Overcoming Insomnia - Therapist Guide

Jack D. Edinger

Colleen E.

Carney

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™

Treatmen ts That Work

Overcoming InsomniaA Cognitive-Behavioral Therapy Approach

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

Jack D. Edinger • Colleen E. Carney

12008

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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 2008616.8’498206—dc22

2007047486

ISBN 978-0-19-536589-4

http://www.oup.com/

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,

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 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 communicat- ing 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 evidence- based 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 forclients address the treatment of insomnia. Over onethird of the adult population experiences insomnia atleast intermittently and 1 to 2% of the general pop-ulation suffers from primary insomnia (a form ofinsomnia devoid of secondary causes). Primaryinsomnia can have severe negative outcomes for theindividual and has implications for the health caresystem. Medication is often prescribed, but can havesignificant side effects.

Unlike pharmacological approaches, CBT insomniaintervention has been shown to yield long-termimprovements. This guide outlines a safe andeffective treatment that targets the behavioral andcognitive components of insomnia. It includesdetailed instructions for assessment and trou-bleshooting. The corresponding client workbookprovides educational information and homeworkforms. Together, they form a complete insom- niatreatment package for a variety of client needs.

Clinicians will find this a welcome addition to theirarmamentarium.

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 Therapists 1

Chapter 2 Pretreatment Assessment 15

Chapter 3 Session 1 : Psychoeducational and Behavioral Therapy Components 31

Chapter 4 S ession 2 : Cognitiv e Therapy Components 49

Chapter 5 Follow-Up Sessions 69

Chapter 6 Considerations in CBT Deliv er y: Challenging P atients and T r eatment S ettings 83

A ppendix Sleep History Questionnair e 97

References 109

About the Authors 11 7

vii

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Chapter 1 Introductor y Information for Ther apists

Background Information and Purpose of This Program

The behavioral component of this treatment manual

originally was prepared as an Appendix to the firstauthor’s ( JDE) National Institutes of Mental Health

funded grant (MH 48187) entitled, “Cognitive-Behavioral Therapy for Treatment of PrimaryInsomnia.” The cognitive component of this manualwas prepared by the second author (CEC) as anAppendix to a grant funded by the National Instituteof Nursing Research (NR 010539) entitled “Cognitive-Behavioral Insomnia Treatment in Chronic FatigueSyndrome.” The primary purpose of this manual is todescribe and operationalize the cognitive-behavioraltherapy (CBT). However, this manual has beenwritten in such a manner as to provide otherinvestiga- tors and clinicians an understanding ofCBT as well as step-by-step instructions forreplicating treatment procedures.

The specific treatment procedures presented hereinhave been derived from various sources. As describedin more detail later in this chapter, the CBT protocolrepresents a “second generation” multicomponentform of therapy that evolved from several decades ofcognitive and behavioral insomnia research. Thistreatment includes selected first generationbehavioral treatment strategies that have provenreasonably effective as stand-alone treatments forinsomnia or for other conditions. However, the CBTprotocol combines several of these therapies toprovide a more omnibus therapy designed to addressthe varying specific treatment needs of the insomnia

patients we encounter. This CBT protocol wasdeveloped from the first author’s early work(Edinger et al., 1992; Hoelscher & Edinger, 1988) andfrom the writings of Bootzin (1977), Morin et al.(1989), Spielman, Caruso, et al. (1987), and Webb (1988).The cognitive component was informed byintegrative cognitive-behavioral models of

1

Morin (1993) and Harvey (2002). One of thecognitive strategies (i.e., Constructive Worry) was

derived from Carney and Waters (2006) and Espie andLindsay (1987). As much of our own and others’research has focused on the type of insomnia knownas Primary Insomnia, the strategies described in thismanual are mainly fashioned for the treatment of thiscondition. However, as discussed in the last chapter ofthis book, these strategies may be considered forother forms of insomnia as well.

This treatment manual is divided into chapters thatdescribe methods of insomnia assessment and theimplementation of our CBT protocol. Each chapterdescribing the treatment protocol provides a“treatment rationale” to be provided to patientsundergoing treatment. Specific information andinstructions to be provided to patients arehighlighted with italics. Investigators who wish toreplicate the procedures described should presentthe highlighted information and instructions totheir patients verbatim. It is also recommended thatthose who wish to use these treatments in their own

insomnia research first review the list of Referencesprovided at the end of this text.

Nature and Significance of Primary Insomnia

The sleep disorder insomnia is characterized by

difficulties initiating, sustaining, or obtainingqualitatively satisfying sleep that occur despiteadequate sleep opportunities/circumstances andresult in notable waking deficits (Edinger et al.,

2004). Over one third of the adult populationexperiences insomnia at least intermittently,

whereas 10% to 15% suffer chronic, unrelentingsleep difficulties. Insomnia may result from variousmedical disorders, psychiatric conditions,substance abuse, and other primary sleep disorders

(e.g., sleep apnea). However, 1% to 2% of thegeneral population suffers from primary insomnia, a

form of insomnia disorder that persists either in theabsence or independent of any such comorbidcondition. Whereas the middle-aged and older adultsare most prone to develop one of the many subtypesof insomnia, primary insomnia is the most commondiagnosis found in younger age groups. As such, therisk for developing this condition remainsrelatively stable across the life span. Although

many insomnia sufferers go undetected (Ancoli-Israel &

2

Roth, 1999), primary insomnia is common inprimary care settings and accounts for over 20% ofall insomnia sufferers who present to specialty sleepdisorders centers (Coleman et al., 1982; Simon &VonKorff, 1997). Thus, primary insomnia appearssufficiently preva- lent and disturbing that itfrequently comes to the attention of both sleepspecialists and general medical practitioners.

Since primary insomnia is devoid of secondary causes,this problem was traditionally viewed as less seriousthan those insomnias arising from medical, psychiatric,substance abuse, or other serious sleep disorders(e.g., sleep apnea). However, epidemiologic evidencesuggests insomnia, uncomplicated by comorbidpsychiatric, substance abuse, or medical disorders,substantially increases health-care utilization/costs andaccounts for as many as 3.5 disability days per monthamong affected individuals (Ozminkowski, Wang, &Walsh, 2007; Simon & VonKorff, 1997; Weissman,Greenwald, Nino-Murcia, & Dement, 1997). Also, sev-eral studies have shown that primary insomniadramatically increases subsequent risk for developing adepressive illness, serious anxiety disorder, orsubstance abuse problem even after other significantrisk 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). Inaddition, primary insomnia contributes to reducedproductivity, accidents at work, increased alcoholconsumption, serious falls among older adults, and asense 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 AmericanPsychiatric Association’s sleep disorder classificationsystem outlined in recent versions of its Diagnostic andStatistical Manual of Mental Disorders. This diagnosis firstappeared in the revised, third edition of theAssociation’s Diagnostic and Statistical Manual (AmericanPsychiatric 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 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-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 thistext (DSM-IV-TR, American Psychiatric Association,1994, 2000). Primary insomnia’s diagnostic criteria

listed in Table 1.1 highlight the primary or central rolethat sleep-wake disturbance serves in defining thiscondition. In fact, these criteria specify that aprimary insomnia diagnosis is assigned when theinsomnia does not occur exclusively during the courseof another primary sleep or psychiatric disorder andis not the direct result of a general medical disorderor substance use/abuse. As such, primary insomnia isperhaps best conceptualized as a diagnosisestablished by exclusion of other primary andsecondary forms of sleep disturbance. Nevertheless,primary insomnia can usually be discerned fromclinical interview, as expensive and time-consuminglaboratory tests are seldom needed for diagnosis ofinsomnia.

