early works, a number of larger randomized clin-

ical trials have shown multicomponent CBT insomnia treatment is

both ecacious and clinically eective for treating primary insomnia.

In ecacy 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 behav-

ioral intervention, sleep medication (tamazepam), a medication place-

bo, and a no-treatment (wait-list) for treating insomnia complaints. In

two large eectiveness trials (Espie, 2001; Espie et al., 2007) conducted

with patients who presented to primary care clinics with insomnia com-

plaints, CBT proved more eective than usual medical management

strategies (medication and sleep advice) for producing sleep improve-

ments. Moreover, a recent critical literature review (Morin et al., 2006)

concluded that there have been a sucient number of ecacy and

eectiveness 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 condence we can oer

the treatment strategies outlined in this manual as a Treatment That

Works for patients with this condition.

Theoretical Model for Cognitive-Behavioral Insomnia Therapy

Spielmans model presented in Figure 1.1 provides a conceptual frame-

work 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 mech-

anisms all contribute to the development of chronic primary sleep

diculties. Some individuals may be particularly vulnerable to sleep

diculties 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 con-

fronted 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

turn, may then be perpetuated by a host of psychological and behav-

ioral factors that emerge in reaction to such a sleep diculty. Thus,

although predisposing and precipitating factors contribute to the ini-

tial development of insomnia, the psychological and behavioral per-

petuating 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 pri-

mary insomnia patients. Setting the stage for sustained sleep diculty is a

thinking style that can include misattributions about the causes of insom-

nia, 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, sup-

port and sustain sleep-disruptive habits and conditioned emotional

responses that either interfere with normal sleep drive or timing mecha-

nisms 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 elu-

sive, unpredictable sleep may only serve to interfere with the bodys home-

ostatic mechanisms that operate automatically to increase sleep drive in the

face of increasing periods of wakefulness (i.e., sleep debt). Alternately, the

8

100

0Premorbid

Predisposing Precipitating Perpetuating

Acute Sub-Acute Chronic

InsomniaThreshold

Figure 1.1Spielmans model describing the evolution of chronic primary insomnia

habit of remaining in bed well beyond the normal rising time following a

poor nights sleep may disrupt the bodys 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 unsuc-

cessful sleep attempts may eventually result in sleep-disruptive conditioned

arousal in the home sleeping environment. Finally, failure to discontinue

mentally demanding work and allot sucient wind-down time before

bed may serve as a signicant 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 ostensi-

bly sustain or add to patients sleep problems.

Risks and Benefits of CBT for Insomnia

Although systematic studies of CBT-related side eects have not been

conducted, the experience base with CBT-based insomnia interventions

suggests this intervention is a safe and eective treatment modality. This

is not to say that side eects 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 eect is enhanced daytime

sleepiness during the initial stages of treatment resulting from restricting

patients times spent in bed. In some patients the initial suggested restric-

tion in time in bed results in mild partial sleep deprivation and, thus, ele-

vated 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 eect also is easily managed via some relax-

ation of the treatment protocol as discussed in more detail in Chapter 5.

In contrast, there are many benets 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 improve-

ments 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 benets up to 24 months after active

treatment (i.e., facilitator contact) concludes. As such, this treatment

diers 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 benet 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 satised with

behavioral insomnia therapy and rated it as more eective than sleep

medication. Findings from another study (Morin et al., 1992) suggested

that patients with chronic insomnia both preferred CBT to pharma-

cotherapy but also expected that CBT would produce greater improve-

ments in daytime functioning, better long-term eects, and fewer

negative side eects. Collectively, these data suggest that insomnia

patients regard behavioral insomnia therapy as a viable and acceptable

treatment for their sleep diculties.

Alternative Treatments

Various stand-alone behavioral strategies including relaxation therapies,

stimulus control, sleep restriction, and paradoxical intention have proven

ecacy for management of insomnia and currently are regarded as well-

established insomnia treatments (Morin et al., 2006). Each of these ther-

apies addresses a specic 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

eective behavioral approach because it is designed to address the cogni-

tive 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 includ-

ed forms of yoga and acupuncture. Both of these treatments have shown

some ecacy 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 cur-

rent access to the behavioral therapies. Recently, pre-market testing of sev-

eral 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

ecacy 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 antidepres-

sants (e.g., doxepin) have been widely used for insomnia manage-

ment. Finally, the melatonin agonist ramelteon, has recently been

approved for treatment of insomnia.

