Overcoming Insomnia

editor-in-chief

David H. Barlow, PhD

scientific advisory board

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Treatments That Work™

OvercomingInsomniaA Cognitive-Behavioral Therapy Approach

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

Jack D. Edinger • Colleen E. Carney

2008

1

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Library of Congress Cataloging-in-Publication Data

Edinger, Jack D.Overcoming insomnia : a cognitive-behavioral therapy approach therapist guide / Jack D. Edinger, Colleen E. Carney.

p.; cm. — (Treatmentsthatwork)Includes bibliographical references.ISBN 978-0-19-536589-4 (pbk.: alk. paper) 1. Insomnia—Treatment—Popular works. 2. Cognitive therapy. I. Carney, Colleen.

II. Title. III. Series: Treatments that work. [DNLM: 1. Sleep Initiation and Maintenance Disorders—therapy. 2. Cognitive Therapy—methods. WM 188 E23o 2008]RC548.E35 2008

616.8’498206—dc22

2007047486

ISBN 978-0-19-536589-4

9 8 7 6 5 4 3 2 1

Printed in the United States of America on acid-free paper

1

v

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, result-

ing in broad-based recommendations to make these practices more

available to the public. Several recent developments are behind this

revolution. First, we have arrived at a much deeper understanding of

pathology, both psychological and physical, which has led to the

development of new, more precisely targeted interventions. Second,

our research methodologies have improved substantially, such that

we have reduced threats to internal and external validity, making the

outcomes more directly applicable to clinical situations. Third, gov-

ernments around the world, health care systems, and policy makers

have decided that the quality of care should improve, that it should

be evidence based, and that it is in the 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 inter-

ventions. Workshops and books can go only so far in acquainting

responsible and conscientious practitioners with the latest behavioral

health care practices and their applicability to individual patients.

This new series, TreatmentsThatWork™, is devoted to communicat-

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

practice.

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

procedures for assessing and treating 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 practi-

tioners in the implementation of these procedures in their practice.

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

based practice offers the most responsible course of action for the mental

health professional. All behavioral health care clinicians deeply desire to

provide the best possible care for their patients. In this series, our aim is to

close the dissemination and information gap and make that possible.

This therapist guide and the companion workbook for clients address

the treatment of insomnia. Over one third of the adult population expe-

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

ulation suffers from primary insomnia (a form of insomnia devoid of

secondary causes). Primary insomnia can have severe negative outcomes

for the individual and has implications for the health care system.

Medication is often prescribed, but can have significant side effects.

Unlike pharmacological approaches, CBT insomnia intervention has been

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

effective treatment that targets the behavioral and cognitive components

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

bleshooting. The corresponding client workbook provides educational

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

nia treatment package for a variety of client needs. Clinicians will find this

a welcome addition to their armamentarium.

David H. Barlow, Editor-in-Chief,™

TreatmentsThatWork

Boston, MA

References

Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59,869–878.

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

vi

vii

Contents

Chapter 1 Introductory Information for Therapists 1

Chapter 2 Pretreatment Assessment 15

Chapter 3 Session 1: Psychoeducational and Behavioral Therapy

Components 31

Chapter 4 Session 2: Cognitive Therapy Components 49

Chapter 5 Follow-Up Sessions 69

Chapter 6 Considerations in CBT Delivery: Challenging Patients

and Treatment Settings 83

Appendix Sleep History Questionnaire 97

References 109

About the Authors 117

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1

Chapter 1 Introductory Information for Therapists

Background Information and Purpose of This Program

The behavioral component of this treatment manual originally was

prepared as an Appendix to the first author’s ( JDE) National Institutes of

Mental Health funded grant (MH 48187) entitled, “Cognitive-Behavioral

Therapy for Treatment of Primary Insomnia.” The cognitive component

of this manual was prepared by the second author (CEC) as an Appendix

to a grant funded by the National Institute of Nursing Research (NR

010539) entitled “Cognitive-Behavioral Insomnia Treatment in Chronic

Fatigue Syndrome.” The primary purpose of this manual is to describe

and operationalize the cognitive-behavioral therapy (CBT). However, this

manual has been written in such a manner as to provide other investiga-

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

instructions for replicating treatment procedures.

The specific treatment procedures presented herein have been derived

from various sources. As described in more detail later in this chapter, the

CBT protocol represents a “second generation” multicomponent form of

therapy that evolved from several decades of cognitive and behavioral

insomnia research. This treatment includes selected first generation

behavioral treatment strategies that have proven reasonably effective as

stand-alone treatments for insomnia or for other conditions. However,

the CBT protocol combines several of these therapies to provide a more

omnibus therapy designed to address the varying specific treatment needs

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

from the first author’s early work (Edinger et al., 1992; Hoelscher &

Edinger, 1988) and from the writings of Bootzin (1977), Morin et al.

(1989), Spielman, Caruso, et al. (1987), and Webb (1988). The cognitive

component was informed by integrative cognitive-behavioral models of

2

Morin (1993) and Harvey (2002). One of the cognitive strategies

(i.e., Constructive Worry) was derived from Carney and Waters (2006)

and Espie and Lindsay (1987). As much of our own and others’ research

has focused on the type of insomnia known as Primary Insomnia, the

strategies described in this manual are mainly fashioned for the treatment

of this condition. However, as discussed in the last chapter of this book,

these strategies may be considered for other forms of insomnia as well.

This treatment manual is divided into chapters that describe methods

of insomnia assessment and the implementation of our CBT protocol.

Each chapter describing the treatment protocol provides a “treatment

rationale” to be provided to patients undergoing treatment. Specific

information and instructions to be provided to patients are highlighted

with italics. Investigators who wish to replicate the procedures described

should present the highlighted information and instructions to their

patients verbatim. It is also recommended that those who wish to use

these treatments in their own insomnia research first review the list of

References provided at the end of this text.

Nature and Significance of Primary Insomnia

The sleep disorder insomnia is characterized by difficulties initiating,

sustaining, or obtaining qualitatively satisfying sleep that occur

despite adequate sleep opportunities/circumstances and result in

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

the adult population experiences insomnia at least intermittently,

whereas 10% to 15% suffer chronic, unrelenting sleep difficulties.

Insomnia may result from various medical disorders, psychiatric con-

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

apnea). However, 1% to 2% of the general population suffers from

primary insomnia, a form of insomnia disorder that persists either in

the absence or independent of any such comorbid condition. Whereas

the middle-aged and older adults are most prone to develop one of the

many subtypes of insomnia, primary insomnia is the most common

diagnosis found in younger age groups. As such, the risk for develop-

ing this condition remains relatively stable across the life span.

Although many insomnia sufferers go undetected (Ancoli-Israel &

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

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

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

VonKorff, 1997). Thus, primary insomnia appears sufficiently preva-

lent and disturbing that it frequently comes to the attention of both

sleep specialists and general medical practitioners.

Since primary insomnia is devoid of secondary causes, this problem was

traditionally viewed as less serious than those insomnias arising from

medical, psychiatric, substance abuse, or other serious sleep disorders

(e.g., sleep apnea). However, epidemiologic evidence suggests insomnia,

uncomplicated by comorbid psychiatric, substance abuse, or medical

disorders, substantially increases health-care utilization/costs and

accounts for as many as 3.5 disability days per month among affected

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

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

eral studies have shown that primary insomnia dramatically increases

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

der, or substance abuse problem even after other significant risk factors

are controlled (Breslau, Roth, Rosenthal, & Andreski, 1996; Chang,

Ford, Mead, Cooper-Patrick, & Klag, 1997; Ford & Kamerow, 1989;

Livingston, Blizard, & Mann, 1993; Vollrath, Wicki, & Angst, 1989).

In addition, primary insomnia contributes to reduced productivity, acci-

dents at work, increased alcohol consumption, serious falls among older

adults, and a sense of being in poor health (Brassington, King, &

Bliwise, 2000; Gislason & Almqvist, 1987; Johnson, Roehrs, Roth,

& Breslau, 1998; Johnson & Spinweber, 1983; Katz & McHorney, 1998).

Thus, when encountered clinically, primary insomnia patients warrant

safe, effective, and enduring treatment.

Diagnostic Criteria for Primary Insomnia Disorder

Primary Insomnia is a diagnosis specific to the American Psychiatric

Association’s sleep disorder classification system outlined in recent versions

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

first appeared in the revised, third edition of the Association’s Diagnostic

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

3

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

American Psychiatric Association, 1994, 2000). Primary insomnia’s diag-

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

sleep-wake disturbance serves in defining this condition. In fact, these

criteria specify that a primary insomnia diagnosis is assigned when the

insomnia does not occur exclusively during the course of another primary

sleep or psychiatric disorder and is not the direct result of a general med-

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

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

mary and secondary forms of sleep disturbance. Nevertheless, primary

insomnia can usually be discerned from clinical interview, as expensive and

time-consuming laboratory tests are seldom needed for diagnosis of

insomnia.

Development of This Treatment Program and Evidence Base

It seems intuitively obvious that practicing good sleep habits (i.e., follow-

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

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

sonable to speculate that psychological and behavioral strategies

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

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

4

Table 1.1 Diagnostic Criteria for Primary Insomnia

A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, forat 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-RelatedSleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia.

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

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

fulness of behavioral interventions receive attention in the scientific

literature. In 1959, Schultz and Luthe were the first to formally report

their success in treating a patient with sleep-onset insomnia using the

form of relaxation therapy (RT) known as autogenic training. Several

years later, Jacobson (1964) reported similar results in a case he treated

with his progressive muscle relaxation. However, not until the early 1970s

were the first randomized clinical trials conducted to document the

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

Although limited in number, these early reports were sufficient to spawn

substantial research and clinical interest in the use of psychological and

behavioral therapies for insomnia treatment during the past two decades.

Arguably one of the more monumental breakthroughs in behavioral

insomnia research was Bootzin’s (1972) observation concerning the

important role of behavioral conditioning in disrupting or promoting

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

behaviors, should respond to instrumental conditioning. Consistent

with this suggestion, he first presented his innovative stimulus control

(SC) insomnia treatment in the early 1970s (Bootzin, 1972). In his early

reports, he demonstrated that a simple, straightforward operant condi-

tioning approach involving standardization of the sleep-wake schedule,

eliminating daytime napping, and discouraging sleep-incompatible

behaviors in the bed and bedroom is particularly effective for treating

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

its general efficacy, SC quickly became one of the most widely used

behavioral insomnia treatments (Lacks & Morin, 1992).

In our early clinical work, we found stimulus control and relaxation

therapies moderately effective for treating the sleep problems of many of

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

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

these treatments included specific strategies for addressing patients’

unhelpful beliefs that served to support their sleep-related anxiety and

promote many of their sleep-disruptive habits. In addition, many people

with insomnia report that cognitive arousal is the most significant factor

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

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

employ specific strategies shown to be effective for decreasing pre-sleep

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

5

treatments did not specifically address the practice of spending excessive

time in bed displayed by many of the patients with sleep maintenance

complaints we encountered. Inasmuch as a case series study by Spielman,

Saskin, and Thorpy (1987) showed that restricting time in bed led to

sleep improvements in a small group of insomnia patients they treated,

we thought a truly omnibus insomnia therapy should include such a

strategy. Finally, we noted the need for specific strategies to enhance

patients’ treatment adherence. In this regard we found that patients

seemed more likely to adhere to treatment recommendations if they were

first provided some limited psychoeducational material designed to give

them a basic understanding of what regulates the human sleep system

and the types of habits that help and hinder the normal sleep process.

Given these observations, the need for a multicomponent cognitive-

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

structed a treatment that included a number of components including

(1) a cognitive module designed to provide psychoeducation about

factors that regulate the human sleep system and to address unhelpful

beliefs about sleep; (2) standard stimulus control instructions to

address patients’ conditioned arousal and eliminate common sleep

disruptive habits (daytime napping, maintaining an erratic sleep-wake

schedule); and (3) a protocol for limiting each patient’s time in bed to

an individually tailored time-in-bed prescription (discussed in detail

in Chapter 3).

To test this approach, we conducted two small case-series studies

using multiple baseline designs. The first of these studies (Hoelscher &

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

vided initial support for our multicomponent approach in that three of

the four patients treated responded well once treatment was initiated. In

our second case series study (Edinger et al., 1992), seven patients under-

went baseline monitoring that varied from 2 to 4 weeks in length and

then successively completed four weekly sessions of relaxation training

followed by four sessions of our multicomponent treatment. Results of

this latter trial again suggested that most patients showed marked

improvements in key sleep measures and such improvements occurred

only after our multicomponent Cognitive-Behavioral Therapy (CBT)

was initiated. Shortly thereafter, Morin, Kowatch, et al. (1993) published

the first randomized clinical trial that showed a multicomponent CBT

6

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

for treating older adults with insomnia.

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

ical trials have shown multicomponent CBT insomnia treatment is

both efficacious and clinically effective for treating primary insomnia.

In efficacy studies (Edinger et al., 2001, 2007; Morin, 1999) conducted

with intentionally recruited and thoroughly screened primary insomnia

samples, CBT has proven superior to relaxation training, sham behav-

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

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

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

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

plaints, CBT proved more effective than usual medical management

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

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

concluded that there have been a sufficient number of efficacy and

effectiveness studies conducted to conclude that CBT for insomnia is a

well-established and proven treatment approach particularly for those

with primary insomnia. Thus, with reasonable confidence we can offer

the treatment strategies outlined in this manual as a “Treatment That

Works” for patients with this condition.

Theoretical Model for Cognitive-Behavioral Insomnia Therapy

Spielman’s model presented in Figure 1.1 provides a conceptual frame-

work for understanding the evolution of chronic primary insomnia

and the role of CBT for managing this condition. According to this

model, predisposing factors, precipitating events, and perpetuating mech-

anisms all contribute to the development of chronic primary sleep

difficulties. Some individuals may be particularly vulnerable to sleep

difficulties either by virtue of having a “weak,” “highly sensitive,”

biological sleep system or personality traits that dispose them to poor

sleep when confronted with stress. When such individuals are con-

fronted with the proper precipitating circumstances (e.g., a stressful

life event, sudden unexpected change in their sleep schedule), they

tend to develop an acute sleep disturbance. This sleep problem, in

7

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

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

although predisposing and precipitating factors contribute to the ini-

tial development of insomnia, the psychological and behavioral per-

petuating factors that sustain it serve as the treatment targets for

behavioral insomnia therapy.

The cognitive behavior model posits that an interplay of cognitive and

behavioral mechanisms act as the key perpetuating mechanisms for pri-

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

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

nia, attentional bias for sleep-related stimuli, worry and/or rumination

about the consequences of poor sleep, and unhelpful beliefs about sleep

promoting practices (Carney & Edinger, 2006; Carney et al., 2006;

Edinger, et al., 2000; Espie, 2002; Harvey, 2002; Morin, 1993; Morin,

Stone, Trinkle, Mercer, & Remsberg, 1993). These cognitions, in turn, sup-

port and sustain sleep-disruptive habits and conditioned emotional

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

nisms or serve as environmental/behavioral inhibitors to sleep (Bootzin,

1977; Morin, 1993; Spielman, Saskin, & Thorpy, 1987; Webb, 1988). For

example, daytime napping or spending extra time in bed in pursuit of elu-

sive, unpredictable sleep may only serve to interfere with the body’s home-

ostatic mechanisms that operate automatically to increase sleep drive in the

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

8

100

0Premorbid

Predisposing Precipitating Perpetuating

Acute Sub-Acute Chronic

InsomniaThreshold

Figure 1.1Spielman’s model describing the evolution of chronic primary insomnia

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

poor night’s sleep may disrupt the body’s circadian or “clock” mechanisms

that control the timing of sleep and wakefulness in the 24-hour day.