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 attentionin the scientific literature. In 1959, Schultz and Luthewere the first to formally report their success intreating a patient with sleep-onset insomnia usingthe form of relaxation therapy (RT) known asautogenic training. Several years later, Jacobson(1964) reported similar results in a case he treatedwith his progressive muscle relaxation. However, notuntil the early 1970s were the first randomizedclinical trials conducted to document the efficacy ofRTs (Borkovec & Fowles, 1973; Nicassio & Bootzin,1974). Although limited in number, these early reportswere sufficient to spawn substantial research andclinical interest in the use of psychological andbehavioral therapies for insomnia treatment duringthe past two decades.

Arguably one of the more monumentalbreakthroughs in behavioral insomnia research wasBootzin’s (1972) observation concerning theimportant role of behavioral conditioning indisrupting or promoting sleep. Indeed, Bootzin wasthe first to suggest that sleep, like other overtbehaviors, should respond to instrumentalconditioning. Consistent with this suggestion, he firstpresented 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 approachinvolving standardization of the sleep-wake schedule,eliminating daytime napping, and discouragingsleep-incompatible behaviors in the bed andbedroom is particularly effective for treating chronicprimary insomnia. Perhaps both due to its practicalappeal and its general efficacy, SC quickly becameone of the most widely used behavioral insomniatreatments (Lacks & Morin, 1992).

In our early clinical work, we found stimuluscontrol and relaxation therapies moderately effectivefor treating the sleep problems of many of theprimary insomnia patients we encountered.However, these treatments also appeared to have

some limitations. Most notably, neither of thesetreatments included specific strategies foraddressing patients’ unhelpful beliefs that served tosupport their sleep-related anxiety and promotemany of their sleep-disruptive habits. In addition,many people with insomnia report that cognitivearousal is the most significant factor in themaintenance of their sleep difficulty (Espie, Brooks,& Lindsay, 1989; Lichstein & Rosenthal, 1980).However, these treatments did not employ specificstrategies shown to be effective for decreasing pre-sleep arousal (Carney & Waters, 2006; Espie andLindsay, 1987). Lastly, these

5

treatments did not specifically address the practice ofspending excessive time in bed displayed by many ofthe patients with sleep maintenance complaints weencountered. Inasmuch as a case series study by

Spielman, Saskin, and Thorpy (1987) showed thatrestricting time in bed led to sleep improvements ina small group of insomnia patients they treated, wethought a truly omnibus insomnia therapy shouldinclude such a strategy. Finally, we noted the needfor specific strategies to enhance patients’treatment adherence. In this regard we found thatpatients seemed more likely to adhere to treatment

recommendations if they were first provided somelimited psychoeducational material designed to givethem a basic understanding of what regulates thehuman sleep system and the types of habits that helpand 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 toaddress unhelpful beliefs about sleep; (2) standardstimulus control instructions to address patients’conditioned arousal and eliminate common sleepdisruptive habits (daytime napping, maintaining anerratic sleep-wake schedule); and (3) a protocol forlimiting each patient’s time in bed to an individuallytailored time-in-bed prescription (discussed indetail in Chapter 3).

To test this approach, we conducted two small case-series studies using multiple baseline designs. Thefirst of these studies (Hoelscher & Edinger, 1988),which included four primary insomnia patients, pro-vided initial support for our multicomponentapproach in that three of the four patients treatedresponded well once treatment was initiated. In oursecond case series study (Edinger et al., 1992), seven

patients underwent baseline monitoring that variedfrom 2 to 4 weeks in length and then successivelycompleted four weekly sessions of relaxation trainingfollowed by four sessions of our multicomponenttreatment. Results of this latter trial again suggestedthat most patients showed marked improvements inkey sleep measures and such improvements occurredonly after our multicomponent Cognitive-BehavioralTherapy (CBT) was initiated. Shortly thereafter,Morin, Kowatch, et al. (1993) published the firstrandomized clinical trial that showed amulticomponent 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 oflarger randomized clinical trials have shownmulticomponent CBT insomnia treatment is bothefficacious and clinically effective for treatingprimary insomnia. In efficacy studies (Edinger et al.,2001, 2007; Morin, 1999) conducted with intentionallyrecruited and thoroughly screened primary insomniasamples, CBT has proven superior to relaxationtraining, sham behavioral intervention, sleepmedication (tamazepam), a medication placebo,and a no-treatment (wait-list) for treating insomniacomplaints. In two large effectiveness trials (Espie,2001; Espie et al., 2007) conducted with patients whopresented to primary care clinics with insomnia com-plaints, CBT proved more effective than usualmedical management strategies (medication andsleep advice) for producing sleep improvements.Moreover, a recent critical literature review (Morinet al., 2006) concluded that there have been asufficient number of efficacy and effectivenessstudies conducted to conclude that CBT for insomniais a well-established and proven treatment approachparticularly for those with primary insomnia. Thus,with reasonable confidence we can offer thetreatment strategies outlined in this manual as a“Treatment That Works” for patients with thiscondition.

Theoretical Model for Cognitive-Behavioral Insomnia Therapy

Spielman’s model presented in Figure 1.1 provides aconceptual frame- work for understanding theevolution of chronic primary insomnia and the roleof CBT for managing this condition. According tothis model, predisposing factors, precipitating events,and perpetuating mechanisms all contribute to thedevelopment of chronic primary sleep difficulties.

Some individuals may be particularly vulnerable tosleep difficulties either by virtue of having a“weak,” “highly sensitive,” biological sleep systemor personality traits that dispose them to poor sleepwhen confronted with stress. When such individualsare confronted with the proper precipitatingcircumstances (e.g., a stressful life event, suddenunexpected change in their sleep schedule), theytend to develop an acute sleep disturbance. Thissleep problem, in

7

100

Insomnia

Threshold

0Premorbid Acute Sub-Acute Chronic

Predisposing Precipitating 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 interplayof cognitive and behavioral mechanisms act as thekey perpetuating mechanisms for primary insomniapatients. Setting the stage for sustained sleep difficultyis a thinking style that can include misattributionsabout the causes of insomnia, attentional bias forsleep-related stimuli, worry and/or rumination aboutthe consequences of poor sleep, and unhelpful beliefsabout 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 habitsand conditioned emotional responses that eitherinterfere 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 ofelu- sive, unpredictable sleep may only serve tointerfere with the body’s homeostatic mechanismsthat operate automatically to increase sleep drive inthe face of increasing periods of wakefulness (i.e.,sleep debt). Alternately, the

8

habit of remaining in bed well beyond the normalrising time following a poor night’s sleep may disruptthe body’s circadian or “clock” mechanisms thatcontrol the timing of sleep and wakefulness in the24-hour day. Additionally, the repeated association ofthe bed and bedroom with unsuccessful sleepattempts may eventually result in sleep-disruptiveconditioned arousal in the home sleepingenvironment. Finally, failure to discontinue mentallydemanding work and allot sufficient “wind-down”time before bed may serve as a significant sleepinhibitor during the subsequent sleep period. In sum,all these factors may contribute to and perpetuatePI (Bootzin & Epstein, 2000; Edinger & Wohlgemuth,1999; Hauri, 2000; Morin, Savard & Blias, 2000). As aresult, our CBT approach is designed to modify therange of cognitions and sleep-related behaviors thatostensi- bly sustain or add to patients’ sleep problems.

Risks and Benefits of CBT for Insomnia

Although systematic studies of CBT-related sideeffects have not been conducted, the experience basewith CBT-based insomnia interventions suggests thisintervention is a safe and effective treatment modality.This is not to say that side effects do not occur, butthose that do occur are generally transient andmanageable with strategies outlined later in thismanual. Perhaps the most common side effect isenhanced daytime sleepiness during the initial stagesof treatment resulting from restricting patients’ timesspent in bed. In some patients the initial suggestedrestric- tion in time in bed results in mild partial sleepdeprivation and, thus, elevated daytime sleepiness.This sleepiness is usually transient and corrected bygradual increases in time in bed. Some patients alsoshow elevated anxiety about sleep when limits areplaced on their times spent in bed and choices of risetimes. This side effect also is easily managed via somerelax- ation 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 thatindicate many patients may prefer CBT overmedicinal approaches. For example, results of onestudy (Morin et al., 1999) showed patients weremore satisfied with behavioral insomnia therapy andrated it as more effective than sleep medication.Findings from another study (Morin et al., 1992)suggested that patients with chronic insomnia bothpreferred CBT to pharmacotherapy but alsoexpected that CBT would produce greater improve-ments in daytime functioning, better long-termeffects, and fewer negative side effects. Collectively,these data suggest that insomnia patients regardbehavioral insomnia therapy as a viable andacceptable treatment for their sleep difficulties.