The benet of medications and particularly the BzRAs is that they have

immediate eects on sleep. As such, sleep medications have their great-

est advantage over CBT for managing acute and brief forms of insom-

nia. 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 cir-

cumstances. 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 ecacy of some

medications when taken continuously for periods up to 12 months in

duration. However, tolerance and consequent reduced ecacy 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 insomnia-

perpetuating mechanisms mentioned previously.

Of course, the relative value of BzRA and CBT therapies largely depends

upon their comparative ecacies for short- and long-term insomnia

management of PI and CMI patients. Unfortunately, there are currently

limited data that speak to the relative ecacy of these two treatment

modalities. One recent study (Sivertsen et al., 2006) compared CBT with

the sleep medication zopiclone and showed CBT produced signicantly

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

dierence 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

xed-dose, and xed-agent pharmacotherapy strategies that do not repre-

sent 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 thor-

ough 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 treat-

ment sessions are then employed to address a range of behavioral and

cognitive treatment targets (perpetuating mechanisms). The following

outline shows the organization and ow 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 ndings 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

15

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 briey 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 clini-

cian ascertains etiological factors and formulates a treatment plan. In

addition to providing a comprehensive assessment of the individuals

specic insomnia complaint and sleep history, the clinical interview

should include evaluation of medication and substance use as well as

identication 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 psycho-

logical 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 com-

plaint. To facilitate the insomnia assessment, the patient may be asked to

complete a sleep history questionnaire like the one provided in the appen-

dix 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 specically for insomnia to guide their inquiries. Whatever

16

method chosen for querying the insomnia suerer, an interview with

his or her bed partner about the patients 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 factorsFactors that exacerbate insomnia or improve sleep patternSleep scheduleDaytime symptoms (fatigue, cognitive impairment, distress about sleep)Social/vocational impactMaladaptive conditioning to bedroomPhysiological/cognitive arousal at bedtimeUnhelpful sleep-related beliefs Symptoms of other sleep disorders Bedtime routines and sleep-incompatible behaviors in bedLifestyle (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 medicationsAlcohol, tobacco, caeine Illicit substances

Medical History/Exam

Medical disorders associated with sleep disruptionChronic painMenopausal status (women)Prostate disease (men)Any recent relevant laboratory test results (e.g., abnormal thyroid function)

Psychiatric Factors

DepressionAnxietyOther mental disordersGeneral day-to-day stress level

Sleep Logs

Prior to providing any treatment instructions, it is useful to have

the patient monitor his or her sleep pattern for a period of at least

2 weeks using a sleep log. Blank copies of the sleep log we use are pro-

vided 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 par-

ticularly valuable tool that allows for prospective monitoring of the

patients sleep habits and pattern over time. The log is designed to

solicit information relevant to each nights 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 o 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 nal morning awakening, and the time of actually arising from

bed. The log also queries about the quality of each nights 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 weeks worth of sleep

information on a single sheet. To ensure the greatest accuracy and use-

fulness of the data obtained, the patient should be encouraged to

complete the sleep log each morning within the rst 30 minutes or so

after arising.

We nd the sleep log is the quintessential tool in our work with insom-

nia 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 patients 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 specic 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 o the lights and attempted to fall asleep at _____ (AM or PM?).

5. After turning o the lights it took me about _____ minutes to fall asleep.

6. I woke from sleep _____ times. (Do not count your nal awakening here.)

7. My awakenings lasted _____ minutes. (List each awakening separately.)

8. Today I woke up at _____ (AM or PM?). (NOTE: this is your nalawakening.)

9. Today I got out of bed for the day at _____ (AM or PM?).

10. I would rate the quality of last nights sleep as: Very Fair ExcellentPoor

1 2 3 4 5 6 7 8 9 10

11. How well rested did you feel upon arising today?Not at All Somewhat Well Rested

1 2 3 4 5 6 7 8 9 10

Figure 2.1Sleep Log

19

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 nights 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 o while watching TV in bed well before the des-

ignated 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 treat-

ment targets uncovered by these sleep log data. The observed behav-

ioral 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 insom-

nia patients. The most obvious problem shown by this log is the

patients erratic sleep pattern. Indeed, the information recorded

shows that the patients 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 patients perspective, highly unpredictable. Patients who show

such patterns often stray from a routine sleep-wake schedule in an

eort 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 sleep-

related beliefs and anxiety that underlie this pattern are treatment

targets that the sleep log has helped uncover.