Additionally, the repeated association of the bed and bedroom with unsuc-

cessful sleep attempts may eventually result in sleep-disruptive conditioned

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

mentally demanding work and allot sufficient “wind-down” time before

bed may serve as a significant sleep inhibitor during the subsequent sleep

period. In sum, all these factors may contribute to and perpetuate PI

(Bootzin & Epstein, 2000; Edinger & Wohlgemuth, 1999; Hauri, 2000;

Morin, Savard & Blias, 2000). As a result, our CBT approach is designed

to modify the range of cognitions and sleep-related behaviors that ostensi-

bly sustain or add to patients’ sleep problems.

Risks and Benefits of CBT for Insomnia

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

conducted, the experience base with CBT-based insomnia interventions

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

is not to say that side effects do not occur, but those that do occur are

generally transient and manageable with strategies outlined later in this

manual. Perhaps the most common side effect is enhanced daytime

sleepiness during the initial stages of treatment resulting from restricting

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

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

vated daytime sleepiness. This sleepiness is usually transient and corrected

by gradual increases in time in bed. Some patients also show elevated

anxiety about sleep when limits are placed on their times spent in bed and

choices of rise times. This side effect also is easily managed via some relax-

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

In contrast, there are many 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 improve-

ments long after treatment ends. The fact that this actually occurs is

supported by the long-term follow-up data reported in CBT trials

9

showing sustained treatment benefits up to 24 months after active

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

differs from most pharmacological approaches (i.e., sleeping pills)

that provide symptomatic relief but fail to address the cognitive and

behavioral factors that sustain insomnia. Indeed, there are currently

no data available to show that sleep improvements persist long after

pharmacotherapy for insomnia is discontinued.

In addition to this benefit there are some data that indicate many patients

may prefer CBT over medicinal approaches. For example, results of one

study (Morin et al., 1999) showed patients were more satisfied with

behavioral insomnia therapy and rated it as more effective than sleep

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

that patients with chronic insomnia both preferred CBT to pharma-

cotherapy but also expected that CBT would produce greater improve-

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

negative side effects. Collectively, these data suggest that insomnia

patients regard behavioral insomnia therapy as a viable and acceptable

treatment for their sleep difficulties.

Alternative Treatments

Various “stand-alone” behavioral strategies including relaxation therapies,

stimulus control, sleep restriction, and paradoxical intention have proven

efficacy for management of insomnia and currently are regarded as “well-

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

apies addresses a specific subset of insomnia-perpetuating mechanisms. In

addition to these therapies, cognitive therapy and sleep hygiene education

are often employed in insomnia management but these therapies do not

currently have empirical support as “stand-alone” interventions. Detailed

descriptions of all of these treatments and their applications can be found

in a number of sources (e.g., Morin et al., 2006; Edinger & Means, 2005;

Edinger & Wohlgemuth, 1999). As noted previously, we have found our

multicomponent therapy to be a more comprehensive and consistently

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

tive and behavioral mechanisms that perpetuate insomnia in the vast

range of primary insomnia patients we encounter.

10

Other non-medicinal approaches for insomnia management have includ-

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

some 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 cur-

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

eral investigational devices for insomnia treatment has begun but such

devices have not yet received FDA approval for insomnia management.

Nonetheless, since it is likely devices may be available in the future, their

efficacy relative to current insomnia therapies will need to be evaluated.

Role of Medications

The most commonly prescribed sleep medications are benzodiazepine

receptor agonists (BzRA). These include several benzodiazepines

(e.g., temazepam) as well as newer non-benzodiazepine agents

(e.g., zolpidem, eszopiclone, zaleplon) that act at the same site on the

GABAA receptor complex. In addition, sedating antidepressant drugs

such as trazodone (TRZ) and various sedating tricyclic antidepres-

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

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

approved for treatment of insomnia.

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

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

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

nia. For example, sleep medications are well suited for treatment of

insomnia arising from an abrupt sleep-wake schedule change (e.g., jet

lag) or as a stress reaction (e.g., bereavement) to unfortunate life cir-

cumstances. In contrast, the role of medications in the management

of chronic insomnia has been debated. Recently some studies (Krystal

et al., 2003; Roth et al., 2005) have shown continued efficacy of some

medications when taken continuously for periods up to 12 months in

duration. However, tolerance and consequent reduced efficacy may

emerge with continued use of some sleep medications, and all sleep

medications hold the risk of psychological dependence when used over

time. Furthermore, whereas medications may reduce sleep-related

11

anxiety for some patients, pharmacologic treatment, in general, is not

designed to address the range of cognitive and behavioral insomnia-

perpetuating mechanisms mentioned previously.

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

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

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

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

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

the sleep medication zopiclone and showed CBT produced significantly

better short- and longer-term improvements on objective indices taken

from electronic sleep recordings but not on subjective measures taken from

sleep logs. Some other studies (e.g., Jacobs et al., 2004; Morin et al., 1999)

that compared treatments consisting of a sleep medication alone, CBT

alone, and a combined CBT and sleep medication therapy showed little

difference in short-term outcomes, but superior longer-term outcomes

with CBT alone compared to medication and combined treatment.

However, all of these studies are limited by their small sample sizes, use of

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

sent standard clinical practice. Thus, additional studies of the relative

values of CBT and sleep medications would be useful.

Treatment Program Outline

The treatment described in the manual should be preceded by a thor-

ough insomnia assessment as described in Chapter 2. This assessment

session should be conducted to ensure that the patient is suitable for

CBT and to instruct the patient in collecting the baseline sleep log

data needed in the initial stages of treatment. The subsequent treat-

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

cognitive treatment targets (perpetuating mechanisms). The following

outline shows the organization and flow of the overall assessment and

CBT insomnia intervention.

I. Pretreatment Assessment

a. Assess nature of insomnia and appropriateness for CBT

b. Assign baseline (pre-therapy) sleep log monitoring

12

II. Presenting Primary Behavioral Treatment Components – Session 1

a. Present treatment rationale and sleep education module

b. Present sleep rules – behavioral insomnia regimen

c. Calculate initial time in bed prescription

d. Assign homework

III. Presenting Cognitive Therapy Strategies – Session 2

a. Review and comment on sleep log findings showing progress

and adherence

b. Provide cognitive rationale to patient

c. Discuss Constructive Worry technique

d. Discuss use of Thought Records

e. Assign homework

IV. Follow-Up/Troubleshooting – Session 3 and Onward

a. Adjusting time in bed recommendations

b. Review and reinforce treatment adherence

c. Troubleshooting – behavioral component

d. Troubleshooting – cognitive component

e. Consideration of therapy termination

Use of the Workbook

A patient workbook has been prepared to accompany the treatment

manual. This workbook includes much educational information

designed to reinforce what is presented in the treatment sessions. The

workbook also includes various blank forms such as the sleep log,

constructive worry sheet, and thought record form that patients

will use to complete their assigned therapy “homework” from week

to week. Since reference will be made to sections of the workbook

13

during the course of therapy, it is recommended that the patient bring

the workbook to each CBT session. However, in the event the patient

fails to do so, it is suggested that the therapist have a workbook and

blank copies of the various forms mentioned available to reference at

each session.

14

15

Chapter 2 Pretreatment Assessment

There are various methods you can use to diagnose and assess Primary

Insomnia (PI) as well as other forms of insomnia. The following

sections briefly discuss each method.

Clinical Interview

The clinical interview is a particularly important component of an

insomnia assessment because it provides the basis from which the clini-

cian ascertains etiological factors and formulates a treatment plan. In

addition to providing a comprehensive assessment of the individual’s

specific insomnia complaint and sleep history, the clinical interview

should include evaluation of medication and substance use as well as

identification of contributory medical and psychiatric conditions.

Essential elements of an insomnia-focused clinical assessment are outlined

in Table 2.1. As suggested by the information shown in the table, the

insomnia-focused interview should provide a thorough descriptive and

functional assessment of the sleep complaint, its history, and the psycho-

logical and behavioral factors that may sustain it. Moreover, the interview

should provide a thorough assessment of the relationship, if any, between

comorbid conditions (medical or psychiatric) and the insomnia com-

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

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

dix prior to the interview. This sort of instrument is designed to gather

the pertinent information needed for a thorough insomnia assessment.

Clinicians may also choose to employ one of the available semi-structured

interviews (Spielman & Anderson, 1999; Savard & Morin, 2002)

designed specifically for insomnia to guide their inquiries. Whatever

16

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 patternSleep scheduleDaytime symptoms (fatigue, cognitive impairment, distress about sleep)Social/vocational impactMaladaptive conditioning to bedroomPhysiological/cognitive arousal at bedtimeUnhelpful sleep-related beliefs Symptoms of other sleep disorders Bedtime routines and sleep-incompatible behaviors in bedLifestyle (daily activity, exercise pattern)Treatment history (self-help attempts, coping strategies, response to previous treatments)Treatment expectations

Medication and Substance Use

Sleep medication – prescription and over-the-counter remedies Other routine prescription and nonprescription medicationsAlcohol, tobacco, caffeine Illicit substances

Medical History/Exam

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

Psychiatric Factors

DepressionAnxietyOther mental disordersGeneral day-to-day stress level

Sleep Logs

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

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

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

vided for the patient in the corresponding workbook and a single

blank copy of this log is shown in Figure 2.1. This instrument is a par-

ticularly valuable tool that allows for prospective monitoring of the

patient’s sleep habits and pattern over time. The log is designed to

solicit information relevant to each night’s sleep including whether

any naps were taken the previous day, whether any medication or

alcohol was ingested at bedtime to facilitate sleep, the time the patient

entered bed, the time the lights were turned off and the patient

attempted to fall asleep, the number of minutes it took to fall asleep,

the number and length of awakenings during the night, the time of

the final morning awakening, and the time of actually arising from

bed. The log also queries about the quality of each night’s sleep and

how well rested the patient felt upon waking. As may be noted from

Figure 2.1, the log is designed to allow entry of 1 week’s worth of sleep

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

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

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

after arising.

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

nia patients since it provides much useful assessment information and it

guides the implementation of our cognitive and behavioral therapy

strategies. As an insomnia assessment tool, the log provides important

information about the patient’s sleep-disruptive habits as well as some

insights into implicit cognitive treatment targets. In some instances,

sleep log data may also be useful for identifying diagnostic subtypes who

may not be good candidates for the treatment program described in this

guide. To demonstrate the specific types of information that may be

gleaned from the sleep log, the ensuing discussion provides a number of

case examples.

17

18 Day of the Week

Calendar Date

1. Yesterday I napped from _____ to _____ (note time of all naps).

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

3. Last night I got in my bed at _____ (AM or PM?).

4. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

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

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

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

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

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 ExcellentPoor

1 2 3 4 5 6 7 8 9 10

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

1 2 3 4 5 6 7 8 9 10

Figure 2.1Sleep Log

19

Case Example #1

Figure 2.2 shows one week of sleep log data for an individual who

manifests a practice seen all too frequently among our insomnia

patients. This individual shows a pattern of retiring to bed for the

evening well in advance of the actual time chosen for beginning

the 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 treat-

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

ioral pattern also may herald underlying misconceptions the patient

may have about sleep needs and sleep-promoting practices that should

be addressed in treatment.

Case Example #2

Figure 2.3 highlights another pattern commonly seen among insom-

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

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.

20

Day of the Week Mon Tue Wed Thurs Fri Sat Sun

Calendar Date 3/5 3/6 3/7 3/8 3/9 3/10 3/11

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 sleepaid (include all prescription and over-the-counter sleep aids). None None None None None None None

3. Last night I got in my bed at _____ (AM or PM?). 9:30 PM 10:00 PM 9:00 PM 9:15 PM 10:00 PM 9:45 PM 9:00 PM

4. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

11:00 PM 11:15 PM 10:45 PM 11:00 PM 11:30 PM 11:45 PM 10:45 PM

5. After turning off the lights it took me about _____ minutes to fall asleep. 25 min 20 min 15 min 45 min 20 min 15 min 30 min

6. I woke from sleep _____ times. (Do not count your final awakening here.) 2 3 2 3 2 1 2

7. My awakenings lasted _____ minutes. (List each awakening separately.) 20 min60 min

15 min45 min30 min

15 min75 min

15 min15 min30 min

15 min15 min 25 min

15 min60 min

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

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

1 2 3 4 5 6 7 8 9 10

5 4 1 2 6 7 4

Figure 2.2Sleep Log Case #1

21

Day of the Week Mon Tue Wed Thurs Fri Sat Sun

Calendar Date 1/15 1/16 1/17 1/18 1/19 1/19 1/21

1. Yesterday I napped from _____ to _____ (note time of all naps). None None None None None None None

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

None None None None None None None

3. Last night I got in my bed at _____ (AM or PM?). 11:00 PM 10:45 PM 10:30 PM 11:30 PM 11:20 PM 2:45 PM 9:30 PM

4. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

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

5. After turning off the lights it took me about _____ minutes to fall asleep. 20 min 45 min 10 min 65 min 35 min 10 min 120 min

6. I woke from sleep _____ times. (Do not count your final awakening here.) 1 2 2 2 1 1 2

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

25 min25 min

45 min90 min

40 min90 min 55 min 5 min

80 min60 min

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

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

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

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

1 2 3 4 5 6 7 8 9 10

5 7 2 1 4 3 2

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

1 2 3 4 5 6 7 8 9 10

5 6 3 1 4 3 1

Figure 2.3Sleep Log Case #2

Case Example #3

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

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

complaining about extreme 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 stu-

dent chooses a bedtime more proximal to this usual sleep onset time,

the sleep latency is markedly reduced. Moreover, the weekend rise times

occur much later and afford the student greater opportunity to obtain a

full night’s sleep given the delayed time of sleep onset. All these indica-

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

drome, a circadian rhythm disorder wherein the endogenous sleep-wake

rhythm is markedly phase delayed. As such, the student is biologically

disposed to fall asleep in the early morning hours and sleep through

much of the morning if allowed to do so. However, on weekdays the

student is required to arise to attend morning classes, so the sleep peri-

od is 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 iden-

tifying the most salient treatment targets in each of your insomnia

patients. As described in greater detail in the ensuing chapter, you will

use completed sleep logs to develop patient-specific Time in Bed

Prescriptions (TIB) as part of your treatment recommendations (see

Chapter 3 for more detail).