Alternative Treatments

Various “stand-alone” behavioral strategies includingrelaxation therapies, stimulus control, sleeprestriction, and paradoxical intention have provenefficacy for management of insomnia and currentlyare regarded as “well- established” insomniatreatments (Morin et al., 2006). Each of these ther-apies addresses a specific subset of insomnia-perpetuating mechanisms. In addition to thesetherapies, cognitive therapy and sleep hygieneeducation are often employed in insomniamanagement but these therapies do not currentlyhave empirical support as “stand-alone” interventions.

Detailed descriptions of all of these treatments andtheir applications can be found in a number ofsources (e.g., Morin et al., 2006; Edinger & Means,2005; Edinger & Wohlgemuth, 1999). As notedpreviously, we have found our multicomponenttherapy to be a more comprehensive and consistentlyeffective behavioral approach because it is designedto address the cognitive and behavioralmechanisms that perpetuate insomnia in the vastrange 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) andvarious sedating tricyclic antidepres-

sants (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 advantageover CBT for managing acute and brief forms ofinsomnia. For example, sleep medications are wellsuited for treatment of insomnia arising from anabrupt sleep-wake schedule change (e.g., jet lag) oras a stress reaction (e.g., bereavement) tounfortunate life circumstances. In contrast, the

role of medications in the management of chronicinsomnia has been debated. Recently some studies

(Krystal et al., 2003; Roth et al., 2005) have showncontinued 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 somesleep medications, and all sleep medications holdthe risk of psychological dependence when used overtime. Furthermore, whereas medications mayreduce 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 CBTtherapies largely depends upon their comparativeefficacies for short- and long-term insomniamanagement of PI and CMI patients. Unfortunately,there are currently limited data that speak to therelative efficacy of these two treatment modalities.One recent study (Sivertsen et al., 2006) compared CBTwith the sleep medication zopiclone and showed CBTproduced significantly better short- and longer-termimprovements on objective indices taken fromelectronic sleep recordings but not on subjectivemeasures taken from sleep logs. Some other studies(e.g., Jacobs et al., 2004; Morin et al., 1999) thatcompared treatments consisting of a sleepmedication alone, CBT alone, and a combined CBTand sleep medication therapy showed little differencein short-term outcomes, but superior longer-termoutcomes with CBT alone compared to medicationand combined treatment. However, all of thesestudies are limited by their small sample sizes, use offixed-dose, and fixed-agent pharmacotherapy strategiesthat do not repre- sent standard clinical practice.Thus, additional studies of the relative values ofCBT 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 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 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

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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

Use of the Workbook

e. Consideration of therapy termination

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 diagnoseand assess Primary Insomnia (PI) as well as otherforms of insomnia. The following sections brieflydiscuss each method.

Clinical Interview

The clinical interview is a particularly importantcomponent of an insomnia assessment because itprovides the basis from which the clini- cianascertains etiological factors and formulates atreatment plan. In addition to providing acomprehensive assessment of the individual’sspecific insomnia complaint and sleep history, theclinical interview should include evaluation ofmedication and substance use as well as

identification of contributory medical and psychiatricconditions.

Essential elements of an insomnia-focused clinicalassessment are outlined in Table 2.1. As suggested bythe information shown in the table, the insomnia-focused interview should provide a thoroughdescriptive and functional assessment of the sleepcomplaint, its history, and the psychological andbehavioral factors that may sustain it. Moreover, theinterview should provide a thorough assessment ofthe relationship, if any, between comorbid conditions(medical or psychiatric) and the insomnia com-plaint. To facilitate the insomnia assessment, thepatient may be asked to complete a sleep historyquestionnaire like the one provided in the appendix

prior to the interview. This sort of instrument isdesigned to gather the pertinent information neededfor a thorough insomnia assessment. Clinicians mayalso choose to employ one of the available semi-

structured interviews (Spielman & Anderson, 1999;Savard & Morin, 2002) designed specifically forinsomnia 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 factorsFactors that exacerbate insomnia or improve sleep pattern Sleep scheduleDaytime symptoms (fatigue, cognitive impairment, distress about sleep)Social/vocational impactMaladaptive conditioning to bedroom Physiological/cognitive arousal at bedtime Unhelpful sleep-related beliefsSymptoms of other sleep disordersBedtime 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, caffeineIllicit substances

Medical History/Exam

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

Psychiatric Factors

Depression AnxietyOther mental disordersGeneral day-to-day

stress level

16

Sleep Logs

Prior to providing any treatment instructions, it isuseful to have the patient monitor his or her sleep

pattern for a period of at least 2 weeks using a sleeplog. Blank copies of the sleep log we use are pro- videdfor the patient in the corresponding workbook and asingle blank copy of this log is shown in Figure 2.1.This instrument is a particularly valuable tool thatallows for prospective monitoring of the patient’s sleephabits and pattern over time. The log is designed tosolicit information relevant to each night’s sleepincluding whether any naps were taken the previousday, whether any medication or alcohol was ingestedat bedtime to facilitate sleep, the time the patiententered bed, the time the lights were turned off andthe patient attempted to fall asleep, the number ofminutes it took to fall asleep, the number and length

of awakenings during the night, the time of the finalmorning awakening, and the time of actually arisingfrom bed. The log also queries about the quality ofeach 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 ofsleep information on a single sheet. To ensure thegreatest accuracy and usefulness of the dataobtained, the patient should be encouraged tocomplete 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

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 fallasleep.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 Fair

Excellent Poor1 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 2.1

Sleep Log

18

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 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 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 sleep- related beliefs and anxiety that

underlie this pattern are treatment targets that the

sleep log has helped uncover.

19

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

1. Yesterday I napped from to (note time of all naps). None None None None 3:30–3:35 PM

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 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 attemptedto 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 awakeningseparately.)

20 min

60 min

15 min

45 min

30 min

15 min

75 min

15 min15 min30 min

15 min

15 min 25 min

15 min

60 min

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

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 night’s sleep as:Very Poor Fair Excellent

1 2 3 4 5 6 7 8 9 10

5 3 2 2 6 7 4


1 2 3 4 5 6 7 8 9 10

5 4 1 2 6 7 4

Figure 2.2

Sleep Log Case #1

20

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





11:00 PM 10:45 PM 10:30 PM 11:30 PM 11:20 PM 2:45 PM 9:30 PM


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 min90 min 55 min 5 min

80 min

60 min

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

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



1 2 3 4 5 6 7 8 9 10

5 7 2 1 4 3 2


1 2 3 4 5 6 7 8 9 10

5 6 3 1 4 3 1

Figure 2.3

Sleep Log Case #221

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) andwaking (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


4 oz

wine

None 2 beers 1 beer None None None



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 fallasleep.

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

here.)

1 2 2 1 1 1 1

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

25 min

25 min

40 min

30 min 20 min 20 min 5 min 20 min

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

awakening.)