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 3/111. Yesterday I napped from _____to _____ (note time of all naps). None None None None 3:30

3:35 PMNone None

2. Last night I took _____ mg of _____ or _____ of alcohol as a sleepaid (include all prescription and over-the-counter sleep aids). 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 o 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 o 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 nal awakening here.) 2 3 2 3 2 1 27. My awakenings lasted _____ minutes. (List each awakening separately.) 20 min

60 min15 min45 min30 min

15 min75 min

15 min15 min30 min

15 min15 min 25 min

15 min60 min

8. Today I woke up at _____ (AM or PM?). (NOTE: this is your nalawakening.)

6:00 AM 5:45 AM 5:00 AM 4:45 AM 6:00 AM 6:45 AM 5:50 AM

9. Today I got out of bed for the day at _____ (AM or PM?). 6:30 AM 6:35 AM 6:30 AM 6:00 AM 7:00 AM 7:30 AM 6:30 AM

10. I would rate the quality of last nights sleep as: Very Poor Fair Excellent

1 2 3 4 5 6 7 8 9 10

5 3 2 2 6 7 4

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

5 4 1 2 6 7 4

Figure 2.2Sleep Log Case #1

21

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 1/211. 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 sleepaid (include all prescription and over-the-counter sleep aids).

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 o 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 o 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 nal awakening here.) 1 2 2 2 1 1 2

7. My awakenings lasted _____ minutes. (List each awakening separately.)50 min

25 min25 min

45 min90 min

40 min90 min 55 min 5 min

80 min60 min

8. Today I woke up at _____ (AM or PM?). (NOTE: this is your nalawakening.)

6:05 AM 8:30 AM 9:00 AM 6:40 AM 5:15 AM 7:25 AM 7:20 AM

9. Today I got out of bed for the day at ____ (AM or PM?). 6:30 AM 8:40 AM 9:05 AM 7:30 AM 5:20 AM 7:30 AM 7:40 AM

10. I would rate the quality of last nights sleep as: Very Poor Fair Excellent

1 2 3 4 5 6 7 8 9 10

5 7 2 1 4 3 2

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

5 6 3 1 4 3 1

Figure 2.3Sleep Log Case #2

Case Example #3

Figure 2.4 highlights the diagnostic usefulness of sleep log data. These

data were collected by a college student who presented to our clinic

complaining about extreme diculty falling asleep each night. This log

clearly shows that the student has marked diculty 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 stu-

dent 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 aord the student greater opportunity to obtain a

full nights sleep given the delayed time of sleep onset. All these indica-

tors suggest the student likely suers from delayed sleep phase syn-

drome, 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 peri-

od is articially 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 nd these logs useful for iden-

tifying 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-specic 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 diculty, wakefulness during sleep) and waking

(e.g., daytime fatigue, sleep worries) symptoms of insomnia. Each item

22

23

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 4/81. Yesterday I napped from _____ to _____ (note time of all naps). None 2:00

4:00 PM5:006:30 PM

None None None None

2. Last night I took _____ mg of _____ or _____ of alcohol as a sleepaid (include all prescription and over-the-counter sleep aids).

4 ozwine

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 o 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 o 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 nal awakeninghere.)