Insomnia Symptom Questionnaire

The Insomnia Symptom Questionnaire (ISQ) developed by Spielman

et al. (1987) is a 13-item self-report instrument designed to assess sleep

(e.g., sleep onset difficulty, wakefulness during sleep) and waking

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

22

23

Day of the Week Tue Wed Thurs Fri Sat Sun Mon

Calendar Date 4/2 4/3 4/4 4/5 4/6 4/7 4/8

1. Yesterday I napped from _____ to _____ (note time of all naps). None 2:00–4:00 PM

5:00–6:30 PM

None None None None

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

4 ozwine

None 2 beers 1 beer None None None

3. Last night I got in my bed at _____ (AM or PM?). 11:00 PM 12:30 PM 11:30 PM 12:00 PM 2:20 PM 2:45 PM 11:30 PM

4. Last night I turned off the lights and attempted to fall asleep at _____ (AM or PM?).

11:00 PM 12:30 PM 11:30 PM 12:00 PM 2:20 PM 2:45 PM 11:30 PM

5. After turning off the lights it took me about _____ minutes to fall asleep. 3.5 hours 3 hours 2.5 hours 3.5 hours 40 min 30 min 3 hours

6. I woke from sleep _____ times. (Do not count your final awakeninghere.)

1 2 2 1 1 1 1

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

25 min25 min

40 min30 min 20 min 20 min 5 min 20 min

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

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

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

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

1 2 3 4 5 6 7 8 9 10

4 4 4 1 6 7 2

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

1 2 3 4 5 6 7 8 9 10

4 3 3 1 7 7 1

Figure 2.4Sleep Log Case #3

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

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

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

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

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

subject’s response line serves as an analog measure of the degree to

which the respondent has the symptom noted by the item. The mean

score across all 13 items constitutes the measure to be used in this study.

In our previous work (Edinger, et al., 2001; Edinger & Sampson, 2003),

we have found the ISQ has acceptable internal consistency (Cronbach’s

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

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

connoting insomnia remission given our early findings suggested this

cutoff has a 92% sensitivity and 64% specificity for discriminating nor-

mal sleepers from primary insomnia sufferers. However, in more recent

unpublished work with a large validation sample, we have determined

that an ISQ total score � 36.5 may be a better benchmark since this

cutoff has an 89% sensitivity and 86.5% specificity for discriminating

patients with primary insomnia from normal sleepers.

Insomnia Severity Index

The Insomnia Severity Index (ISI: Morin, 1993) is a 7-item questionnaire

that provides a global measure of perceived insomnia severity based on

the following indicators: difficulty falling asleep, difficulty staying asleep,

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

ment with daytime functioning; degree to which impairments are

noticeable; and distress or concern with insomnia symptoms. Each item

is rated on a 5-point (0 to 4) Likert scale and the total score ranges from

0–28. The following guidelines are recommended for interpreting the

total score: 0–7 (no clinical insomnia), 8–14 (sub-threshold insomnia),

15–21 (insomnia of moderate severity), and 22–28 (severe insomnia). The

ISI has good internal consistency (Cronbach’s alpha � 0.91) and test-

retest reliability (r � 0.80). It has been validated against sleep logs and

electronic sleep recordings (Bastien, Vallieres, & Morin, 2001) and has

proven sensitive to therapeutic changes in several treatment studies of

insomnia (Morin et al., 1999). In recent years, the ISI has become

24

increasingly popular in insomnia work and now is recommended as a

standard assessment tool in insomnia research studies (Buysse et al.,

2006). Since the ISI has the mentioned guidelines for score interpreta-

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

tial insomnia severity and the clinical significance of improvements

achieved during insomnia treatment.

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

This instrument, like the ISI, is a widely used and currently recom-

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

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

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

rated items (0–3 scale) assessing sleep quality and disturbances over

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

latency, sleep duration, sleep efficiency (i.e., the proportion of time in

bed that is actually spent asleep), sleep quality, disturbances to sleep,

medication use, and daytime dysfunction. A summation of these seven

component scores yields a global score of sleep quality, ranging from

0 to 21. Previous research (Buysse et al., 1989) has shown that a PSQI

total score of � 5 has good sensitivity (89.6%) and specificity (86.5%)

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

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

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

provides a global sleep quality assessment and is not specifically or

exclusively designed for insomnia assessment. Moreover, we (Carney et

al., 2006) have found that elevated levels of anxiety may contribute to

PSQI score elevations in some types of insomnia patients. Hence, the

patient’s anxiety level at the time of PSQI administration should be

considered when interpreting the summary score obtained.

Dysfunctional Beliefs and Attitudes About Sleep Questionnaire (DBAS)

This instrument is a valuable tool for identifying unhelpful sleep-related

beliefs and attitudes presumed to help perpetuate insomnia problems.

Currently both the original parent version and an abbreviated version are

25

available for clinical and research use. The original DBAS-30 includes

30 items that comprise five subscales designed to assess (1) attributions

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

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

tions of loss of control and unpredictability of sleep (e.g., “I am worried

that I may lose control over my abilities to sleep”); (3) perceived sleep needs

and sleep expectations (e.g., “Because I am getting older, I need less

sleep”); (4) misattributions about causes of insomnia (e.g., “I feel insom-

nia is basically the result of aging and there isn’t much that can be done

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

(e.g., “When I don’t get the proper amount of sleep on a given night, I

need to catch up the next day by napping or the next night by sleeping

longer). A 100-millimeter (mm) analog scale (i.e., horizontal line) labeled

“strongly disagree” at its far left extreme and “strongly agree” at its far

right extreme accompanies each item and is used by respondents to indi-

cate their degree of endorsement. When completing the DBAS-30,

respondents are required to draw a vertical line through the point on the

100-mm scale to indicate their degree of agreement or disagreement with

each item. The distance in mm between the far left extreme of the analog

scale and the response line then is used as the item’s “score.” With one

exception all items are structured so that higher scores (i.e., stronger item

agreement) connote more dysfunctional beliefs.

Recently an abbreviated 16-item version (DBAS-16) of the original

DBAS-30 has become available. This abridged version is similar in for-

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

imposed on visual analog scales for indicating agreement/disagreement

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

ding to the degree of belief (e.g., 10 � agree completely) is circled.

A total score is calculated by summing the item scores and dividing the

resultant sum by 16 (i.e., a mean item score). Both the DBAS-30 and

DBAS-16 have shown acceptable levels of internal consistency

(Cronbach’s � values � .80). Furthermore we recently have found

DBAS-16 total scores � 3.8 to be suggestive of the level of unhelpful

beliefs common among individuals with clinically significant insomnia

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

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

ing from our cognitive-behavioral intervention.

26

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is an eight-item self-report questionnaire

designed to assess daytime sleepiness in common day-to-day situations

such as “Watching TV” or “Sitting and talking to someone.”

Respondents are instructed to indicate how likely they are to fall asleep

in each situation using a 4-point rating scale (0 � “would never doze”

to 3 � “high chance of dozing”). The ESS score is obtained by sum-

ming all item responses so scores may range from 0 to 24 with higher

scores suggesting greater daytime sleep tendency. A score of 10 or

more is considered to indicate clinically significant daytime sleepiness.

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

ment has shown very acceptable internal consistency (Cronbach’s � �

0.88) and test-retest reliability (r � .82) within both non-complaining

groups and in groups of clinical sleep-disordered patients (Johns, 1991;

Johns, 1994) Additionally, Epworth ratings have been found to correlate

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

ness ( Johns, 1991).

Whereas some insomnia patients will obtain scores in the “sleepy” range

on this instrument, they commonly do not obtain scores indicating

they are very sleepy. Overweight patients who report loud nocturnal

snoring and who score above the clinical 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 recom-

mended. Brief psychological questionnaires such as the current version

of the Beck Depression Inventory (BDI-II), the Beck Anxiety

Inventory, the Spielberger State-Trait Anxiety Inventories, and the

Brief Symptom Inventory are all useful in this regard. Although they

have limited value when used in isolation, these questionnaires may

provide important supplemental information not apparent from the

clinical interview.

27

In some cases, it may be necessary to conduct a more thorough

psychological assessment. The Minnesota Multiphasic Personality

Inventory-2 (MMPI-2) is an extensive psychological questionnaire

that produces personality profiles for a wide range of psychopathol-

ogy. Validity scales provide information on response biases such as

patients’ attempts to either deny or exaggerate psychopathological

symptoms. Individuals with insomnia produce specific MMPI-2

profiles characterized by depression, anxiety, and somatization of

emotional conflict. While some sleep disorders centers routinely

administer the MMPI-2 to all patients as part of the intake evaluation,

it may be considered too lengthy and time-consuming for some

venues.

Actigraphy

Actigraphy is another technique to assess sleep-wake patterns over

time. Actigraphs are small, wrist-worn devices (about the size of a

wristwatch) that measure movement. They contain a microprocessor

and onboard memory and can provide objective data on daytime

activity. Computer software that accompanies most brands of acti-

graphs include scoring algorithms for estimating sleep and wake time

for each night the actigraph is worn. Most such software also allows

for outputting a day-to-day plot of the sleep-wake schedule when the

patient is asked to wear the actigraph day and night for a series of

days.

Actigraphy is used to clinically evaluate insomnia, circadian rhythm

sleep disorders, excessive sleepiness, and restless leg syndrome. It is also

used in the assessment of the effectiveness of treatments for these disor-

ders, including behavioral therapy.

Actigraphy has not traditionally been used in routine diagnosis of sleep

disorders but is increasingly being employed in sleep clinics to replace

full polysomnography. Its greatest value may be that of providing an

object verification of the patient’s sleep-wake schedule and adherence to

recommended rising times and TIB prescriptions included in the treat-

ment recommendation discussed in the next chapter.

28

Polysomnography

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

ologic variables are measured and recorded during sleep. Physiologic

sensor leads are placed on the patient in order to record the following:

■ Brain electrical activity

■ Eye and jaw muscle movement

■ Leg muscle movement

■ 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, polysomnog-

raphy is not necessary for diagnosing insomnia, although in some cases

it is helpful in determining whether or not there is a medical reason for

the 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 men-

tioned herein may provide much needed diagnostic and assessment

information in selected cases of primary insomnia as well as with other

insomnia patients who have underlying sleep disorders or complex

comorbid disorders.

29

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31

Chapter 3 Session 1: Psychoeducational and BehavioralTherapy Components

(Corresponds to chapter 2 of the workbook)

Materials Needed

■ Audiotape to record sleep education segment of session (optional)

■ Figure 3.1: Circadian Temperature Rhythm

■ Figure 3.2: Effects of Jet Lag

■ Patient’s completed sleep logs (see Chapter 2)

Outline

■ Present rationale for treatment

■ Provide sleep education

■ Review “sleep rules” and provide brief summary of each

■ Make time in bed (TIB) recommendations

■ Assign homework

Treatment Rationale

Use the information from Chapter 1 to present the client with a brief

overview of Cognitive-Behavioral Therapy (CBT) for Primary Insomnia

(PI). Review with the patient Spielman’s 3-P model of insomnia and how

it suggests that predisposing factors (e.g., biological or personality traits) and

precipitating events (events or circumstances that are stressful or otherwise

disruptive to normal sleep-wake routines) can lead to the development of

32

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

ing mechanisms including unhelpful misconceptions about sleep, anxiety

about sleeping poorly, conditioned arousal to the bed and bedroom, and

various sleep disruptive habits (e.g., daytime napping, spending excessive

time in bed). Explain that this treatment program is designed to correct

those unhelpful sleep-related beliefs and anxiety as well as common sleep-

disruptive habits that maintain or contribute to insomnia.

You may use the following sample dialogue:

We have conducted a thorough evaluation of your sleep problem, and

based on our findings we believe you will benefit from some informa-

tion about sleep and some recommendations designed to help you

change your sleep habits. When sleep problems linger on, as they have

in your case, usually unhelpful sleep-related beliefs and habits develop

and add to the sleep problem. The treatment you receive will educate

you about your sleep problem and help you correct those unhelpful

beliefs and habits you have so that you can again develop a more nor-

mal sleep pattern.

Then, move on to providing the patient with information about sleep.

Sleep Education

The sleep education provided to patients during CBT has two primary

functions. First, it helps patients overcome their misconceptions and

anxiety-provoking beliefs about sleep so that they may develop realistic

sleep expectations. Also, it enables patients to better understand the

rationale for the behavioral regimen used in this treatment. This under-

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

treatment recommendations.

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

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

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

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

This information also appears in the corresponding patient workbook.

You may use the following sample dialogue:

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

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

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

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

you obtain. The information I’m about to give you will help you

understand how your body’s sleep system works and prepare you for the

specific treatment suggestions you will be given.

Before you make any changes in your sleep habits, it is important that

you ask the question, “How much sleep do I need each night?”

Generally speaking, there is no one amount of sleep that “fits” everyone.

Most normal adults sleep 6 to 8 hours per night. However, some people

need only 3 or 4 hours of sleep each night, whereas others require 10 to

12 hours of sleep on a nightly basis. At this point, it is important to set

aside any previous notions or beliefs you might have about your sleep

needs. These beliefs may be wrong and may hinder your progress. The

treatment we give you will help you discover the amount of sleep that

satisfies your needs and lets you feel alert and energetic during the day.

In addition to getting rid of any old ideas you have about your sleep

needs, it is important that you learn some things about how your

body’s sleep system works. People, like many animals, have powerful

internal “clocks” that affect their behavior and bodily functioning.

The “body clock” works in roughly a 24-hour period and produces

24-hour cycles in such things as digestion, body temperature, and the

sleep-wake pattern. For example, if we record a person’s body temper-

ature for several days in a row, we will see a consistent up and down

pattern or rhythm in temperature across each 24-hour day. The

temperature will be at its lowest point around 3 or 4 AM, will rise

throughout the morning and early afternoon, and will hit its peak

around 3 or 4 PM. Then, once again the temperature will begin to

fall until it hits its low point in the early morning hours.

The influence of the internal circadian clock on the sleep-wake cycle is

apparent if one studies the relationship between the body’s 24-hour tem-

perature rhythm and the timing of the sleep period. Suppose a person is

placed in a place like a cave, away from daylight, external clocks, and

all other time-of-day indicators. In this situation, the person will con-

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

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

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34

a close relationship between the temperature cycle and the sleep-wake

pattern they show. This relationship is shown in the Circadian

Temperature Rhythm graph included in your workbook.

(Direct the patient to the graph in the workbook or show him

Figure 3.1.)

As shown by this graph, the main sleep period begins when the body

temperature is falling and later ends after the body temperature

begins rising again. Hence, although the 24-hour temperature cycle

shown does not control the human sleep-wake pattern, the tempera-

ture rhythm reflects the working of the body clock and can be used to

predict when sleep is likely to occur in the 24-hour day.

In the real world, work schedules, meal times, and other activities

work together with our body clocks to help us keep a stable sleep-wake

pattern. However, significant changes in our sleep-wake schedule can

interfere with our ability to sleep normally. This may be caused by

what is often called “jet lag.” If, for example, a man who lives in

New York flies to Los Angeles, he initially is likely to have some

difficulty with his sleep and to experience some daytime fatigue once

he arrives in California. This occurs because the 3-hour time-zone

change places his new desired sleep-wake schedule at odds with his

“body clock” that is “stuck” in his old time zone. This situation is

shown in the second graph included in your workbook.

(Direct the patient to the graph in Chapter 2 of the workbook or show

him Figure 3.2.)

The man’s body clock remains on New York time and initially lags

behind the real-world clock time in California.

This traveler is likely to become sleepy 3 hours earlier than he wishes

and to wake up 3 hours before he prefers on the initial days of his

trip. Fortunately, with repeated exposure to the light-dark pattern in

the new time zone, the body clock resets and allows the traveler to

“get in sync” with the new time zone. However, this traveler is again

likely to experience temporary problems with his sleep and daytime

fatigue when he first returns to New York.