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



1 2 3 4 5 6 7 8 9 10

4 4 4 1 6 7 2


1 2 3 4 5 6 7 8 9 10

4 3 3 1 7 7 1

Figure 2.4

Sleep Log Case #323

is accompanied by a 100-mm visual-analog scale (i.e.,horizontal line) that is labeled “not at all” at its leftextreme and “always” at its right extreme. Inresponding to this instrument, respondents draw avertical line through the point on each item’s analogscale (i.e., 100-mm line) to indicate their responses.The distance from the left end of the line to asubject’s response line serves as an analog measureof the degree to which the respondent has thesymptom noted by the item. The mean score across

all 13 items constitutes the measure to be used in thisstudy. In our previous work (Edinger, et al., 2001;

Edinger & Sampson, 2003), we have found the ISQhas acceptable internal consistency (Cronbach’sa. = 0.73) and sensitivity to treatment-related sleepimprovements. Inour research we have used a total ISQ score < 41

as the clinical cutoff connoting insomnia remissiongiven our early findings suggested this cutoff has a92% sensitivity and 64% specificity for discriminatingnor- mal sleepers from primary insomnia sufferers.However, in more recent unpublished work with alarge validation sample, we have determined that anISQ total score < 36.5 may be a better benchmarksince this cutoff has an 89% sensitivity and 86.5%specificity for discriminating patients with primaryinsomnia from normal sleepers.

Insomnia Severity Index

The Insomnia Severity Index (ISI: Morin, 1993) is a 7-item questionnaire that provides a global measure ofperceived insomnia severity based on the followingindicators: difficulty falling asleep, difficulty stayingasleep, and early morning awakenings; satisfactionwith sleep; degree of impairment with daytimefunctioning; degree to which impairments arenoticeable; and distress or concern with insomniasymptoms. Each item is rated on a 5-point (0 to 4)Likert scale and the total score ranges from 0–28. Thefollowing guidelines are recommended for

interpreting the total score: 0–7 (no clinicalinsomnia), 8–14 (sub-threshold insomnia), 15–21

(insomnia of moderate severity), and 22–28 (severeinsomnia). The ISI has good internal consistency(Cronbach’s alpha = 0.91) and test- retestreliability (r = 0.80). It has been validated againstsleep logs and electronic sleep recordings (Bastien,Vallieres, & Morin, 2001) and has proven sensitive totherapeutic changes in several treatment studies ofinsomnia (Morin et al., 1999). In recent years, theISI has become

24

increasingly popular in insomnia work and now isrecommended as a standard assessment tool ininsomnia research studies (Buysse et al., 2006).Since the ISI has the mentioned guidelines for scoreinterpreta- tion, this instrument can be used easily inclinical venues for judging initial insomnia severityand the clinical significance of improvementsachieved during insomnia treatment.

Pittsburgh Sleep Quality Index (PSQI: Buysse et al., 1989)

This instrument, like the ISI, is a widely used andcurrently recommended (Buysse et al., 2006) tool forassessing sleep disturbance in insomnia patients aswell as in patients with other types of sleep disor-ders. The PSQI is composed of four open-endedquestions and 19 self- rated items (0–3 scale) assessingsleep quality and disturbances over the previous 1-month interval. Domains assessed include sleep onsetlatency, sleep duration, sleep efficiency (i.e., theproportion of time in bed that is actually spentasleep), sleep quality, disturbances to sleep,medication use, and daytime dysfunction. Asummation of these seven component scores yields aglobal score of sleep quality, ranging from 0 to 21.Previous research (Buysse et al., 1989) has shown thata PSQI total score of > 5 has good sensitivity(89.6%) and specificity (86.5%) in discriminating thosewith insomnia from good sleepers. As such, aposttreatment PSQI score < 5 has been used in somestudies as indicating insomnia remission. However,it should be noted that the PSQI provides a globalsleep quality assessment and is not specifically orexclusively designed for insomnia assessment.Moreover, we (Carney et al., 2006) have found thatelevated levels of anxiety may contribute to PSQIscore elevations in some types of insomnia patients.Hence, the patient’s anxiety level at the time of PSQIadministration should be considered when interpretingthe 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 originalDBAS-30 includes 30 items that comprise five subscalesdesigned to assess (1) attributions about the effects ofinsomnia (e.g., “I am concerned that chronic insom- niamay have serious consequences on my physicalhealth”); (2) perceptions of loss of control andunpredictability of sleep (e.g., “I am worried that I maylose control over my abilities to sleep”); (3) perceivedsleep needs and sleep expectations (e.g., “Because I amgetting older, I need less sleep”); (4) misattributionsabout causes of insomnia (e.g., “I feel insomnia isbasically the result of aging and there isn’t much thatcan be done about this problem”); and (5) expectationsabout sleep-promoting habits (e.g., “When I don’t getthe proper amount of sleep on a given night, I need tocatch up the next day by napping or the next night bysleeping longer). A 100-millimeter (mm) analog scale(i.e., horizontal line) labeled “strongly disagree” at itsfar left extreme and “strongly agree” at its far rightextreme accompanies each item and is used byrespondents to indicate their degree of endorsement.When completing the DBAS-30, respondents arerequired to draw a vertical line through the point onthe 100-mm scale to indicate their degree of agreementor disagreement with each item. The distance in mmbetween the far left extreme of the analog scale andthe response line then is used as the item’s “score.”With one exception all items are structured so thathigher scores (i.e., stronger item agreement) connotemore dysfunctional beliefs.

Recently an abbreviated 16-item version (DBAS-16) of theoriginal DBAS-30 has become available. This abridgedversion is similar in for- mat to the original instrumentbut it uses 10-point Likert scales super- imposed onvisual analog scales for indicating agreement/disagreement with the various items. For each of the 16

beliefs, the number corresponding to the degree ofbelief (e.g., 10 = agree completely) is circled. Atotal score is calculated by summing the item scoresand dividing the resultant sum by 16 (i.e., a mean itemscore). Both the DBAS-30 and DBAS-16 have shownacceptable levels of internal consistency

(Cronbach’s a. values > .80). Furthermore werecently have found DBAS-16 total scores > 3.8 tobe suggestive of the level of unhelpful beliefs commonamong individuals with clinically significant insomniaproblems. Both DBAS instruments can be used toidentify specific problematic beliefs to target intreatment and to assess belief changes resulting fromour cognitive-behavioral intervention.

26

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is an eight-item self-reportquestionnaire designed to assess daytime sleepiness incommon day-to-day situations such as “Watching TV” or“Sitting and talking to someone.” Respondents areinstructed to indicate how likely they are to fallasleep in each situation using a 4-point rating scale (0= “would never doze” to 3 = “high chance ofdozing”). The ESS score is obtained by summing allitem responses so scores may range from 0 to 24 withhigher scores suggesting greater daytime sleeptendency. A score of 10 or more is considered toindicate clinically significant daytime sleepiness. A scoreof 18 or more connotes someone who is very sleepy. Thisinstru- ment has shown very acceptable internalconsistency (Cronbach’s a. = 0.88) and test-retestreliability (r = .82) within both non-complaining groupsand in groups of clinical sleep-disordered patients (Johns,1991; Johns, 1994) Additionally, Epworth ratings havebeen 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 amore thorough psychological assessment. TheMinnesota Multiphasic Personality Inventory-2(MMPI-2) is an extensive psychologicalquestionnaire that produces personality profiles fora wide range of psychopathol- ogy. Validity scalesprovide information on response biases such aspatients’ attempts to either deny or exaggeratepsychopathological symptoms. Individuals withinsomnia produce specific MMPI-2 profilescharacterized by depression, anxiety, andsomatization of emotional conflict. While somesleep disorders centers routinely administer theMMPI-2 to all patients as part of the intakeevaluation, it may be considered too lengthy andtime-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, excessivesleepiness, and restless leg syndrome. It is also used

in the assessment of the effectiveness of treatmentsfor 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 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 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


Chapter 3 Session 1 : P sy choeducational and Beha v ioral Therap y 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 clientwith a brief overview of Cognitive-Behavioral Therapy(CBT) for Primary Insomnia (PI). Review with thepatient Spielman’s 3-P model of insomnia and how itsuggests that predisposing factors (e.g., biological orpersonality traits) and precipitating events (events orcircumstances that are stressful or otherwise disruptive

to normal sleep-wake routines) can lead to thedevelopment 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 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 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 withinformation 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 isimportant that you have a better understanding of yoursleep 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 satisfiesyour 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 thesleep-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 himFigure 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 bodyclock 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 withhis 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” inhis 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 lagsbehind 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