1 2 2 1 1 1 1

7. My awakenings lasted _____ minutes. (List each awakening separately.)10 min

25 min25 min

40 min30 min 20 min 20 min 5 min 20 min

8. Today I woke up at _____(AM or PM?). (NOTE: this is your nalawakening.)

8:05 AM 9:30 AM 9:00 AM 8:40 AM 12:15 AM 11:25 AM 8:30 AM

9. Today I got out of bed for the day at _____ (AM or PM?). 8:30 AM 9:40 AM 9:05 AM 8:45 AM 12:20 AM 11:30 AM 8:40 AM

10. I would rate the quality of last nights sleep as: Very Poor Fair Excellent

1 2 3 4 5 6 7 8 9 10

4 4 4 1 6 7 2

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

4 3 3 1 7 7 1

Figure 2.4Sleep Log Case #3

is accompanied by a 100-mm visual-analog scale (i.e., horizontal line)

that is labeled not at all at its left extreme and always at its right

extreme. In responding to this instrument, respondents draw a vertical

line through the point on each items analog scale (i.e., 100-mm line) to

indicate their responses. The distance from the left end of the line to a

subjects 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 (Cronbachs

0.73) and sensitivity to treatment-related sleep improvements. In

our research we have used a total ISQ score 41 as the clinical cuto

connoting insomnia remission given our early ndings suggested this

cuto has a 92% sensitivity and 64% specicity for discriminating nor-

mal sleepers from primary insomnia suerers. 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

cuto has an 89% sensitivity and 86.5% specicity 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: diculty falling asleep, diculty staying asleep,

and early morning awakenings; satisfaction with sleep; degree of impair-

ment 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

028. The following guidelines are recommended for interpreting the

total score: 07 (no clinical insomnia), 814 (sub-threshold insomnia),

1521 (insomnia of moderate severity), and 2228 (severe insomnia). The

ISI has good internal consistency (Cronbachs alpha 0.91) and test-

retest 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 interpreta-

tion, this instrument can be used easily in clinical venues for judging ini-

tial insomnia severity and the clinical signicance 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 recom-

mended (Buysse et al., 2006) tool for assessing sleep disturbance in

insomnia patients as well as in patients with other types of sleep disor-

ders. The PSQI is composed of four open-ended questions and 19 self-

rated items (03 scale) assessing sleep quality and disturbances over

the previous 1-month interval. Domains assessed include sleep onset

latency, sleep duration, sleep eciency (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 specicity (86.5%)

in discriminating those with insomnia from good sleepers. As such, a

posttreatment PSQI score 5 has been used in some studies as indicat-

ing insomnia remission. However, it should be noted that the PSQI

provides a global sleep quality assessment and is not specically 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

patients 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 ve subscales designed to assess (1) attributions

about the eects of insomnia (e.g., I am concerned that chronic insom-

nia may have serious consequences on my physical health); (2) percep-

tions 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 insom-

nia is basically the result of aging and there isnt much that can be done

about this problem); and (5) expectations about sleep-promoting habits

(e.g., When I dont 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 indi-

cate 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 items 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 for-

mat to the original instrument but it uses 10-point Likert scales super-

imposed on visual analog scales for indicating agreement/disagreement

with the various items. For each of the 16 beliefs, the number correspon-

ding 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

(Cronbachs 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 signicant insomnia

problems. Both DBAS instruments can be used to identify specic prob-

lematic beliefs to target in treatment and to assess belief changes result-

ing 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 sum-

ming 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 signicant daytime sleepiness.

A score of 18 or more connotes someone who is very sleepy. This instru-

ment has shown very acceptable internal consistency (Cronbachs

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

signicantly (r .514, p .01) with objective tests of daytime sleepi-

ness ( 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 cuto are likely to suer 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 recom-

mended. 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 proles for a wide range of psychopathol-

ogy. Validity scales provide information on response biases such as

patients attempts to either deny or exaggerate psychopathological

symptoms. Individuals with insomnia produce specic MMPI-2

proles characterized by depression, anxiety, and somatization of

emotional conict. 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 acti-

graphs 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 eectiveness of treatments for these disor-

ders, 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 verication of the patients sleep-wake schedule and adherence to

recommended rising times and TIB prescriptions included in the treat-

ment recommendation discussed in the next chapter.

28

Polysomnography

Polysomnography is a diagnostic test during which a number of physi-

ologic 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

Airow

Respiratory eort (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 patients home setting. In most cases, polysomnog-

raphy 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 patients sleep problems (e.g., sleep apnea or periodic limb move-

ments 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 decision-

making can be gleaned from the clinical interview and sleep log.