In addition to our body clock, getting older usually leads to

changes in our sleep. As we age, we tend to spend more time

35

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Figure 3.1Circadian Temperature Rhythm

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Figure 3.2Effects of Jet Lag

37

awake in bed and less time in the deepest parts of sleep. Because

sleep becomes more “shallow” and broken as we age, we may notice

a decrease in the quality of our sleep as we grow older. Although

these changes set the stage for the development of sleep problems,

they do not guarantee such problems. However, because of these

changes, it is probably unrealistic to expect that you will again

have the type of sleep you enjoyed at a much younger age than

you are now.

Finally, before attempting to change your sleep habits, it is important

that you understand the effects of sleep loss on you. This understand-

ing is important because many who have sleep problems make these

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

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

following a poor night’s sleep in order to avoid or recover lost sleep.

Although these habits seem logical and sensible, they all may serve

to continue the sleep problems. In fact, these habits are usually the

opposite of what needs to be done to improve sleep.

In some respects, losing sleep one night may lead to getting more or

better sleep the following night. In fact, the drive to sleep gets stronger

the longer one is awake before attempting to sleep again. For exam-

ple, a person is much more likely to sleep for a long time after being

awake for 16 hours in a row than after being awake for only 2 hours.

It is important to remain awake through each day in order to build

up enough sleep drive to produce a full night’s sleep.

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

well. If people are totally deprived of a night’s sleep, they usually

become very sleepy, have some trouble concentrating, and generally

feel somewhat irritable. However, they typically can continue most

normal daytime activities even after a night without any sleep at all.

When allowed to sleep after a longer than normal period of being

awake, most people will tend to sleep longer and more deeply than

they typically do on a normal night. Although people tend not to

recover all of the sleep time they lost, they do typically recover the deep

sleep they lost during longer than usual periods without sleep. Hence,

your body’s sleep system has some ability to make up for times when

you don’t get the amount of sleep you need.

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

bly noticed that you occasionally had a relatively good night’s sleep

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

your body’s sleep system has an ability to make up for some of the sleep

loss you experience over time. Although your sleep is not normal, you

can take some comfort in this observation. The important point to

remember is that you do not need to worry a great deal about lost

sleep nor should you actively try to recover lost sleep. Needless worry

and attempts to recover lost sleep will only worsen your sleep problem.

This information is not intended to “make light” of your sleep prob-

lem. You do indeed have a sleep problem that needs to be treated.

This discussion is intended to help you to understand your problem.

With this knowledge you should now understand the purpose for the

treatment recommendations I’m making. Do you have any questions

about what you have just heard ?

Behavioral Treatment Regimen

The behavioral treatment regimen uses stimulus control and sleep restric-

tion strategies to standardize the patient’s sleep-wake schedule, eliminate

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

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

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

mendations included in this regimen are standard for all patients.

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

mate (derived from sleep logs) of each patient’s sleep requirement. Since

TIB prescriptions may vary from patient to patient, these prescriptions

allow for the tailoring of this regimen to fit each patient’s specific sleep

needs.

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

the workbook and provide a brief justification for each behavioral 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 extended periods without being asleep. Long

periods of being awake in bed usually lead to tossing and turning,

39

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

in turn, make it more difficult to fall asleep. Also, if you lie in bed

awake for long periods, you are training yourself to be awake in bed.

When sleep does not come on or return quickly, it is best to get up, go

to another room, and return to bed only when you feel sleepy enough

to fall asleep quickly. Generally speaking, you should get up if you

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

though you are about to go to sleep.

Rule 4: Don’t Worry, Plan, etc., in Bed

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

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

the mind awake, making it extremely difficult to fall asleep.

Do not worry, mull over your problems, plan future events, or do

other thinking while in bed. These activities are bad mental habits.

If your mind seems to be racing or you can’t seem to shut off your

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

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

ing 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.

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41

Rule 6: Go to Bed When You Are Sleepy, but Not Before the Time Suggested

Advise the patient to attempt sleep only when he is feeling sleepy.

In general, you should go to bed when you feel sleepy. However, you

should not go to bed so early that you find yourself spending far more

time in bed each night than you need for sleep. Spending too much

time in bed results in a very broken night’s sleep. If you spend too

much time in bed, you may actually make your sleep problem worse.

I will help you to decide the amount of time to spend in bed and what

times you should go to bed at night and get out of bed in the morning.

Determining Time in Bed Prescriptions

As briefly discussed in Chapter 2, you will use the patient’s pretreatment

sleep logs to determine how much time he or she should stay in bed.

First, calculate the average total sleep time (ATST) displayed by the

patient as shown on his completed sleep logs. Then, use the following

formula to make a recommendation of how long the patient should

remain in bed each night.

Time in Bed (TIB) � Average Total Sleep Time (ATST) � 30 minutes

Remember to add 30 minutes, which accounts for the time it takes to fall

asleep as well as a few normal, brief nocturnal arousals.

To illustrate how a TIB prescription is determined, consider the sleep log

data shown in Figure 3.3. This log presents 6 days worth of data as well as

calculations of the average total sleep time (ATST) and average time in bed

across this 6-day period. Note in this example the patient slept 400 minutes

per night, on average, but had an average time in bed of 540 minutes (i.e.,

9 hours) per night. The ATST falls between 61⁄2 and 7 hours and, as such,

does not seem at all abnormal. However, there is a marked discrepancy

between the average time slept and the average time in bed. Given the data

shown, the TIB prescription derived using the above formula would be

430 minutes, or 7 hours and 10 minutes. Hence, that TIB prescription

42

would be used as the initial time allotment for the nocturnal sleep period.

Of course, patient preferences should be considered when establishing the

initial TIB allotment, and it is perfectly acceptable to round the TIB pre-

scription identified in this example to either 7 hours or 71⁄4 hours if such

rounding helps with the patient’s sleep scheduling. It should be noted that

in practice it is preferable to derive the initial TIB prescription from sleep

log data collected for 2 or more weeks so that a more stable estimate of

ATST can be made.

Once the initial TIB prescription is determined, it is important to help

the patient choose a standard wake-up time and earliest bedtime so

that the prescription can be followed. In doing so, it is important to

have the patient consider both “ends” of the night. A patient may ini-

tially 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 earli-

est 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 addi-

tional 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 con-

sistent adherence to the behavioral strategies described earlier show marked

reductions in their wake time during the night within the first 2 to 3 weeks

43

Figure 3.3Calculating a Time in Bed (TIB) Prescription

Day of the Week Mon Tue Wed Thurs Fri Sat

Calendar Date 3/5 3/6 3/7 3/8 3/9 3/10

1. Yesterday I napped from _____ to _____ (note time of all naps). None None None None None None

2. Last night I took ______ mg of _____ or _____ of alcohol as a sleep aid (include all prescription and over-the-counter sleep aids). None None None None None None

3. Last night I got in my bed at ______ (AM or PM?). 11:00 PM 11:30 PM 11:15 PM 10:30 PM 11:15 PM 10:30 PM

4. Last night I turned off the lights and attempted to fall asleep at ______ (AM or PM?).

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

5. After turning off the lights it took me about _____ minutes tofall asleep.

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

6. I woke from sleep ______ times. (Do not count your final awakening here.)

2 1 3 2 1 2

7. My awakenings lasted _______ minutes. (List each awakeningseparately.) 25 min

15 min 60min

10 min 25 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

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

1 2 3 4 5 6 7 8 9 10

2 3 2 3 2 3

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

1 2 3 4 5 6 7 8 9 10

1 4 2 5 1 3

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

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 treat-

ment 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 recom-

mendations we have discussed consistently each and every day of the

week. If you are able to do that, you likely will start to see some

improvements in your sleep within the next 2 to 3 weeks. You are

likely to notice first that the time you take to get to sleep and the

amount of time you spend awake during the night will decrease

significantly. Although you may not see large changes in the amount

of time you sleep each night during this time period, your sleep should

start to become more solid and restorative. However, if you do not

follow the recommendations we have discussed consistently, your

progress will likely be much slower or you may not see any significant

changes in your sleep. Thus, it is important that you follow the treat-

ment recommendations we discussed consistently so that you obtain the

types of results you are seeking.

As you begin this treatment at home, it is also important for you to

understand that the sleep schedule we agreed upon for you today may

leave you feeling a little sleepy in the daytime, particularly during the

first week as you get adjusted to this new schedule. If you notice an

increase in sleepiness, avoid activities wherein your sleepiness might be

dangerous to you such as driving long distances or operating hazardous

machinery. If you continue to feel sleepy in the daytime beyond the first

week, that usually means we have limited your time in bed at night too

much and you would benefit by increasing this time somewhat. If this is

the case when you return for your next session, we will review your sleep

logs and make the needed adjustments in your nightly sleep schedule to

44

address this problem. Moreover, we can continue to make such adjust-

ments from session to session until we arrive at the schedule that works

best for you. It is important that you follow the treatment recommenda-

tions consistently from week to week and chart your progress on the sleep

logs in your workbook. This will allow us to assess your progress and

determine what, if any, changes in your schedule might be needed.

Managing Patients Unable to Attend Routine Follow-Up Sessions

It is desirable to provide patients one or more return visits to encourage

and reinforce treatment adherence, resolve difficulties they are having

with treatment enactment, and assist them in making TIB adjustments.

However, we encounter some patients who live a great distance from

our clinic or for other reasons are not able to return for follow-up ses-

sions. Both our clinical experiences and our recent research findings

(Edinger et al., 2007) suggest that some patients are able to achieve

significant sleep improvements over time following only one session

wherein the information covered in this chapter is presented. However,

in such cases, it is useful to give the patient instructions that will enable

him to make needed TIB alterations to establish an optimal sleep

wake pattern. For such individuals, you may use the following sample

dialogue:

You should try this sleep-wake schedule for at least two weeks and

determine how well you sleep at night and how tired or alert you feel

in the daytime. If you sleep well most nights and are as alert as you

would like to be in the daytime, then you probably should make no

changes in your time in bed each night. If, however, you find you are

sleeping well at night, but you feel tired most days, you should try

increasing your time in bed at night by 15 minutes. If, for example, you

begin with 7 hours in bed per night the first week and find that you

are tired in the daytime despite sleeping soundly at night, you should

try spending 7 hours and 15 minutes in bed each night during the sec-

ond week. If, with this amount of time in bed, you continue to sleep

soundly at night but still feel tired in the daytime, you can add another

15 minutes to the time in bed during the third week and so on.

45

However, when you notice an increase in the amount of time you are

awake in bed each night, you will know that you are spending too

much time in bed at night. If this occurs, you should decrease your time

in bed by 15 minutes per week until you find the amount of time that

enables you to sleep soundly through the night and feel reasonably alert

in the daytime. You should also decrease your time in bed after the first

2 weeks if the initial amount of time in bed we choose together today

does not reduce your time awake in bed each night.

To help you make decisions about changing your time in bed, it

may be helpful to consider some simple guidelines. If you routinely

take more than 30 minutes to fall asleep or you are routinely awake

for more than 30 minutes during the night, you probably should

reduce the amount of time you spend in bed each night. You also

should consider decreasing your time in bed if you find that you

routinely awaken more than 30 minutes before you plan to. Of

course, the key word here is “routinely.” Occasional nights during

which you have a somewhat delayed start to your sleep or you have

more wakefulness than usual once you get to sleep, should not be

viewed as reasons for changing your sleep schedule. Only when such

occurrences are frequent or routine should you try a somewhat

shorter time in bed. In the end, the best guideline to use is how you

feel each day. If you are satisfied with how you generally feel in the

daytime, you can assume that the sleep you are obtaining at night

is sufficient.

Providing Basic Sleep Hygiene Education

In addition to providing the sleep improvement guidelines mentioned

earlier, the patient should be given some standard sleep hygiene education

and instructions to encourage lifestyle practices that promote sleep qual-

ity and daytime alertness. These recommendations are a common com-

ponent of behavioral insomnia therapy, have good “face validity,” and are

easily understood by the majority of patients. They are also included in

Chapter 2 of the workbook. To facilitate the patient’s acceptance of and

46

adherence to these recommendations, the following rationale should first

be provided to the patient.

The sorts of daytime activities in which you engage, the foods and

beverages you consume, and the surroundings in which you sleep

may all influence how well you sleep at night and how you feel in

the daytime. Thus, in addition to making the specific changes to

your sleep habits we have discussed, you also may benefit from

making some changes to your lifestyle and bedroom to promote a

more normal sleep-wake pattern.

Once this general rationale has been presented, the patient should be

given the specific sleep hygiene recommendations described in the follow-

ing instructions:

Recommendation 1: Limit your use of caffeinated foods and beverages

such as coffee, tea, soft drinks with added caffeine, or chocolates.

Caffeine is a stimulant that may make it harder for you to sleep well

at night. You should also know that caffeine stays in your system for

several hours after you consume it. Therefore, we recommend that you

limit your caffeine to the equivalent of no more than three cups of

coffee per day and that you not consume caffeine in the late afternoon

or evening hours.

Recommendation 2: Limit your use of alcohol. Alcoholic beverages may

make you drowsy and fall asleep more easily. However, alcohol also usu-

ally 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 it may make it harder to get to sleep quickly.

Recommendation 4: Try a light bedtime snack that includes such items

as cheese, milk, or peanut butter. These foods contain chemicals that

your body uses to produce sleep. As a result, this type of bedtime snack

may actually bring on drowsiness.

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48

Recommendation 5: Make sure that your bedroom is quiet and dark.

Noise and even dim light may interrupt or shorten your sleep. You can

block out unwanted noise by wearing earplugs, running a fan, or using

a so-called “white noise” machine that is specifically designed to screen

sleep-disruptive noise. Also, if possible, eliminate the use of night-lights

and consider using dark shades in your bedroom so that unwanted

light does not awaken you too early in the morning.

Recommendation 6: Make sure the temperature in your bedroom is

comfortable. Generally speaking, temperatures much above 75 degrees

Fahrenheit cause unwanted wake-ups from sleep. Thus, during hot

weather, we suggest you use an air conditioner to control the tempera-

ture 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 work-

book (or listen to the audiotape recording if one was made), as well as

the sleep rules and recommendations outlined

✎ Instruct the patient to continue recording his sleep habits using the

sleep logs provided in the workbook

✎ For patients who cannot return for routine follow-up, review methods

for adjusting TIB prescriptions if necessary, based on the information

provided in today’s session

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Chapter 4 Session 2: Cognitive Therapy Components

(Corresponds to chapter 3 of the workbook)

Materials Needed

■ Patient’s completed sleep logs

■ Audiotape to record cognitive education segment of session

(optional)

■ Constructive Worry Worksheet and instructions for completion

■ Thought Record and instructions for completion

Outline

■ Review and comment on sleep log findings showing progress

and treatment adherence

■ Provide cognitive rationale to patient

■ Discuss Constructive Worry technique

■ Discuss use of Thought Records

■ Assign homework

Review Homework and Treatment Adherence

Specifically targeting cognitive change may be important for increased

adherence to behavioral recommendations, as well as eliminating sleep-

interfering thoughts. As a result, Session 2 is devoted to restructuring

50

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 recom-

mendations by asking how each one went. Be sure to praise all instances

of adherence. In areas of non-adherence, try to frame it positively:

I can see that you had some trouble getting out of bed in the morning,

but I also notice that you were able to do this on two of the mornings.