12:00 AM

6:00 AM

12:00 PM

6:00 PM

12:00 AM

6:00 AM

12:00 PM

6:00 PM

12:00 AM

6:00 AM

12:00 PM

6:00 PM

12:00 AM

Circadian Temperature Variation

Circadian Temperature

Biological Wake

Slee

Slee

Biological Be

Figure3.1

Circadian Temperature Rhythm

Circadian Temperature Rhythm Desired Sleep/Wake Schedule

Desired Bedtime

Biological Bedtime

Figure 3.2

Effects of Jet Lag

36

Circadian Var

12:00 A

6:00 A

12:00 P

6:00 P

12:00 A

6:00 A

12:00 P

6:00 P

12:00 A

6:00 A

12:00 P

6:00 P

12:00 A

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 thanyou 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 whatneeds 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. Needlessworry and attempts to recover lost sleep will only worsenyour 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 understandyour problem. With this knowledge you should nowunderstand the purpose for the treatmentrecommendations I’m making. Do you have anyquestions about what you have just heard ?

Behavioral Treatment Regimen

The behavioral treatment regimen uses stimuluscontrol and sleep restriction strategies tostandardize the patient’s sleep-wake schedule,eliminate sleep-incompatible behaviors that occur inthe 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 behavioralrecommendations included in this regimen arestandard for all patients. However, the TIBprescriptions provided are based on a pretreatmentesti- mate (derived from sleep logs) of each patient’ssleep requirement. Since TIB prescriptions may varyfrom patient to patient, these prescriptions allow for

the tailoring of this regimen to fit each patient’sspecific sleep needs.

Refer the patient to the sleep improvement

guidelines in Chapter 2 of the workbook and provide

a brief justification 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.

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 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 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 extendedperiods without being asleep. Long periods of beingawake 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 orto engage in thinking or worrying. Engaging inthese sorts of activities only serves to keep the mindawake, 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 tobe 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 par- tially 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 nightthan 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 thetime it takes to fall

asleep as well as a few normal, brief nocturnalarousals.

To illustrate how a TIB prescription is determined,consider the sleep log data shown in Figure 3.3. Thislog presents 6 days worth of data as well ascalculations of the average total sleep time (ATST) andaverage time in bed across this 6-day period. Note inthis 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 markeddiscrepancy between the average time slept and theaverage time in bed. Given the data shown, the TIBprescription derived using the above formula wouldbe 430 minutes, or 7 hours and 10 minutes. Hence,that TIB prescription

41

would be used as the initial time allotment for thenocturnal sleep period. Of course, patient preferencesshould be considered when establishing the initial TIBallotment, and it is perfectly acceptable to round theTIB 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 inpractice it is preferable to derive the initial TIBprescription from sleep log data collected for 2 ormore weeks so that a more stable estimate of ATSTcan 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


None None None None None None

2. Last night I took mg of or of alcohol as asleep 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


11:30 PM 11:30 PM 11:15 PM 11:00 PM 11:15 PM 10:50 PM


20 min 35 min 75 min 45 min 15 min 20 min

6. I woke from sleep times. (Do not count yourfinal awakening here.)

2 1 3 2 1 2

7. My awakenings lasted minutes. (List each awakening

separately.)

25 min15 min 60min

10 min25 min30 min

60 min40 min 90 min

30 min45 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


1 2 3 4 5 6 7 8 9 10

2 3 2 3 2 3


1 2 3 4 5 6 7 8 9 10

1 4 2 5 1 3

AVERAGE

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

43

of treatment implementation. Improvements

(increases) in average sleep time at night are less

dramatic and occur much more gradually during treat-

ment. 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 havediscussed 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 oryou may not see any significant changes in your sleep.Thus, it is important that you follow the treat-ment recommendations we discussed consistently so thatyou obtain the types of results you are seeking.

As you begin this treatment at home, it is also importantfor you to understand that the sleep schedule we agreed upon for you today may leave you feeling a littlesleepy 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 returnvisits to encourage and reinforce treatment

adherence, resolve difficulties they are having withtreatment enactment, and assist them in making TIBadjustments. However, we encounter some patientswho live a great distance from our clinic or for otherreasons are not able to return for follow-up ses-sions. Both our clinical experiences and our recent

research findings (Edinger et al., 2007) suggest thatsome patients are able to achieve significant sleepimprovements over time following only one sessionwherein the information covered in this chapter ispresented. However, in such cases, it is useful to givethe patient instructions that will enable him to makeneeded TIB alterations to establish an optimalsleep wake pattern. For such individuals, you mayuse 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, youfind you are sleeping well at night, but you feel tired most days, you should try increasing your time in bed atnight 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 atnight 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 oftime 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 andfeel 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 timein 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 followingrationale 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, thepatient should be given the specific sleep hygienerecommendations described in the follow- inginstructions:

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 youto 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 walk- ing, 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 itmay 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 hotweather, 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 audiotaperecording 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 : Cogniti v e Therap y 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 forcompletion

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 beimportant for increased adherence to behavioralrecommendations, as well as eliminating sleep-interfering 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 ifwe 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 con- versations 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 havehad 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 worryand 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 quietingan 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 otherbenefits 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 thatthe worry they could not switch off in the bedroom became a non- worry 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 chancesof being able to sleep.

51

Assess if the patient has any questions and whetherany of this discussion seems to be personallyapplicable. Reinforce the patient’s identificationwith the problem. For example, if the patient says,“I definitely worry in bed about every little thing.” Besure to say, “Okay, then it’s going to be important forus to focus on this and for you to complete someadditional homework over the next 2 weeks.”

Constructive Worry

Many people with insomnia complain of “unfinishedbusiness” following them into the bedroom andcreating arousal/distress in bed. Indeed, problemsolving in the presleep period has been implicatedas one of the strongest predictors of difficulties

falling asleep (Wicklow & Espie, 2000). Espie andLindsay (1987) were among the first to report positiveresults for an early evening procedure that targetedpresleep worry. Similarly, Carney and Waters (2006)demonstrated that a single night of using an earlyevening procedure called Constructive Worryresults 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 isimportant to pair this procedure with stimuluscontrol (i.e., the instruction to leave the bedroomwhen problem solving or worrying) and other stressmanagement techniques such as relaxation and/ortime management techniques. Introduce the exercisewith 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’suse are provided in the workbook. A sample,completed worksheet is shown in Figure 4.1. Thefollowing instructions also appear in the workbookand should be used as a guide when completing theworksheet with the patient in session.

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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 inthe “Solutions” column. This need not be the finalsolution 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 writethat 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 some- time 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 thepatient and ask him or her to try to fill it out eachevening. If the patient has difficulty thinking of anyworries on a particular night, instruct the patient towrite

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CONCERNS SOLUTIONS

1. The air conditioning isn’t

working in the car

2.Money!

1. Could ask my wife if she has time

to take it in

2. Could call tomorrow for a

Saturday appointment

1. Will make an appointment with our financial planner tomorrow

2 Will agree to that project for extra income

3. Will cut out my latte over the

next month

4. I will wait until my credit card

is due to pay it

Figure 4.1

Example of completed Completed Constructive Worry Worksheet

down “No Concerns.” Also, be sure to ask the patient

if she foresees any barriers to completing this

exercise. Finally, engage in problem solving with the

patient to reduce such barriers to adherence.

Thought Records

Cognitive restructuring is most often associated withthe seminal text Cognitive Therapy of Depression byAaron Beck and colleagues (Beck, Rush, Shaw, &Emery, 1979). Beck et al. wrote about fears of becom-ing ill as a result of insomnia and the discrepancybetween objective and subjective sleep timeestimation in people with Major Depression.These observations are common features of peoplewith insomnia irrespective of whether they haveMajor Depressive Disorder. Beck’s early writingswere applied to insomnia by Morin (1993), whodeveloped a cognitive therapy component forinsomnia.