Indeed, these two sources usually provide sucient information to

identify pertinent cognitive and behavioral treatment targets in the

insomnia patient. However, the additional assessment methods men-

tioned 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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31

Chapter 3 Session 1: Psychoeducational and BehavioralTherapy 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: Eects of Jet Lag

Patients 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 Spielmans 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

32

sleep problems. These problems are then made worse by various perpetuat-

ing 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 sleep-

disruptive 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 ndings we believe you will benet from some informa-

tion 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 nor-

mal 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 under-

standing, in turn, increases the likelihood that patients will adhere to

treatment recommendations.

During this rst session of treatment, provide the patient with informa-

tion on sleep norms, circadian rhythms, the eects of aging on sleep,

and sleep deprivation. If you wish, you may audiotape this part of the

session and give a copy of the tape to the patient to review at home.

This information also appears in the corresponding patient workbook.

You may use the following sample dialogue:

This treatment will require you to make some major changes in your

sleep habits so you can improve your sleep. However, before you learn

these new habits, it is important that you have a better understanding

of your sleep needs and what controls the amount and quality of sleep

you obtain. The information Im about to give you will help you

understand how your bodys sleep system works and prepare you for the

specic 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 ts 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

satises 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

bodys sleep system works. People, like many animals, have powerful

internal clocks that aect 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 persons body temper-

ature 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 inuence of the internal circadian clock on the sleep-wake cycle is

apparent if one studies the relationship between the bodys 24-hour tem-

perature 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 con-

tinue to show a consistent temperature rhythm and sleep-wake pattern

that complete a full cycle about every 24 hours. In most people, there is

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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 tempera-

ture rhythm reects 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, signicant 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 ies to Los Angeles, he initially is likely to have some

diculty 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 mans 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 rst 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

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Biological Wake Time

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Figure 3.1Circadian Temperature Rhythm

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Figure 3.2Eects of Jet Lag

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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 eects of sleep loss on you. This understand-

ing is important because many who have sleep problems make these

problems worse by what they do to make up for lost sleep. For exam-

ple, people may take daytime naps, go to bed too early, or sleep in

following a poor nights 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 exam-

ple, 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 nights sleep.

Extended periods of sleep loss, of course, may have some bad eects as

well. If people are totally deprived of a nights 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 bodys sleep system has some ability to make up for times when

you dont get the amount of sleep you need.

Since you have kept a sleep log for a couple of weeks, you have proba-

bly noticed that you occasionally had a relatively good nights sleep

after one or several nights of poor sleep. Such a pattern suggests that

your bodys 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 prob-

lem. 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 Im making. Do you have any questions

about what you have just heard ?

Behavioral Treatment Regimen

The behavioral treatment regimen uses stimulus control and sleep restric-

tion strategies to standardize the patients sleep-wake schedule, eliminate

sleep-incompatible behaviors that occur in the bed and bedroom, and

restrict time in bed (TIB) in an eort to force the development of an

ecient, consolidated sleep pattern. The majority of behavioral recom-

mendations included in this regimen are standard for all patients.

However, the TIB prescriptions provided are based on a pretreatment esti-

mate (derived from sleep logs) of each patients sleep requirement. Since

TIB prescriptions may vary from patient to patient, these prescriptions

allow for the tailoring of this regimen to t each patients specic sleep

needs.

Refer the patient to the sleep improvement guidelines in Chapter 2 of

the workbook and provide a brief justication for each behavioral rec-

ommendation 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.

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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 unin-

tentionally 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 Cant Sleep

Many people linger in bed for minutes, or even hours, when they cant 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,

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becoming frustrated, or worrying about not sleeping. These reactions,

in turn, make it more dicult 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

nd yourself awake for 20 minutes or so and you do not feel as

though you are about to go to sleep.

Rule 4: Dont Worry, Plan, etc., in Bed

Bedtime is not the time to attempt problem solving or to engage in think-

ing or worrying. Engaging in these sorts of activities only serves to keep

the mind awake, making it extremely dicult 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 cant seem to shut o your

thoughts, get up and go to another room until you can return to bed

without this thinking interrupting your sleep. If this disruptive think-

ing occurs frequently, you may nd 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 par-

tially satises your sleep needs and, thus, will weaken your sleep drive

at night.

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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 nd 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 nights 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 briey discussed in Chapter 2, you will use the patients 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 patie