That’s great. Let’s return to this issue at the end of this session and see

if we can figure out a way to increase this to 7 days a week.

Cognitive Rationale for Patient

Begin a discussion about the role of cognitions in the maintenance

of insomnia. You may use the following sample dialogue:

Last week we focused on changing behaviors that had negative effects

on sleep. Today, we will discuss the role of your thoughts in insomnia

and give you strategies to help with any problems you may be having

in this regard. Specifically, we will focus on how thoughts and beliefs

can cause insomnia or at least make it worse. What role do thoughts

play in insomnia? Some people don’t even consider that how we think

and how we feel can have a huge impact on how we sleep. It turns

out that what and how we think affects how we sleep, how we feel,

and how we deal with periods of sleep loss. Lots of research and 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 think-

ing is not typical of how they normally think, but since they have

had insomnia, their type of thinking has changed and the way they

view sleep has changed too. The Insomnia Brain tends to be very

“noisy” and very focused on the effects of not sleeping. Let’s take a few

minutes to examine the Insomnia Brain and we’ll offer some strategies

for managing this unhelpful state of mind.

Negative thoughts in the insomnia brain spread like wildfire. All the

thoughts are negative and they are usually related in some way.

Positive thoughts don’t make it in. Most people with insomnia tell us,

“I don’t understand it, I am not usually a worrier, but once I get into

bed I think about the weirdest things and I have no control.” This is

the Insomnia Brain—and it can seem unrelenting.

Do you have difficulty shutting your mind off at night? The problem

is that we cannot sleep when our brain is alert. Moreover, the more

this happens in your bed on a nightly basis, the more likely it is to

continue to happen. This is because it becomes an unintentional and

unwanted habit. The good news is that all habits can be broken if

you have a good strategy.

Do you tend to get upset about not sleeping or worry about whether

or not you will be able to manage during the day? Many people with

insomnia will say, “I wasn’t worried at all today but as soon as my

head hit the pillow, it was like a switch went off.” Does this ever hap-

pen to you? It means that your bed has become a signal for worry

and upset. There are ways to change this signal.

Remember your homework from last session? You were to leave the

room when you were unable to sleep. One of the most effective

strategies for quieting an active mind is to leave the bedroom when

your mind starts to take over. This will break the habit. It may take

several attempts at first but your brain will eventually get the pic-

ture that your bed is not the place for it to be active. This practice

may have other benefits too. Taking the Insomnia Brain out of bed

results in becoming more clearheaded and being better able to

switch off your troublesome thinking. Most people tell us that

the worry they could not switch off in the bedroom became a 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 oppor-

tunity for sleep, but the chance of you sleeping while your brain is

active is limited. Getting this type of mental activity under control

by spending a few minutes out of bed will increase your chances

of being able to sleep.

51

Assess if the patient has any questions and whether any of this discus-

sion seems to be personally applicable. Reinforce the patient’s

identification with the problem. For example, if the patient says, “I

definitely worry in bed about every little thing.” Be sure to say, “Okay,

then it’s going to be important for us to focus on this and for you to

complete some additional homework over the next 2 weeks.”

Constructive Worry

Many people with insomnia complain of “unfinished business” follow-

ing them into the bedroom and creating arousal/distress in bed. Indeed,

problem solving in the presleep period has been implicated as one

of the strongest predictors of difficulties falling asleep (Wicklow &

Espie, 2000). Espie and Lindsay (1987) were among the first to report

positive results for an early evening procedure that targeted presleep

worry. Similarly, Carney and Waters (2006) demonstrated that a single

night of using an early evening procedure called Constructive Worry

results in decreased presleep arousal. As a result, providing a tool to

manage nocturnal worry is often helpful. If nighttime worry is a

significant issue, it is important to pair this procedure with stimulus

control (i.e., the instruction to leave the bedroom when problem solv-

ing or worrying) and other stress management techniques such as relax-

ation and/or time management techniques. Introduce the exercise with

a rationale such as the following:

While most people find that getting out of the bed is enough to

address their nighttime worry problem, some continue to worry. Some

bedtime worries are a result of keeping so busy during the day that

no time is available to deal with the worries. Sleep is the first

opportunity that is quiet enough for your brain to try to complete its

unfinished business. Does this sound like it applies to you?

The Constructive Worry Worksheet is taken from Carney & Waters

(2006) and copies for the patient’s use are provided in the workbook.

A sample, completed worksheet is shown in Figure 4.1. The following

instructions also appear in the workbook and should be used as a guide

when completing the worksheet with the patient in session.

52

1. Write down the problems facing you that have the greatest

chances of keeping you awake at bedtime, and list them in the

“Concerns” column.

2. Then, for each problem you list, think of the next step you might

take to help fix it. Write it down in the “Solutions” column. This

need not be the final solution to the problem, since most prob-

lems have to be solved by taking a series of steps anyway, and you

will be doing this problem-solving task again tomorrow night and

the night after until you finally get to the best solution.

■ If you know how to fix the problem completely, then write

that down.

■ If you decide that this is not really a big problem, and you will

just deal with it when the time comes, then write that down.

■ If you decide that you simply do not know what to do about

it, and need to ask someone to help you, write that down.

■ If you decide that it is a problem, but there seems to be no

good solution at all, and that you will just have to live with

it, write that down, with a note to yourself that maybe 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 the patient and ask him

or her to try to fill it out each evening. If the patient has difficulty think-

ing of any worries on a particular night, instruct the patient to write

53

54

CONCERNS SOLUTIONS

1. The air conditioning isn’t working 1. Could ask my wife if she has time toin the car take it in

2. Could call tomorrow for a Saturdayappointment

2. Money! 1. Will make an appointment with ourfinancial planner tomorrow

2 Will agree to that project for extraincome

3. Will cut out my latte over thenext month

4. I will wait until my credit card is due to pay it

down “No Concerns.” Also, be sure to ask the patient if she foresees any

barriers to completing this exercise. Finally, engage in problem solving

with the patient to reduce such barriers to adherence.

Thought Records

Cognitive restructuring is most often associated with the seminal text

Cognitive Therapy of Depression by Aaron Beck and colleagues (Beck,

Rush, Shaw, & Emery, 1979). Beck et al. wrote about fears of becom-

ing ill as a result of insomnia and the discrepancy between objective

and subjective sleep time estimation in people with Major

Depression. These observations are common features of people with

insomnia irrespective of whether they have Major Depressive

Disorder. Beck’s early writings were applied to insomnia by Morin

(1993), who developed a cognitive therapy component for insomnia.

Figure 4.1Example of completed Completed Constructive Worry Worksheet

Morin suggested the use of the Thought Record to restructure some

unhelpful or inflexible thoughts and beliefs about insomnia (Morin,

1993). In line with these works, we have found the following instruc-

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 “go crazy” if their insomnia persists. These worries can be

very frightening, so it is often helpful to take a more critical look at

the types of beliefs that lead to such distress.

The Thought Record is a very simple tool, yet we find that it is a

very powerful instrument. It’s powerful because it curbs the Insomnia

Brain’s tendency to be negative and consider only the worst case

scenarios of sleep loss. Balanced thoughts also challenge those beliefs

that generate anxiety. Lastly, we find that this tool helps people see

that they are not powerless; their efforts toward changing their sleep

habits produce improvements in their sleep and in their daytime

fatigue and mood.

It is important to complete a Thought Record in session so that the

patient understands it well enough to complete it between sessions. A

sample, completed record is shown in Figure 4.2. A sample for the

patient to use as a model, as well as blank copies for the patient to fill

out, is also included in the workbook. You may use the following sug-

gested dialogue to help the patient complete a blank Thought Record

during the session.

Let’s walk through an example of a Thought Record to help with

troubling thoughts or beliefs about sleep. Think of a time, perhaps

even last night when you had strong feelings or upsetting thoughts

related to your insomnia. What were you doing or where were you

when you had these feelings or thoughts? Write them down in the

Situation column. What kind of mood or feelings were you exper-

iencing? Write down feelings in the Mood column. What are you

thinking or what were you thinking when you began to feel this way?

55

Are you concerned about how you will deal with another day with

this insomnia? Are you predicting that you’ll never sleep? Write these

down in the Thoughts column. Even if some of your thoughts seem to

be untrue or silly, it is important to write them down. There are no

wrong thoughts to write down.

The next step is to look at why this thought may seem true. What’s

the evidence for this thought? Write this down in the Evidence for the

Thought column. Most people can remember a time when they had

difficulty dealing with their insomnia. The Insomnia Brain 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 we overlook that

there are small things that don’t support the thought. For example, we

may forget that there have been times when we have felt good after a

poor night’s sleep; or when we felt poorly after a good night’s sleep; or

we jump to conclusions or focus on the worst possible outcome. Write

all this evidence down in the Evidence against the Thought column.

Examining the evidence against the belief forces the Insomnia Brain

to focus on thoughts that are less anxiety-provoking or less frustrating.

The last step in this process is to consider both the evidence for and

against the belief and think of a thought that lies somewhere in the

middle. This thought should consider that there may be some part of

the evidence for the belief that may be true, but it should take into

consideration that there is plenty of evidence against the belief. For

example, a balanced alternative to the thought, “I’m never going to

make it through tomorrow” is: “I sometimes feel groggy at work after

a poor night, but not always, and I always seem to cope pretty well

with it.” Write this new thought down in the Adaptive/Coping

Statement column. Most people tend to feel a little better after com-

pleting this exercise. Try it over the next week or two until our next

visit and we’ll review it then.

56

57

Situation Mood (Intensity 0–100%)

Thoughts Evidence for the thought

Evidence againstthe thought

Adaptive/Coping statement

Do you feel any differently?

Sitting at my desk thinkinghow sluggish I feel

Down (75%)

Frustrated (100%)

Worried(80%)

Tired(100%)

I’m never goingto get through today

I’m going to mess up

I need to get some sleep

I can’t concentrate

I’m going to get sick if I keep goinglike thisI can’t keepgoing on like this

What’s wrongwith me?

Last week I made a mistake on my report

I’ve already stopped exercising

I’m startingto feel less like doing things

I’ve made mistakes at work when I have had a goodnight’s sleep

I’ve had insomniafor over a yearand haven’t been sick

I notice I feel alittle better after lunch

I always seem tohave an okday despitemy insomnia

I don’t feel my best, but the truth is, I alwaysmake it through (70%)

Just because I don’t feel at my best, doesn’t mean that anything bad is going to happen (75%)

I’ve noticed there are things I can do to cope with the fatigue, so it is not hopeless (80%)

Down (30%)

Frustrated (60%)

Worried (10%)

Tired (70%)

Figure 4.2Example of completed Thought Record

In reviewing the Thought Record with the patient, it is important

to indicate that the patient’s thoughts and feelings are valid. It is also

important to acknowledge that you know it may seem difficult to the

patient to change her thoughts given how automatic they are. Ask the

patient to explore whether there may be costs to having such strong

conviction in these thoughts and whether these thoughts may be

adding to the problem (i.e., emotional reasoning). This may be done

by highlighting what Greenberger and Padesky (1995) call the

Thought-Mood connection. For example, if the patient is having

the thought, “I’m never going to get to sleep,” ask them how they feel

when they think they are never going to get to sleep. Hopeful or hope-

less? 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 pat-

terns” 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 pre-

dict they consequently will have a bad day. Similarly, it is normal to

experience an increase in sleepiness and a decline in mental and emo-

tional functioning in the early afternoon. This is a normal phenome-

non called the “post-lunch dip.” It corresponds to a “dip” in one’s

body temperature after lunch. This is often the time when people with

insomnia nap, cancel appointments, or leave work. They believe that

this dip is evidence that they cannot function. Providing education on

this phenomenon and focusing on coping strategies to ride out sleep

inertia or the circadian dip (e.g., exposure to fresh air, activity, coping

58

statements such as “this is just temporary”) will be helpful for

patients.

Emotional Reasoning: Some patients focus on their feelings as facts. For

example, they believe that the presence of anxious feelings is evidence

that they will not sleep. Such a belief will lead to further anxiety when

sleep does not come quickly.

All-or-none thinking: “I didn’t sleep last night.” Explore with your

patient the cost of thinking “I don’t sleep.” Is it increased anxiety? It is

often helpful to train patients to “find the missing sleep” in their sleep

logs and to “catch themselves asleep.” Did they miss parts of the plot of

the television program they were watching? When patients report that

they have been awake “all night long,” ask what they were doing. It is

highly unlikely that they were lying motionless in their bed for 8 hours

without sleeping. Some patients have difficulty with sleep perception

because their brain activity is “noisier” than most people when they

sleep (Krystal et al., 2002). Some people need the reassurance that their

body is “sleeping” from an objective standpoint and is thus restoring

and protecting itself; however, it feels like very poor or “no” sleep

because of the mental activity.

Self-fulfilling prophecy: People with insomnia often predict that their day

will be terrible because they had poor sleep—is it possible that they

approach their day in a way that ensures this will be true? It has been

said, “Whether you think you can or you cannot, you are right either

way.” There is tremendous power in the mind’s ability to create a reality

consistent with its beliefs. As a result, it is important to give the patient

the option of creating a self-efficacious, coping reality instead of a bleak

one.

Catastrophizing: “I’m going to go crazy.” The fear of serious mental

or physical illness as a consequence of the insomnia is a common fear

for insomnia sufferers. It is important to follow their fears to their

most catastrophic conclusion to understand someone’s fear of insom-

nia. This has been described elsewhere (Burns, 1980) as the “down-

ward arrow” method, which is illustrated in the following case

vignette. In this dialogue, T represents the therapist and P represents

the patient.

59

Case Vignette

T: You told me that you start to worry as soon as you notice that you have

been in bed an hour without sleeping. Can you tell me a little about the

thoughts or images you experience when you notice the clock?

P: I think, “Oh God, I have a big day at work tomorrow. If I don’t get to

sleep, I’ll be useless at work.”

T: You’re worried you’ll be useless at work, what would that mean?

P: I could get into trouble.

T: And then what? What would be the worst case scenario?

P: Well, I’d get fired, I guess. Well I probably wouldn’t get fired, but

that’s what I am worried about.

T: Well let’s stay with this fear for a moment. Can you get a picture of

getting fired because of your insomnia?

P: Yes, I’ve pictured it many times. My boss is telling me my work has been

slipping and I look like I’m sleepwalking, so he’s going to let me go.

T: And then what?

P: Well, I could never do well on a job interview feeling the way I do, so

I don’t think I could get another job. Well, maybe I could . . .

T: Let’s stay with this a moment if you can. So you might not be able to

find another job?

P: Well, yeah, and then I can’t pay my bills and then I’m homeless.

T: So you’re homeless and then what?

P: Well, that’s it. I’m homeless. I can’t take care of myself and I’ll be like

that forever I guess.

T: Wow, it sounds like there’s a lot riding on whether you get to sleep

tonight. Maybe by looking at this chain of events operating below the

surface we can understand why you become so anxious when you can’t

sleep. Losing an hour of sleep triggers a chain of thoughts that leads to

you becoming homeless forever. No wonder you are so upset when you

get into bed. Do you think we could take a closer look at this belief ?

60

Exploring this fear and empathizing that it’s no wonder the patient is

worried about sleep when the stakes seem so high (i.e., it feels as though

they may become ill), is a good starting point for modification of this

belief. Many patients are surprised that they have such catastrophic

beliefs lurking beneath the surface.