54

Morin suggested the use of the Thought Record torestructure some unhelpful or inflexible thoughtsand beliefs about insomnia (Morin, 1993). In linewith these works, we have found the followinginstruc- tions 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 “gocrazy” 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 ofsleep 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 insession so that the patient understands it wellenough to complete it between sessions. A sample,completed record is shown in Figure 4.2. A samplefor the patient to use as a model, as well as blankcopies for the patient to fill out, is also included inthe workbook. You may use the following sug- gesteddialogue to help the patient complete a blankThought 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 thatyou’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 remem- bers 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 weoverlook 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 theworst possible outcome. Write all this evidence down inthe 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 itthrough 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 Mood (Intensity0–100%)

Thoughts Evidence for thethought

Evidence againstthe thought

Adaptive/Coping statement

Do you feel anydifferently?

Sitting at my Down (75%) I’m never going Last week I I’ve made I don’t feel my Down (30%)desk thinkinghow sluggish I

Frustrated (100%)to get throughtoday

made a mistakeon my report

mistakes at workwhen I have

best, but thetruth is, I always

Frustrated (60%)

feel Worried(80%)

I’m going to mess up

I’ve already stopped

had a goodnight’s sleep

make itthrough (70%)

Worried (10%)

Tired (70%)

Tired(100%)

I need to get some sleep

exercising

I’m starting

I’ve had insomniafor over a year and haven’t

Just because Idon’t feel at my best,

I can’t to feel been sick doesn’t meanconcentrate

I’m going to get sick

less likedoing things I notice I feel a

little better after lunch

that anything bad is going tohappen (75%)

if I keep goinglike thisI can’t keepgoing on like this

I always seem to have an okday despite my insomnia

I’ve noticedthere are things I can doto copewith the fatigue,

What’s wrong with me?

so it isnot hopeless (80%)

Figure 4.2

Example of completed Thought Record57

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

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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.” Explorewith 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 logsand to “catch themselves asleep.” Did they miss partsof the plot of the television program they werewatching? When patients report that they have beenawake “all night long,” ask what they were doing. Itis highly unlikely that they were lying motionless in

their bed for 8 hours without sleeping. Some patientshave difficulty with sleep perception because their brainactivity is “noisier” than most people when they sleep(Krystal et al., 2002). Some people need thereassurance that their body is “sleeping” from anobjective standpoint and is thus restoring andprotecting 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 ofserious mental or physical illness as a consequenceof the insomnia is a common fear for insomnia

sufferers. It is important to follow their fears totheir most catastrophic conclusion to understand

someone’s fear of insomnia. This has beendescribed elsewhere (Burns, 1980) as the “down-ward arrow” method, which is illustrated in thefollowing case vignette. In this dialogue, Trepresents the therapist and P represents thepatient.

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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?

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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 thatothers are “noticing” their poor performance. Theymay worry about this out of a fear of negativeevaluation from others. This belief is often untruebecause most people with insomnia function quitewell. What tends to be different after a poor night’s

sleep is the amount of extra effort required to do reg-ular tasks (Espie and Lindsay, 1987). Even if thefollowing belief is true, “People notice that I amincompetent at work because of my insomnia,”

exploring whether it is true 100% of the time andexploring the consequences of holding such a beliefcan be helpful. For example, if there are fears ofnegative evaluation, believing that this is true willresult in increased anxiety in performancesituations. We know that anxiety can interfere withperformance; thus, fears of poor performance willresult in poorer performance. It is helpful to explorewhether this formulation may apply to the patient andwhether it would be useful to modify this belief.

Overgeneralization: Overfocusing on a single instance(i.e., I had trouble completing my crossword puzzlethis morning . . .) as proof that their beliefs are true(“ . . . so, I am mentally useless at work today.”)Encourage patients to see the range of evidencebecause people with insomnia tend to copeextraordinarily 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 man-

aged 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

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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, youmay note some patients have difficulties completingone or more of the columns. Some people mistakemoods and thoughts, some people think that they haveno thoughts (i.e., their mind is blank), some havetrouble generating evidence, and others have difficultyintegrating the evidence into a balanced thought.Greenberger and Padesky (1995) have many suggestionsfor helping patients who have these difficulties. TheSituation column can be completed by asking thepatient: “Who was with you when you started feelingbad? What were you doing? Where were you? When did ithappen?” For example, a patient may tell you about asituation in which she started worrying about herability to sleep that night. When probed with thesequestions, the patient can usually fill in the blanks,and tell you she was in the living room with her spousewatching television after dinner. Moods are bestdescribed using one word. When patients needmultiple words to describe a mood, they are mostlikely 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?

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What is the worst case scenario?” Also, ask thepatient if this situation reminds her of other similarsituations. This usually results in generating somethoughts or images. If the patient had difficultynaming a mood and was instead listing “thoughts,”be sure to make note of these thoughts so you canpresent them for inclusion in the Thoughts columnlater. You can give patients the following hint to helpidentify thoughts in the future: “The next time youare experiencing a strong emotion, ask yourself tonotice what is going through your mind.”

Most automatic thoughts in insomnia patients relateto a fear that something is very wrong with themand that they are helpless to change it. Elicitingcatastrophic statements from the patient’s thoughts ishelpful to get at the core beliefs. For example, apatient is afraid of setting the alarm and reports thethought, “If I set the alarm then I know I will onlyhave 7 hours to sleep, and every hour that goes by I’llbe thinking that I have to get up.” Ask the patientwhy having only 6 hours, or 5 hours, of sleep isdistressing, and what is the worst case scenarioimagined for that situation. Then, take the worstcase scenario (e.g., getting fired from a job becausesleep loss is causing unacceptably poor workperformance) and reflect it back to the patient suchas: “Gosh, if you think you are going to get firedbecause of your insomnia, it sounds as though therereally is so much riding on you getting to sleep eachnight.” This will either elicit more cata- strophicstatements or the patient may engage in reportingevidence against the thought because thecatastrophic nature of the thought is dis- concerting.When generating automatic thoughts, it is usuallyimportant to generate several thoughts and not stopat one. One technique for facil- itating the recordingof multiple thoughts is to lead the patient to thenext thought by repeating how she was thinking andfeeling and ask what happened next: “So you werefeeling anxious and thinking, ‘I’m going to have to callin sick.’ And then what?”

Most patients do not have difficulty generatingevidence for the thought in the Evidence for theThought column, because the thoughts are seen asvery compelling. One common problem is thetendency to rush through the evidence and say,“Yeah, but I know that’s not really true.” It’simportant to spend some time on the evidence for

the belief and reflect that the patient isn’t “crazy” sothere must be a good reason to have this belief.Exploring the kernel of truth in the evidence for thebelief is really important.

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Generating items for the Evidence against theThought column can be challenging for somepatients. Keep track in earlier sessions of anyevidence the patient cited that is contrary to thebelief. For example, the patient may talk about ahorrible day in which nothing catastrophichappened. Or the most feared situation (e.g., “goingcrazy”) has not occurred despite the fact that thepatient had suffered from years of insomnia.

Focusing on evidence of the patient’s effective copingcan also help here. The following questions may alsohelp:

“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

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input into the Insomnia Brain. For example, “Okay, soyou are 5% less anxious? That’s still an improvementfrom 5 minutes ago. Small victories are important in thisprocess, so good for you.” Patients will generally reportthat their mood is less negative following the exercise.If there has not been a mood improvement, seeChapter 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 retro- spectively 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

65

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 expla- nation 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 thesereally 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 ambiva-

lence 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 FatigueSyndrome.