Mind reading: Some people with insomnia believe that others are “notic-

ing” their poor performance. They may worry about this out of a fear of

negative evaluation from others. This belief is often untrue because most

people with insomnia function quite well. What tends to be different

after a poor night’s sleep is the amount of extra effort required to do reg-

ular tasks (Espie and Lindsay, 1987). Even if the following belief is true,

“People notice that I am incompetent at work because of my insomnia,”

exploring whether it is true 100% of the time and exploring the conse-

quences of holding such a belief can be helpful. For example, if there are

fears of negative evaluation, believing that this is true will result in

increased anxiety in performance situations. We know that anxiety can

interfere with performance; thus, fears of poor performance will result in

poorer performance. It is helpful to explore whether this formulation may

apply to the patient and whether it would be useful to modify this belief.

Overgeneralization: Overfocusing on a single instance (i.e., I had trou-

ble completing my crossword puzzle this morning . . .) as proof that

their beliefs are true (“ . . . so, I am mentally useless at work today.”)

Encourage patients to see the range of evidence because people with

insomnia tend to cope extraordinarily well 90% of the time.

Discounting the positive/Focusing exclusively on the negatives: There are

often hundreds of instances of coping and good functioning within the

day that are discounted in lieu of one instance wherein functioning

was lower (e.g., the patient forgets about one appointment). There are

likely times when the patient may have had a poor night and still 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

61

explore, not whether or not they are “true.” In other words, it is impor-

tant 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 forc-

ing themselves to consider alternative thoughts in addition to their neg-

ative thoughts. If it becomes a habit, they will have a choice. If their

current pattern continues, it allows the Insomnia Brain to focus only on

confirmatory evidence (i.e., that they can’t cope, things are hopeless,

etc.). Forcing the Insomnia Brain to consider other evidence will be

uncomfortable at first, but soon it will become a habit and these

thoughts will lose their negative potency.

In working through the Thought Record in session, you may note some

patients have difficulties completing one or more of the columns. Some

people mistake moods and thoughts, some people think that they have

no thoughts (i.e., their mind is blank), some have trouble generating

evidence, and others have difficulty integrating the evidence into a bal-

anced thought. Greenberger and Padesky (1995) have many suggestions

for helping patients who have these difficulties. The Situation column

can be completed by asking the patient: “Who was with you when you

started feeling bad? What were you doing? Where were you? When did it

happen?” For example, a patient may tell you about a situation in which

she started worrying about her ability to sleep that night. When probed

with these questions, the patient can usually fill in the blanks, and tell

you she was in the living room with her spouse watching television after

dinner. Moods are best described using one word. When patients need

multiple words to describe a mood, they are most likely describing a

thought instead.

The Thoughts column can be challenging for some patients. You want

to elicit what was going through the patient’s mind during the upset-

ting 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 morn-

ing. What is the worst possible thing about waking up in the morning?

62

What is the worst case scenario?” Also, ask the patient if this situation

reminds her of other similar situations. This usually results in generat-

ing some thoughts or images. If the patient had difficulty naming a

mood and was instead listing “thoughts,” be sure to make note of these

thoughts so you can present them for inclusion in the Thoughts column

later. You can give patients the following hint to help identify thoughts

in the future: “The next time you are experiencing a strong emotion, ask

yourself to notice what is going through your mind.”

Most automatic thoughts in insomnia patients relate to a fear that some-

thing is very wrong with them and that they are helpless to change it.

Eliciting catastrophic statements from the patient’s thoughts is helpful to

get at the core beliefs. For example, a patient is afraid of setting the alarm

and reports the thought, “If I set the alarm then I know I will only have

7 hours to sleep, and every hour that goes by I’ll be thinking that I have

to get up.” Ask the patient why having only 6 hours, or 5 hours, of sleep

is distressing, and what is the worst case scenario imagined for that situ-

ation. Then, take the worst case scenario (e.g., getting fired from a job

because sleep loss is causing unacceptably poor work performance) and

reflect it back to the patient such as: “Gosh, if you think you are going to

get fired because of your insomnia, it sounds as though there really is so much

riding on you getting to sleep each night.” This will either elicit more cata-

strophic statements or the patient may engage in reporting evidence

against the thought because the catastrophic nature of the thought is dis-

concerting. When generating automatic thoughts, it is usually important

to generate several thoughts and not stop at one. One technique for facil-

itating the recording of multiple thoughts is to lead the patient to the

next thought by repeating how she was thinking and feeling and ask

what happened next: “So you were feeling anxious and thinking, ‘I’m going

to have to call in sick.’ And then what?”

Most patients do not have difficulty generating evidence for the thought

in the Evidence for the Thought column, because the thoughts are seen

as very compelling. One common problem is the tendency to rush

through the evidence and say, “Yeah, but I know that’s not really true.”

It’s important to spend some time on the evidence for the belief and

reflect that the patient isn’t “crazy” so there must be a good reason to

have this belief. Exploring the kernel of truth in the evidence for the

belief is really important.

63

Generating items for the Evidence against the Thought column can be

challenging for some patients. Keep track in earlier sessions of any

evidence the patient cited that is contrary to the belief. For example, the

patient may talk about a horrible day in which nothing catastrophic

happened. Or the most feared situation (e.g., “going crazy”) has not

occurred despite the fact that the patient had suffered from years of

insomnia. Focusing on evidence of the patient’s effective coping can also

help here. The following questions may also help:

■ “If someone you cared about thought their insomnia problem was

hopeless, would you tell them, ‘Yeah, you’re right, it is hopeless.’ Why

not? Why wouldn’t this be helpful ?”

■ “Are you discounting your strong coping skills? I’m impressed by the

tremendous coping resources you seem to have.”

■ “Has there been a time in the past when you had very little sleep and

functioned well ?”

■ “Have there been times in the past when you had lots of sleep and felt

poorly during the day?”

■ “Have there been situations when this thought is not true 100% of

the time? For example, you say you get headaches when you have

insomnia; do you have headaches every single day?”

The “cognitive errors” discussed earlier may also help patients with this

column.

Generating an Adaptive/Coping Statement can be difficult for patients.

Some patients will focus on the evidence for the belief and have difficulty

incorporating the evidence against the belief. Others will want to focus

exclusively on the evidence against the thought, which is equally prob-

lematic. One of the easiest formulas to derive a coping statement is to

start with a statement from the evidence for the belief column, and fol-

low it with a “BUT,” and then a statement from the evidence against the

belief column. For example, “I sometimes forget things at work, BUT,

sometimes I forget things even if I had a decent night’s sleep.” Encourage

the patient to modify this statement until it seems believable and it is

something that can be remembered. Positively reinforce even tiny

improvements in mood, as this is evidence that there has been some

64

input into the Insomnia Brain. For example, “Okay, so you are 5% less

anxious? That’s still an improvement from 5 minutes ago. Small victories are

important in this process, so good for you.” Patients will generally report

that their mood is less negative following the exercise. If there has not

been a mood improvement, see Chapter 5 for some troubleshooting tips.

After jointly completing a Thought Record, ask if the patient has any

questions and instruct her to complete a Thought Record whenever a

negative sleep-related shift in thoughts or mood occurs. If patients

initially have difficulty noticing this shift, get them to practice by 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 sit-

uations 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 like-

ly 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 these really bad

headaches.

T: And the headaches are evidence that you may be getting sick?

P: Yeah. My doctor ran some tests and said it was stress but I’m sure

there is something else wrong.

T: That must be scary to think that you have an undetected illness. I’m

relieved that the tests haven’t revealed a serious illness. Wouldn’t it be

good news if it were stress related?

P: I guess. I don’t see how it could be stress.

T: How much do you know about the kind of body changes stress

produces?

P: Not much. I guess it makes you tense. Are the headaches because

of the tension?

T: I’m not sure. Do you think they could be?

P: I don’t know. I can’t believe it’s stress.

T: Isn’t having insomnia stressful?

P: It definitely is.

T: Maybe we could spend a few minutes talking about stress symptoms

and how to manage them?

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One final issue that may surface in therapy is when thoughts are related

to believing that CBT will not work. It is important to explore resistance

to therapy in a nonjudgmental, curious way. Many patients have tried

several treatments and are understandably frustrated and scared that they

are losing control over their ability to sleep. Highlighting the 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 Fatigue Syndrome.

T: It must be frustrating to have tried so many treatments in the past and

nothing works. To try so many medications in the past makes me

think that you would really like to improve your sleep. Would you

like to try a new approach over the next couple of weeks? Would it

hurt to try something that may help you sleep better?

P: Well yeah, it may hurt. If something else doesn’t work, things will

seem hopeless.

T: Sounds like you’ve been feeling hopeless about your sleep. Is this

something worth talking about?

This brief interchange highlights how a patient’s initial resistance to

CBT might be addressed.

Homework

✎ Instruct the patient to continue recording her sleep habits using the

sleep logs provided in the workbook

67

✎ Ask the patient to fill out the Constructive Worry Worksheet in the

early evenings and bring completed forms to the follow-up session,

if applicable

✎ Ask patients to also complete Thought Records whenever they notice a

sleep-related bothersome thought or feeling (e.g., usually at least one

daily), and to bring these records to the follow-up session, if applicable

68

69

Chapter 5 Follow-Up Sessions

Once patients are provided the behavioral and cognitive strategies

discussed in the previous two chapters, they usually benefit from one or

more follow-up sessions to (1) assist them in making needed adjust-

ments in their TIB prescriptions, (2) encourage and reinforce their

adherence to treatment recommendations, and (3) “troubleshoot” the

problems they may be having with the behavioral or cognitive tech-

niques they have been taught.

There are no new materials needed during these follow-up sessions. The

therapist should be guided by the patient’s self-report of progress as well

as by a review of completed sleep logs, Constructive Worry Worksheets,

and Thought Records. You should review all of these “homework”

materials that the patient brings to the session and provide guidance as

needed using the information that follows.

Adjusting Time in Bed Recommendations

The method for making adjustments in TIB prescriptions was discussed

in Chapter 3. Review the patient’s completed sleep logs each week and

determine his average sleep efficiency during the week prior to the current

session. Sleep efficiency is calculated by dividing the patient’s average total

sleep time (ATST) over the time period since the previous session by the

average time spent in bed (ATIB) and then multiplying the result by

100% (Sleep Efficiency � (ATST/ATIB) � 100%). If the patient’s sleep

efficiency is � 85% and the patient has noted daytime sleepiness with the

current TIB prescription, suggest a 15-minute increase in TIB. Suggest a

15-minute decrease in TIB if the patient’s sleep efficiency is � 80%. If the

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patient is sleeping soundly most nights and feeling alert in the daytime,

then no TIB adjustment is needed.

At times patients will develop problems with excessive sleepiness as a

result of restricting their TIB to the initially prescribed amount. This

problem may occur in some insomnia patients who markedly 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 pri-

mary sleep maintenance insomnia. Initial evaluation showed that she

manifested many sleep-disruptive habits such as frequent napping while

watching the evening news and remaining in bed as much as 10 hours on

some of her more difficult nights. Given these findings, CBT was initiated.

Pretreatment sleep logs had shown Ms. T.’s average sleep time at night to

be approximately 6.5 hours, so she was initially restricted to 7 hours in bed

each night at the start of treatment. Five days after her first appointment

she phoned the therapist with concerns about markedly increased daytime

sleepiness. In fact, she noted that she had fallen asleep in her car after

having stopped for a traffic light. Because of this, she had become con-

cerned about driving her car and wondered what she should do.

Questioning of the patient indicated that she had adhered to the TIB

restriction very strictly and she was sleeping very soundly on most nights.

However, she continued to feel sleepy in the daytime and had to constantly

fight off naps. Hence, the therapist suggested she increase her time in bed

by 30 minutes per night to try to reduce this sleepiness. He also suggested

that she ask her husband to take over all driving responsibilities until she

returned to the clinic for follow-up 1 week later. Upon her presentation for

her ensuing appointment, she reported reduced daytime sleepiness with the

increased time in bed. Her sleep logs showed she was sleeping fairly well at

night with very few extended awakenings. As she continued to report some

mild sleepiness, the therapist suggested she add another 15 minutes to her

TIB each night. After trying this new TIB prescription, she reported an

elimination of her daytime sleepiness and a continuation of improved

sleep at night. ■

Case Example #2

■ Ms. C. was a 66-year-old retired female who presented with severe

sleep-maintenance insomnia that developed after her retirement.

Following an assessment that suggested a diagnosis of primary insomnia,

she was begun on a course of CBT. After 2 weeks of following this regimen

she returned to the clinic anxiously explaining that her sleep had gotten

worse. Furthermore, she reported that the strict behavioral regimen made

her very anxious and she felt under too much pressure to sleep. To address

this problem, a more lenient TIB prescription was established and the

patient was allowed to take a brief (30 min) daytime nap each day if she

felt the need to do so. With these changes, the patient was able to relax

and gradually showed nocturnal sleep improvements over the ensuing

month of treatment. ■

Reviewing and Reinforcing Treatment Adherence

In addition to assisting patients with setting their sleep and wake

times, use the follow-up sessions to reinforce the patient’s adherence

to the prescribed CBT regimen and completion of the Constructive

Worry Worksheet and Thought Records. Assess patient adherence by

reviewing the sleep rules and recommendations integral to this pro-

gram (see Chapter 3 for list of sleep rules) and asking the patient

about his adherence to each one. You should freely compliment the

patient who closely follows all treatment recommendations and com-

pletes the cognitive homework exercises. In doing so, however, it is

particularly useful to point out the relationship between the patient’s

treatment adherence and improvement noted by his sleep logs or

other outcome measure being used (see Chapter 2 for a list of meas-

ures and self-reports). For example, you may make comments such

as, “You have done an excellent job following through on the strategies

we discussed last time. As you can see, your efforts have paid off. Your logs

show that you are now sleeping much better. Keep up the good work!” In

providing such comments it is important to remain genuine and

avoid patronizing the patient. Thus, language that feels comfortable

and consistent with the therapist’s usual interactional style should be

used in reinforcing adherence.

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72

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 misunder-

standing 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 sug-

gested that he suffered from primary insomnia and warranted a trial of

behavioral therapy. He was provided our CBT treatment as described in

this manual. After 1 week of treatment, he reported back to our center

noting little improvement. From a review of his sleep logs and a discussion

with him, it was discovered that he failed to adhere to a standard wake-up

time as instructed. In fact, on three of the nights during the first week of

treatment, he stayed in bed over 2 hours beyond his prescribed wake-up

time reportedly to compensate for periods of wakefulness during the night.

Also, he admitted to failing to get out of bed during extended periods of

wakefulness because he thought that if he would lie in bed long enough

he would eventually go to sleep. Although he adamantly denied daytime

napping, he did admit to some unintentional dozing around 7:00 PM

each evening while he was reclining on the couch watching TV.

To correct the patient’s sleep problem, the therapist first explained the

deleterious effect the noted nonadherence would continue to have on

Mr. X.’s sleep. Subsequently, the patient and therapist jointly decided that

the patient would place his alarm clock in a location far from his bed so

that he could not reach it without getting up. This measure was used to

force the patient to get out of bed at the selected wake-up time. In addition,

the therapist helped the patient decide what activities he might do instead

of lying in bed when he experienced extended nocturnal awakenings.

Specifically, the patient was instructed to consider watching TV, reading

magazine articles, or listening to music. Finally, the patient was encour-

aged to refrain from reclining while watching TV in the evening and to

have his wife help him remain awake during the early evening hours. At a

follow-up session 1 week later, the patient showed markedly improved

adherence and a reduction in his sleep maintenance difficulty. ■

Case Example #4

■ Mr. M. was a 52-year-old college professor who presented with sleep

onset and maintenance difficulties. After a thorough assessment it was

determined that he suffered from primary insomnia and would benefit

from CBT. After 2 weeks of this treatment, Mr. M. returned to the sleep

clinic noting marked improvement in his sleep-onset problem but contin-

ued 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 recommen-

dation 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 evalua-

tion suggested a history of sleep difficulties that reportedly were sometimes

caused by conflicts with coworkers and supervisors. Nonetheless, the

patient appeared to often allot 9 or more hours for sleep at night and he

reported he preferred to keep his bedroom TV playing so he would have

73

something to distract him if he did awaken during the night. When the

CBT regimen was introduced, he appeared somewhat skeptical, particu-

larly when it was suggested that he stop watching TV in his bedroom and

that he reduce his time in bed. Although the patient stated he would try

the regimen, he showed evidence of only marginal adherence when he

returned for his subsequent treatment session. Specifically, he continued his

former practice of keeping the TV on all night and he often stayed in bed

at least 1 hour more than recommended. Although Mr. R. continued to

voice skepticism, he eventually did agree to conduct a series of “clinical

experiments” on himself to see the effects of each of the disputed CBT

suggestions. Hence, during the subsequent 2 weeks he agreed to remove

himself from his bedroom when he couldn’t sleep instead of watching TV

in bed. When, on a subsequent visit, he reported being surprised that this

strategy did lead to gradual sleep improvement, he agreed to reduce his

time in bed to an amount that closely approximated the therapist’s sugges-

tions. Upon his subsequent return, he again agreed the clinical experiment

had benefited him. Although the patient noted that he would not agree to

avoid sleeping in on weekend mornings, he did agree to stay in bed no

longer than 1 hour beyond his weekday rising time. Since the patient had

made reasonable progress and seemed very resistant to further changes, the

therapist chose to commend him on his accomplishments and refrained

from attempts at additional interventions that very likely would have

been met with excessive resistance. ■

Case Example #6

■ Ms. Q. was a 45-year-old employed woman with difficulty initiating

sleep and subsequent daytime fatigue. She readily accepted the sleep hygiene

recommendation to exercise regularly as she indicated she believed that

exercise would help her sleep more soundly at night and give her more pep

in the daytime. However, 4 weeks into treatment, she had failed to estab-

lish any regular exercise program. She complained that she had difficulty

finding time for exercise due to her ongoing work and family responsibili-

ties. The therapist suggested that she try to integrate some exercise by using

stairs instead of the elevator whenever possible at her work site and taking

a brisk 20-minute walk around the parking deck at work during her lunch

break at least three times per week. Ms. Q. found these suggestions helpful

and subsequently was able to initiate this plan over the subsequent several

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 the habit of having 1–2 shots of

bourbon in the evening shortly before bedtime. Typically the patient had

little difficulty falling asleep but he often awakened and could not return

to sleep easily. Whereas the patient’s enactment of most treatment recom-

mendations was very acceptable, his sleep logs showed he continued to con-

sume 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 proce-

dure 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 activ-

ity. 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 exer-

cise and to reduce the likelihood of becoming too aroused to successfully

complete it on their own.

Cognitive Restructuring : There are a number of potential problems that

can occur with patients completing a Thought Record. Such barriers

75

include difficulty remembering to complete one, difficulty with complet-

ing 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 mak-

ing 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 non-

judgmental 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’ cog-

nitive errors discussed in the previous chapter.

All of the previously mentioned troubleshooting advice should address

the common problem that the patient’s mood does not improve after

completing the Thought Record. When there is no mood improvement,

76

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 ade-

quate 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 neces-

sary to rewrite them in a way that is more believable.

Case Example #8

■ Ms. S. was a 33-year-old female who presented with sleep onset insomnia.

She reported prominent worries about sleep and nightly dependence on sleep

medications. She had a history of problems with anxiety. An examination

of her sleep logs revealed excessive time-in-bed and variable bedtimes and

rise times. CBT recommendations included psychoeducation about sleep

need, instructions to reduce her time in bed to match her sleep production

(e.g., 7 hours), establishing a regular bedtime and rise time, and to get out

of bed when unable to sleep (i.e., stimulus control). Ms. S. returned to the

clinic 2 weeks later and reported almost no adherence to the sleep schedule or

stimulus control instructions. She explained that she could not adhere to the

treatment because she needed 8 hours to function. The next two sessions were

devoted to restructuring the belief that she could not function without 8 hours

of sleep. Her Thought Records revealed a core belief of helplessness. She

believed that she had limited coping abilities and that she was “always one

crisis away from becoming permanently disabled.” She had images of herself

in a wheelchair in a “mental institution.” These beliefs were formed many

years prior when she suffered from debilitating panic attacks. Focusing on the

positive instances of coping, which included her gaining mastery over her

panic attacks, allowed her to modify her helplessness beliefs. This cognitive

shift resulted in almost total adherence to the behavioral recommendations

77

and a mean posttreatment sleep onset latency in the normal range (posttreat-

ment 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 discrepan-

cy, 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 con-

trary). The cost to believing “I don’t sleep” is increased anxiety, and anxi-

ety increases the likelihood of sleep disruption. Following is an example of

some “detective work” in investigating the report of “no sleep.”

78

Case Vignette

T: I see on your Thought Record that your thoughts have included “I

can’t believe I went another night without sleeping.” “I haven’t slept in

over 2 weeks.” and “Can you die from not sleeping?” I also notice that

you have rated frustration and anxiety at 100%.

P: You’d be anxious and frustrated if you didn’t sleep either.

T: I would like us to examine whether there may be a connection

between some of these thoughts and your mood. Is there any possible

connection between the thought, “I haven’t slept in over 2 weeks” and

anxiety or frustration?

P: Of course. It’s scary to not sleep.

T: I can see how thinking you haven’t slept in 2 weeks would be scary.

I wanted to make sure that I understand this; you have not slept even

1 minute in 2 weeks?

P: Well, very little anyway.

T: Oh okay, there has been some sleep, but very little?

P: Almost none.

T: I can see how it would be upsetting to have very little sleep, but I

could see how it would be even more upsetting if there was absolutely

zero sleep. In fact, I have never had a case with no sleep for 2 weeks

so I am relieved to hear there has been at least a little bit of sleep. Can

you estimate how much sleep is a “little bit of sleep” over the last

2 weeks?

P: I don’t know, maybe a few minutes.

T: Okay, a few minutes. I remember you told me that you were irritated

when your husband woke you to tell you that you were snoring. Was this

the few minutes we are talking about?

P: I guess. I was so irritated because I felt as though I was just about to

fall asleep and then he nudged me. It didn’t seem like I was sleeping

but I guess I must have been. You can’t snore when you’re awake,

right? Also, I looked in the mirror yesterday and saw the imprint of

79

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 day-

time naps over the last week. It is important for us to “find forgotten

sleep,” especially since you have said that thinking you don’t sleep at

all increases your anxiety. When you are more anxious, are you more

likely to have worse sleep?

P: Well, yes.

T: Then it would be important for us to make sure you are not telling

yourself something that makes you more anxious, right?

P: I guess. Although I don’t think I am sleeping that much, I don’t usually

remember seeing the clock or getting up between 2–6 AM, so it’s possi-

ble that I am sleeping a little during that time.

T: So we have a few minutes during the day, a few minutes in the first

half of the night, and about a 4-hour window in the second half of

the night when there is an undetermined amount of sleep. It looks

like your body is really working to give you bits of sleep here and

there, even if you are not always aware of it, and even if it doesn’t

always feel like it. Does this help at all with the thought that you

might die from not sleeping?

P: Well, I’m probably not going to die. It was just scary to think I wasn’t

sleeping at all. I guess I’m sleeping a little.

T: Do you think that being less anxious about this may allow you to get

even more sleep?

P: I hope so!

Summary

Although we have no hard and fast rule about the number of follow-up

sessions to provide patients, most of our primary insomnia patients

respond to treatment in 3–4 sessions total. Of course, there are those who

80

respond more gradually but do achieve a satisfactory outcome. In the end,

therapy should be guided by the patient’s sleep performance reflected by

sleep log data and by the patient’s subjective appraisal. Optimal sleep

performance is characterized by sleeping soundly at night and having no

daytime symptoms (e.g., fatigue, impaired concentration, distress about

sleep) of insomnia. In this case, sleep logs would show the patient has a

regular sleep-wake schedule and typically has little difficulty falling asleep

or staying asleep through the night. Along with this observation, the

logs and the patient’s self-report should indicate that the final morning

awakening typically occurs slightly before the alarm clock sounds. If

the patient sleeps soundly but most often is awakened by the alarm, it is

likely that the patient could and would sleep a little longer each night had

the alarm not be set. In such cases, it is usually useful to expand the TIB

window somewhat until the sleep pattern described emerges. However,

once the patient achieves a sound sleep pattern at night and is satisfied

with his daytime function, therapy termination may be considered.

When therapy termination is discussed with patients, it is important to

review all of the new sleep and insomnia management skills they have

learned during the treatment. In this regard, it is important to empha-

size that they now have the “tools” they need to manage their sleep prob-

lems 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 pos-

sible 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: ChallengingPatients and Treatment Settings

Overview of the Treatment Challenges

Thus far, the discussion in this manual has summarized strategies to

employ during individual therapy sessions with unmedicated primary

insomnia patients. Of course, many patients who present for treatment

do so in the context of ongoing use of sleep medications. Many other

treatment-seeking patients have concurrent comorbid medical or psy-

chiatric 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,

84

are prescribed alone or in addition to the approved medications to treat

sleep difficulties. In addition, a variety of other medications including

antidepressants such as the sedating tricyclics (e.g., doxepine) and tra-

zodone, and the atypical antipsychotic, quetiapine, are often used to

manage patients’ sleep complaints. These latter medications lack FDA

approval and are used “off-label” for treating insomnia. Finally, various

over-the-counter medications are available and are used frequently by

insomnia patients in their efforts at self-management.

Over the years, concerns have been raised about protracted use of medica-

tions to address chronic primary insomnia. Although there is considerable

“clinical lore” supporting the prescription medications used “off-label” for

sleep, currently there are few data to support their safety and efficacy for

long-term treatment of primary insomnia. Likewise, there are extremely

limited data concerning the safety and efficacy of those sleep medications

available without prescription. With some of the first generation FDA-

approved BZRA hypnotics, medication tolerance develops with continued

use such that patients experience reduced efficacy while being maintained

on stable therapeutic doses for extended periods of time. Abrupt with-

drawal of such medications often results in a transient, albeit distressing,

worsening of sleep that convinces many patients to quickly resume their

medication use. In contrast, some of the longer acting BZRAs may result

in unwanted next-day effects such as sluggishness or “hangover.”

Fortunately the newer generation BZRAs (e.g., zolpidem, eszopiclone,

zaleplon) have far less pronounced unwanted properties such as these,

and some such agents have proven safe and effective over extended peri-

ods 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

that context, she experienced the onset of her sleep difficulties. Shortly after

her sleep problem began, she obtained a prescription for lorazepam to treat

her sleep difficulty, and she had taken that medication almost nightly since

that time. She also subsequently received an additional prescription for

zolpidem, 10 mg, to help her sleep. Hence, when she presented for treatment,

she was taking 10 mg of zolpidem along with .5 to 1 mg of lorazepam on a

nightly basis as sleep aids. Her stated goal for treatment was to learn how to

sleep without sleep medications. However, she noted that she became very

anxious and unable to sleep without lorazepam and she admitted she

thought she would be unable to initiate and maintain sleep unless she took

both of her sleep medications. In support of this, she noted that her efforts to

stop these medications had been met with her experiencing elevated anxiety

about sleep and pronounced wakefulness during the subsequent night. With

her medications, she indicated that she was able to function in the daytime

without severe daytime sleepiness (Epworth Sleepiness Scale � 9). However,

she did indicate that her sleep still was not ideal and she experienced a

significant level of fatigue many days each week despite her nightly use of

medicinal sleep aids. Her sleep log shows her sleep pattern at the time of her

initial clinic visit (see Figure 6.1). Despite her nightly medication use, she

still showed difficulty initiating sleep on two nights and relatively poor qual-

ity 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 present-

ed 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 man-

agement 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 depend-

ence 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 abil-

ity to obtain adequate sleep. In a sense, they have lost faith in

themselves as sleepers. As a consequence, they come to rely on sleep

medication(s) to obtain the sleep they need.

85

86

Day of the Week Thurs Fri Sat Sun Mon Tues Wed

Calendar Date 10/19 10/20 10/21 10/22 10/23 10/24 10/25

1. Yesterday I napped from _____ to _____ (note time of all naps). None None None None None None None

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

1 mgLorazepam10 mgZolpidem

1 mgLorazepam10 mgZolpidem

1 mgLorazepam10 mgZolpidem

1 mgLorazepam10 mgZolpidem

1 mgLorazepam10 mgZolpidem

1 mgLorazepam10 mgZolpidem

1 mgLorazepam10 mgZolpidem

3. Last night I got in my bed at ______ (AM or PM?). 11:30 AM 12:00 AM 1:00 AM 2:30 AM 12:30 AM 1:30 AM 12:30 AM

4. Last night I turned off the lights and attempted to fall asleep at ______(AM or PM?).

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

5. After turning off the lights it took me about _____ minutes to fall asleep. 105 5 5 1 90 5 30

6. I woke from sleep ______ times. (Do not count your finalawakening here.)

2 3 1 Don’tremember

2 3 3

7. My awakenings lasted _______ minutes. (List each a wakeningseparately.)

5

5

555

5 ?5

5

555

555

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

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

9. Today I got out of bed for the day at ____ (AM or PM?). 9:30 AM 8:00 AM 8:45 AM 10:45 AM 10:10 AM 8:15 AM 7:45 AM

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

1 2 3 4 5 6 7 8 9 10

6 4 8 8 6 4 6

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

1 2 3 4 5 6 7 8 9 10

1 1 6 10 6 6 4

Figure 6.1Sleep Log: Sleep Medication User

Insomnia patients who use hypnotics chronically present with many of

the cognitive and behavioral treatment “targets” discussed in previous

chapters. Specifically, they have catastrophic beliefs about the daytime

effects of their sleep difficulties as well as a misunderstanding of how

their sleep habits may contribute to their insomnia. Accordingly they

demonstrate many of the common sleep disruptive compensatory prac-

tices (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 behav-

ioral targets that merit the therapist’s attention.

Since many chronic hypnotic users present with the desire to discontin-

ue their sleep medications, it is important to implement a treatment

plan that enables them to do so yet maintain or reestablish a satisfacto-

ry 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 medica-

tion, 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 “home-

work” to address such beliefs. It is also important to have patients

adhere strictly to the behavior strategies discussed in Chapter 3 to pro-

duce a consolidated and consistent sleep pattern while they are still tak-

ing their medications. Encouraging implementation and adherence to

these strategies often results in improved sleep patterns and enhances

chances for success in the subsequent medication taper process.