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

67

✎ Ask the patient to fill out the Constructive Worry

Worksheet in the early evenings and bringcompleted forms to the follow-up session, ifapplicable

✎ 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

68

Chapter 5 Follow-Up S essions

Once patients are provided the behavioral andcognitive strategies discussed in the previous twochapters, they usually benefit from one or morefollow-up sessions to (1) assist them in makingneeded adjustments in their TIB prescriptions, (2)encourage and reinforce their adherence totreatment recommendations, and (3) “troubleshoot”the problems they may be having with thebehavioral or cognitive techniques they have beentaught.

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 TIBprescriptions was discussed in Chapter 3. Reviewthe patient’s completed sleep logs each week anddetermine his average sleep efficiency during theweek prior to the current session. Sleep efficiencyis calculated by dividing the patient’s average totalsleep time (ATST) over the time period since theprevious session by the average time spent in bed(ATIB) and then multiplying the result by 100%(Sleep Efficiency = (ATST/ATIB) X 100%). If

the patient’s sleep efficiency is > 85% and thepatient has noted daytime sleepiness with thecurrent TIB prescription, suggest a 15-minuteincrease in TIB. Suggest a 15-minute decrease inTIB if the patient’s sleep efficiency is < 80%. Ifthe

69

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

underes- timate 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 hourson 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 shoulddo. 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 addanother 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 improvedsleep 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 begunon 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 theirsleep and wake times, use the follow-up sessions toreinforce the patient’s adherence to the prescribedCBT regimen and completion of the Constructive WorryWorksheet and Thought Records. Assess patientadherence by reviewing the sleep rules andrecommendations integral to this program (see

Chapter 3 for list of sleep rules) and asking thepatient about his adherence to each one. You shouldfreely compliment the patient who closely follows alltreatment recommendations and com- pletes thecognitive homework exercises. In doing so, however, it isparticularly useful to point out the relationship betweenthe patient’s treatment adherence and improvementnoted by his sleep logs or other outcome measure

being used (see Chapter 2 for a list of measures andself-reports). For example, you may make commentssuch as, “You have done an excellent job followingthrough on the strategies we discussed last time. As youcan see, your efforts have paid off. Your logs show that youare now sleeping much better. Keep up the good work!” In

providing such comments it is important to remaingenuine and avoid patronizing the patient. Thus,language that feels comfortable and consistent withthe therapist’s usual interactional style should beused 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 day-

time. A careful review of sleep logs should be

employed to identify non- adherence 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. Froma 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 ifhe would lie in bed long enoughhe would eventually go to sleep. Although he adamantly denied daytime napping, he did admit to some unintentional dozing around 7:00 PM each evening whilehe was reclining on the couch watching TV.

To correct the patient’s sleep problem, the therapist first explained the deleterious effect the noted nonadherencewould 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-uptime. 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 watchingTV, reading magazine articles, or listening to music. Finally,the patient was encouraged to refrain from reclining whilewatching 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 extend- ing his middle-of-the-night awakenings, he was discouraged from contin- uing 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 sometimescaused 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 statedhe 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 stayedin 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 experimenthad 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 readilyaccepted 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 pepin 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 ather 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

74

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 thehabit 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 ofpotential problems that can occur with patientscompleting 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 troubleshootingadvice should address the common problem that thepatient’s mood does not improve after completingthe Thought Record. When there is no moodimprovement,

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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 examinationof 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 tofunction. The next two sessions weredevoted 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 resultedin almost total adherence to the behavioral recommendations

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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 betweenthe 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

1minute 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 last2weeks?

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 thatmuch, I don’t usually remember seeing the clock orgetting up between 2–6 AM, so it’s possible that Iam 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 totreatment in 3–4 sessions total. Of course, there arethose who

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respond more gradually but do achieve a satisfactoryoutcome. In the end, therapy should be guided by the

patient’s sleep performance reflected by sleep logdata and by the patient’s subjective appraisal.Optimal sleep performance is characterized bysleeping soundly at night and having no daytimesymptoms (e.g., fatigue, impaired concentration,distress about sleep) of insomnia. In this case, sleeplogs would show the patient has a regular sleep-wakeschedule and typically has little difficulty fallingasleep or staying asleep through the night. Alongwith this observation, the logs and the patient’s self-

report should indicate that the final morningawakening typically occurs slightly before the alarmclock sounds. If the patient sleeps soundly but mostoften is awakened by the alarm, it is likely that thepatient could and would sleep a little longer eachnight had the alarm not be set. In such cases, it isusually useful to expand the TIB window somewhatuntil the sleep pattern described emerges. However,once the patient achieves a sound sleep pattern atnight 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 “permis-

sion” 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 P atients and T r eatment S ettings

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,

83

are prescribed alone or in addition to the approvedmedications to treat sleep difficulties. In addition, avariety of other medications includingantidepressants such as the sedating tricyclics (e.g.,doxepine) and trazodone, and the atypicalantipsychotic, quetiapine, are often used to managepatients’ sleep complaints. These latter medicationslack FDA approval and are used “off-label” fortreating insomnia. Finally, various over-the-countermedications are available and are used frequently byinsomnia patients in their efforts at self-management.

Over the years, concerns have been raised aboutprotracted use of medications to address chronicprimary insomnia. Although there is considerable“clinical lore” supporting the prescription medicationsused “off-label” for sleep, currently there are few datato support their safety and efficacy for long-termtreatment of primary insomnia. Likewise, there areextremely limited data concerning the safety andefficacy of those sleep medications available withoutprescription. With some of the first generation FDA-approved BZRA hypnotics, medication tolerancedevelops with continued use such that patientsexperience reduced efficacy while being maintainedon stable therapeutic doses for extended periods oftime. Abrupt withdrawal of such medications oftenresults in a transient, albeit distressing, worsening ofsleep that convinces many patients to quickly resumetheir medication use. In contrast, some of the longeracting BZRAs may result in unwanted next-day effectssuch 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 prop- erly. She noted pain, immobility and general distress over her condition. In

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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 experiencingelevated 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). Despiteher 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 thorough-

ly, 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

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 fromto (note time of all naps). None None None None None None None

2. Last night I took mg of or of alcohol asa sleep aid (include all prescription and over-the-counter sleep aids).

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


11:30 AM 12:00 AM 1:00 AM 2:30 AM 12:30 AM 1:30 AM 12:30 AM


105 5 5 1 90 5 30


2 3 1 Don’t remember

2 3 3

7. My awakenings lasted minutes. (List each a wakening 5 55 ?

5 5 5

separately.) 5 5 55 5 5 5 5


9:30 AM 7:15 AM 8:45 AM 10:30 AM 10:00 AM 8:00 AM 7.15 AM



1 2 3 4 5 6 7 8 9 10

6 4 8 8 6 4 6


1 2 3 4 5 6 7 8 9 10

1 1 6 10 6 6 4

Figure 6.1

Sleep Log: Sleep Medication User

86

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 com-

bines 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 sta-

ble, 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 CBTstrategies discussed in the previous chapters andshows a stable sleep pattern for at least 2 consec-utive weeks, a medication-tapering strategy can beintroduced. From a safety viewpoint, mostprescription and over-the-counter medications takenfor sleep can be discontinued fairly rapidly withoutuntoward medical concerns. However, patients whoare dependent on sleep medications usually are moresuccessful discontinuing such medications if allowedto taper them more slowly and deliberately. In thisregard, strategies discussed elsewhere (Belleville etal., 2007, Soeffing et al., 2007) have provenefficacious for such patients. These approaches allow aslow, graded, “step- down” approach to tapering thatoffers the patient a gentle pace at fading themedication while allowing some sense of graduallyincreasing self- efficacy in regard to thediscontinuation process. For example, the approachdescribed recently by Morin et al. involves thefollowing sequence of steps: (1) setting a goal formedication use/reduction each week; (2) when morethan one medication is being used, reduction to asingle medication at a stable dose is set as the firstgoal; (3) the initial dosage of the medication isreduced by 25% every 2 weeks until the lowest avail-able (therapeutic) dosage is reached; (4) drug-free

nights are gradually introduced with drug-free nightsbeing planned in advance; and (5) the number ofdrug-free nights per week is gradually increaseduntil the patient is medication free. While institutingthis sort of withdrawal plan it is important to have thepatient continue monitoring her sleep with the sleeplog and to continue with the cognitive tools(Thought Records, Constructive Worry Worksheets) asneeded. It is also important to monitor CBTadherence 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 fargreater proportion of all treatment-seeking insom-nia patients present with complex comorbidconditions. A variety of medical conditions, andparticularly those that result in chronic pain,breathing difficulties, or immobility, can give rise toinsomnia problems. Likewise, a large proportion ofpsychiatric conditions have insomnia as a primarypresenting symptom. Furthermore, manymedications prescribed for the treatment of medicaland psychiatric conditions may have insomnia as acommon side effect. Finally, excessive use of alcohol,

caffeine, and various illicit substances may cause oradd to insomnia problems. In a sizable proportionof patients, a mixture of medical, psychiatric, and

substance-related causes of insomnia coexist andcom- plicate 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 randomizedclinical trials have investigated the efficacy of CBTfor treating insomnia patients with various types ofcomorbid conditions. The more convincing studieshave focused on medical disorders and havesuggested that CBT is efficacious for treatinginsomnia in patients with chronic pain (Currie et al.,2000), fibromyalgia (Edinger et al., 2005), mixed oldermedical patients (Rybarczyk et al., 2002) and cancersurvivors (Savard et al., 2005). Well- conductedrandomized trials of CBT for insomnia treatment inpsychi- atric samples have generally been lacking.However, a few clinical case series studies(Morawetz, 2003; Kuo, et al., 2001) have suggestedthat CBT does seem effective for treatment ofinsomnia in patients with comorbid depression.Whereas these findings are encouraging, addi-tional randomized trials are needed to confirm theusefulness 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.

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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. Atthe 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 averagesleep 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

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



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


10.30 PM 11:30 PM 8:20 PM 9:35 PM 8:20 PM 10:40 PM 10:35 PM


90 35 60 90 70 45 60


2 1 3 2 1 2 1

7. My awakenings lasted minutes. (List each awakening25

40

2025

4515

60separately.) 20

20 25 40 20


5:30 AM 5:15 AM 6:00 AM 6:15 AM 7:00 AM 6:35 AM 5:30 AM



1 2 3 4 5 6 7 8 9 10

7 5 7 7 5 7 7


1 2 3 4 5 6 7 8 9 10

6 7 7 6 7 7 6

Figure 6.2

Sleep Log: Baseline

92

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





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


15 15 15 15 20 15 15


1 1 1 1 1 1 1

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

15 15 30 25 25 25 35


5:31 AM 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


1 2 3 4 5 6 7 8 9 10

9 8 8 9 8 8 8


1 2 3 4 5 6 7 8 9 10

9 8 8 9 8 8 8

Figure 6.3

Sleep Log: Post-CBT

93

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. Whena 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 theCBT strategies are well suited for treating those withcomorbid insomnia, there is still need for somecaution when employing these techniques with suchpatients. Admittedly, given the limited datasuggesting the efficacy of CBT with comorbidpatients, there is much to be learned aboutoptimizing outcomes with these individuals. Indeed,there are many questions yet to be answered. Amongthe more pertinent are (1) How can we best combineCBT with pharmacotherapy and other medicalmanagement of the exist- ing comorbid disorder? (2)

Do the specific sleep-focused CBT techniques need tobe altered or augmented in any way to maximize

outcomes with comorbid insomnia? (3) Should CBT forinsomnia be incorporated into more global cognitive-behavioral protocols that exist for various comorbidconditions (e.g., depression, anxiety disorders, etc.)?

and (4) Does CBT for insomnia in comorbid patientsrequire more extended therapy and follow-up thancommonly required for primary insomnia? These,among many other questions, need to be addressed

before this treatment can be confidently extended tovarious other comorbid groups. For a more thoroughdiscussion of this topic, the reader is referred to therecent excellent review article by Smith et al. (2005).Nonetheless, the research conducted to date as wellas with results with cases such as the one pre- sentedhere encourage further applications of this modalityfor addressing comorbid insomnia problems.

Dissemination of CBT Across Settings

Whereas CBT has proven efficacy for primaryinsomnia and holds much promise for treating thosewith various comorbidities, it is cur- rentlychallenging to make this therapy available to all whomay benefit from it. Whereas 10% to 15% of thepopulation 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 forinsomnia, some investigators have testedtreatment models suitable for medical practicesettings or the public at large. Given that insomniasufferers typically present first in primary caresettings, it seems reasonable to consider providingCBT training to those health care professionals (e.g.,nurses, general practitioners) commonly found insuch settings. Two studies designed to test theefficacy of such an approach have demonstrated thatboth family physicians (Baillargeon et al., 1998) andoffice-practice nurses (Espie et al., 2001; Espie et al.,2007) can effectively administer CBT components ingeneral medical practice settings. In contrast,Oosterhuis and Klip (1997) reported delivery ofbehavioral insomnia therapy via a series of eight, 15-minute educational programs broadcast on radio andtelevision in the Netherlands. Over 23,000 peopleordered the accompanying course material, and datafrom a random subset of these showed that sleepimprovements and reductions in hypnotic use,medical visits, and physical complaints wereachieved by this educational program. Thus, itappears that behavioral insomnia treatments can beeffectively delivered by various providers anddelivery of such treatment even via mass mediaoutlets may provide benefits to some insomniasufferers. Of course, the relative efficacy of thesealternate modes of treatment delivery vis-à-vis moretraditional 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 book-

based 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 phoneconsultations with a therapist provided someadvantage over bibliotherapy alone at least in theshort term. Recently, Strom et al. (2004) tested a 5-week self-help inter- active CBT program deliveredto insomnia patients via the Internet. Althoughthose receiving CBT showed no greater improvementthan a wait-list control group, this study doesdemonstrate that treatments such as CBT can bedisseminated widely via the Internet. However, how

to ensure the value and efficacy of such applicationsremains a current challenge. Nonetheless, thesestudies provide some initial ideas for widerdissemination of CBT strategies. Such efforts may be

useful to fill the void until a sufficient number oftraditional providers are trained in these strategiesand the more challenging insomnia patients will beable to access the comprehensive CBT they ultimatelymay need.

96

Appendi x

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: Years:

Children:

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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 b) on a bad night

3. 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 . . .


5. How long are you awake during the night after initially falling asleep . . .


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).

——————————————————————————————————––

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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 dueto 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 contrastto 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

Situation Chance of dozing

Sitting and reading

Watching TV

Sitting inactive in a public place (e.g., atheater or a meeting)

As a passenger in a car for an hour without a break

100

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 minutesin the traffic

7. On the graph below, indicate how sleepy you generally feel atthe times indicated by choosing the most appropriate corresponding number from the scale below and circling thatnumber on the graph.

9:00 AM 1 2 3 4 5 6 7

Noon 1 2 3 4 5 6 76:00 PM 1 2 3 4 5 6 79:00 PM 1 2 3 4 5 6 7

1 = Feeling active and vital; wide awake2 = Functioning at a high level, but not at peak; able to concentrate3 = Relaxed, awake; not full alertness; responsive4 = A little foggy; not at peak; let down5 = Fogginess; beginning to lose interest in remaining awake;slowed down6 = Sleepiness; prefer to be lying down; fighting sleep; woozy7 = 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)

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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 atleast 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 some difficulty great difficulty

1 2 3 4 5 6 7 8 9 10

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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 whileyou sleep, or thatyou 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 NoIf 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 andwander 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

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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: General Medical History

1. Please check (V) in the boxes beside those medical problems you have now or have had in the past.

V Problem V Problem V 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 age20

(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 healthprofessional? 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: Yes No(circle one) If

yes, list relationship.

——————–————–————–————–—

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 recordedin 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.

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Documents

Overcoming Insomnia - Therapist Guide