Once the patient successfully implements the CBT strategies discussed in

the previous chapters and shows a stable sleep pattern for at least 2 consec-

utive weeks, a medication-tapering strategy can be introduced. From a

safety viewpoint, most prescription and over-the-counter medications

taken for sleep can be discontinued fairly rapidly without untoward med-

ical concerns. However, patients who are dependent on sleep medications

usually are more successful discontinuing such medications if allowed to

taper them more slowly and deliberately. In this regard, strategies discussed

elsewhere (Belleville et al., 2007, Soeffing et al., 2007) have proven

efficacious for such patients. These approaches allow a slow, graded, “step-

down” approach to tapering that offers the patient a gentle pace at fading

the medication while allowing some sense of gradually increasing self-

efficacy in regard to the discontinuation process. For example, the

approach described recently by Morin et al. involves the following

sequence of steps: (1) setting a goal for medication use/reduction each

week; (2) when more than one medication is being used, reduction to a

single medication at a stable dose is set as the first goal; (3) the initial dosage

of the medication is reduced by 25% every 2 weeks until the lowest avail-

able (therapeutic) dosage is reached; (4) drug-free nights are gradually

introduced with drug-free nights being planned in advance; and (5) the

number of drug-free nights per week is gradually increased until the

patient is medication free. While instituting this sort of withdrawal plan it

is important to have the patient continue monitoring her sleep with the

sleep log and to continue with the cognitive tools (Thought Records,

Constructive Worry Worksheets) as needed. It is also important to moni-

tor CBT adherence using the techniques outlined in Chapter 5.

88

Whereas this combined approach tends to produce the best results,

patients may vary in the success they achieve. Some show a good

response and become able to sleep medication free. Others experience

setbacks along the way due to unexpected stressors or other factors.

Some patients may view such setbacks as indications of treatment fail-

ure, 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 pri-

mary insomnia, a far greater proportion of all treatment-seeking insom-

nia patients present with complex comorbid conditions. A variety of

medical conditions, and particularly those that result in chronic pain,

breathing difficulties, or immobility, can give rise to insomnia prob-

lems. Likewise, a large proportion of psychiatric conditions have insom-

nia as a primary presenting symptom. Furthermore, many medications

prescribed for the treatment of medical and psychiatric conditions may

have insomnia as a common side effect. Finally, excessive use of alcohol,

caffeine, and various illicit substances may cause or add to insomnia

problems. In a sizable proportion of patients, a mixture of medical,

psychiatric, and substance-related causes of insomnia coexist and com-

plicate insomnia management.

In cases of comorbid insomnia, it is always helpful to optimize manage-

ment 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, fre-

quently 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 cogni-

tive and behavioral factors may perpetuate insomnia over time. Even

among individuals whose sleep disturbance initially emerged as a symp-

tom 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 perpet-

uating insomnia in comorbid patients, CBT strategies may be useful as

primary or adjunctive insomnia treatment for these individuals.

To date, a relatively limited number of randomized clinical trials have

investigated the efficacy of CBT for treating insomnia patients with var-

ious types of comorbid conditions. The more convincing studies have

focused on medical disorders and have suggested that CBT is efficacious

for treating insomnia in patients with chronic pain (Currie et al., 2000),

fibromyalgia (Edinger et al., 2005), mixed older medical patients

(Rybarczyk et al., 2002) and cancer survivors (Savard et al., 2005). Well-

conducted randomized trials of CBT for insomnia treatment in psychi-

atric samples have generally been lacking. However, a few clinical case

series studies (Morawetz, 2003; Kuo, et al., 2001) have suggested that

CBT does seem effective for treatment of insomnia in patients with

comorbid depression. Whereas these findings are encouraging, addi-

tional randomized trials are needed to confirm the usefulness of CBT

with psychiatric patients.

Nonetheless, it is useful to consider CBT insomnia treatment for those

psychiatric patients who present obvious cognitive and behavioral treat-

ment targets discussed in the previous chapters. The following case

example shows the potential usefulness of CBT strategies with a psychi-

atric patient. The patient described here suffered chronic insomnia

comorbid to a serious anxiety disorder.

90

Case Example: Insomnia and Comorbid Anxiety Disorder

■ The patient was a 56-year-old married man who participated in a

CBT insomnia treatment study at a VA hospital. The patient has been

seen for treatment at the hospital for a number of years in relation to the

combat-related posttraumatic stress disorder he developed as a result of his

service experience during the Vietnam War. At the time the patient pre-

sented 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 pharma-

cotherapy (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 disor-

ders. However, the recording showed very poor sleep with a sleep onset

latency of 63 minutes, 90 minutes of wakefulness during the middle of the

night, and a total sleep time of only 4 hours. A sleep log maintained by

the patient for several weeks prior to treatment corroborated the findings

from his sleep recording. Specifically this sleep log showed an average

sleep onset latency of 82 minutes, an average wake time during the night

of 165 minutes, and an average sleep time of only 4 hours and 25 minutes

per night. The patient’s sleep log for the first week of this monitoring

period, which captures this general pattern of sleep difficulty, is shown in

Figure 6.2. This log shows the patient’s variable sleep schedule as well as

his penchant to allot excessive times each night for sleep.

To treat this condition the patient received four biweekly 30- to 60-minute

sessions that included the psychoeducational information and sleep

improvement recommendations presented in Chapter 3. During this time

period, no changes were made in his pharmacological treatment for his

PTSD condition. Over the course of the CBT treatment, the patient’s sleep

improved markedly. Sleep logs maintained by the patient immediately fol-

lowing treatment showed an average sleep onset latency of 15 minutes per

night, an average wake time during the night of slightly less than 31 min-

utes, and an average total sleep time of 5 hours and 45 minutes. Figure 6.3

91

92 Day of the Week Sat Sun Mon Tue Wed Thurs Fri

Calendar Date 9/21 9/22 9/23 9/24 9/25 9/26 9/27

1. Yesterday I napped from _______ to _______ (note time of all naps). None None None None None None

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

None None None None None None None

3. Last night I got in my bed at _______ (AM or PM?). 10.30 PM 11:30 PM 8:20 PM 9:35 PM 8:20 PM 10:40 PM 10:35 PM

4. Last night I turned off the lights and attempted to fall asleep at _______(AM or PM?).

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

5. After turning off the lights it took me about _______ minutes to fall asleep. 90 35 60 90 70 45 60

6. I woke from sleep _______ times. (Do not count your finalawakening here.)

2 1 3 2 1 2 1

7. My awakenings lasted _______ minutes. (List each awakeningseparately.) 25

20 40

202025

2540 45

1520 60

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

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

9. Today I got out of bed for the day at _______ (AM or PM?). 8:15 AM 8:30 AM 7:10 AM 6:45 AM 7:25 AM 7:05 AM 8:15 AM

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

1 2 3 4 5 6 7 8 9 10

7 5 7 7 5 7 7

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

1 2 3 4 5 6 7 8 9 10

6 7 7 6 7 7 6

Figure 6.2Sleep Log: Baseline

93

Day of the Week Tue Wed Thurs Fri Sat Sun Mon

Calendar Date 12/17 12/18 12/19 12/20 12/21 12/22 12/23

1. Yesterday I napped from _______ to _______ (note time of all naps). None None None None None None None

2. Last night I took _______ mg of _______ or _______ of alcohol as a 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?). 11:45 PM 11:35 PM 12:00 AM 12:10 AM 11:40 PM 11:30 PM 11:40 PM

4. Last night I turned off the lights and attempted to fall asleep at_______ (AM or PM?).

11:45 PM 11:35 PM 12:00 AM 12:10 AM 11:40 PM 11:30 PM 11:40 PM

5. After turning off the lights it took me about _______ minutes to fallasleep.

15 15 15 15 20 15 15

6. I woke from sleep _______ times. (Do not count your final awakening here.)

1 1 1 1 1 1 1

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

15 15 30 25 25 25 35

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

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

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

1 2 3 4 5 6 7 8 9 10

9 8 8 9 8 8 8

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

1 2 3 4 5 6 7 8 9 10

9 8 8 9 8 8 8

Figure 6.3Sleep Log: Post-CBT

shows the first week of these sleep log data collected by the patient follow-

ing treatment. This log shows the marked improvements in the patient’s

sleep pattern as well as greater stability in his chosen sleep schedule. When

a follow-up of this patient was conducted 6 months after he completed

treatment, his sleep pattern continued to show the improvement displayed

immediately after treatment with virtually no change in his sleep or wake

time measures. ■

Whereas treatment results like these suggest that the CBT strategies are

well suited for treating those with comorbid insomnia, there is still need

for some caution when employing these techniques with such patients.

Admittedly, given the limited data suggesting the efficacy of CBT with

comorbid patients, there is much to be learned about optimizing out-

comes with these individuals. Indeed, there are many questions yet to be

answered. Among the more pertinent are (1) How can we best combine

CBT with pharmacotherapy and other medical management of the exist-

ing comorbid disorder? (2) Do the specific sleep-focused CBT techniques

need to be altered or augmented in any way to maximize outcomes with

comorbid insomnia? (3) Should CBT for insomnia be incorporated into

more global cognitive-behavioral protocols that exist for various comor-

bid conditions (e.g., depression, anxiety disorders, etc.)? and (4) Does

CBT for insomnia in comorbid patients require more extended therapy

and follow-up than commonly required for primary insomnia? These,

among many other questions, need to be addressed before this treatment

can be confidently extended to various other comorbid groups. For a

more thorough discussion of this topic, the reader is referred to the recent

excellent review article by Smith et al. (2005). Nonetheless, the research

conducted to date as well as with results with cases such as the one pre-

sented here encourage further applications of this modality for addressing

comorbid insomnia problems.

Dissemination of CBT Across Settings

Whereas CBT has proven efficacy for primary insomnia and holds

much promise for treating those with various comorbidities, it is cur-

rently challenging to make this therapy available to all who may benefit

from it. Whereas 10% to 15% of the population has chronic insomnia,

94

there are currently a paucity of trained providers who offer the treat-

ment described in this manual. Furthermore, those who are trained and

skilled in these techniques tend to be found in larger medical centers or

specialty sleep centers and not in the general medical practice settings

where most treatment-seeking insomnia patients present for their care.

Thus, expanding the provider pool and exporting this treatment to the

venues wherein most insomnia patients receive their initial treatment

remain as challenges to this therapeutic modality.

In efforts to facilitate dissemination of CBT for insomnia, some inves-

tigators have tested treatment models suitable for medical practice

settings or the public at large. Given that insomnia sufferers typically

present first in primary care settings, it seems reasonable to consider

providing CBT training to those health care professionals (e.g., nurses,

general practitioners) commonly found in such settings. Two studies

designed to test the efficacy of such an approach have demonstrated that

both family physicians (Baillargeon et al., 1998) and office-practice

nurses (Espie et al., 2001; Espie et al., 2007) can effectively administer

CBT components in general medical practice settings. In contrast,

Oosterhuis and Klip (1997) reported delivery of behavioral insomnia

therapy via a series of eight, 15-minute educational programs broadcast

on radio and television in the Netherlands. Over 23,000 people ordered

the accompanying course material, and data from a random subset of

these showed that sleep improvements and reductions in hypnotic use,

medical visits, and physical complaints were achieved by this educa-

tional program. Thus, it appears that behavioral insomnia treatments

can be effectively delivered by various providers and delivery of such

treatment even via mass media outlets may provide benefits to some

insomnia sufferers. Of course, the relative efficacy of these alternate

modes of treatment delivery vis-à-vis more traditional treatment with

experienced CBT therapists is yet to be determined.

Other efforts aimed at treatment dissemination have tested treatment

protocols that can be self-administered outside the clinic setting.

Mimeault and Morin (1999), for example, tested a self-help CBT book-

based treatment (i.e., bibliotherapy) with and without supportive phone

consultations against a wait-list control. Compared to the control condi-

tion, those treated with the bibliotherapy showed substantially greater

sleep improvements, and these improvements were maintained at a

95

3-month follow-up. The addition of phone consultations with a thera-

pist provided some advantage over bibliotherapy alone at least in the

short term. Recently, Strom et al. (2004) tested a 5-week self-help inter-

active CBT program delivered to insomnia patients via the Internet.

Although those receiving CBT showed no greater improvement than a

wait-list control group, this study does demonstrate that treatments such

as CBT can be disseminated widely via the Internet. However, how to

ensure the value and efficacy of such applications remains a current chal-

lenge. Nonetheless, these studies provide some initial ideas for wider

dissemination of CBT strategies. Such efforts may be useful to fill the

void until a sufficient number of traditional providers are trained in these

strategies and the more challenging insomnia patients will be able to

access the comprehensive CBT they ultimately may need.

96

97

Appendix

98

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: ___________________________

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 . . .

a) on a good night? ______ b) on a bad night? ______

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

a) on a good night? ______ b) on a bad night? ______

6. How long have you had this problem? ______

Has it increased in severity, and if so, over what period of time? ______

7. What do you feel is the major cause(s) of your sleep problem?

———————————–––———————–——–——–——–——–——

———————————————————––——–——–——–——–——

——————–—————————————–——–——–——–——–——

8. Did you have sleep problems as a child? Yes No (circle one)

Please describe the problem(s).________________________________________

——————————————————————————————————––

99

100

B. Daytime Functioning:

1. Do you have a problem with severe sleepiness (feeling very sleepy or struggling tostay awake during the daytime? Yes No (circle one)

If yes, how many days during the average week? ________________________

2. Do you often have a problem with your performance at work because of sleepiness?Yes No (circle one)

3. Have you ever had car accidents because of sleepiness (not due to alcohol or drugs)?Yes No (circle one)

4. Have you ever had near car accidents (for example, driving off the road) because ofsleepiness (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 ifyou have not done some of these things recently, try to work out how they wouldhave affected you. Use the following scale to choose the most appropriate numberfor 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., a theater or a meeting) _________________

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

Lying down to rest in the afternoon when circumstances permit _________________

Sitting and talking to someone _________________

Sitting quietly after lunch without alcohol _________________

In a car, while stopped for a few minutes in the traffic __________________

7. On the graph below, indicate how sleepy you generally feel at the times indicatedby choosing the most appropriate corresponding number from the scale belowand circling that number on the graph.

9:00 AM 1 2 3 4 5 6 7

Noon 1 2 3 4 5 6 7

6:00 PM 1 2 3 4 5 6 7

9:00 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)

101

4. How often do you travel across time zones? _________ times per month

5. Do you have a bed partner? Yes No (circle one)If yes, are you and your bed partner having any problems that might be interferingwith 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 min-utes

either trying to fall asleep or trying to return to sleep? _________ nights per week.

8. How many mornings during the average week do you wake up at least 1 hour

before your normal wake-up time and cannot return to sleep? _________mornings per week.

9. Please circle a number from 1 to 10 to indicate how much difficulty you have relax-ing 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 threequestions about your sleep.

1. Has anyone ever told you that you snore loudly? Yes No (circle one)If yes, has your snoring caused people to refuse to sleep in the same room with you? Yes No

2. Has anyone ever told you that you seem to stop breathing while you sleep, or 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 tomove) 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 and wander during the night _________ times per month

d) Have nightmares _________ times per month

e) Have fearful thoughts or images as you are falling asleep _________ times per month

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E. Medication History:

1. Currently, how many times during the month do you use medications to help yousleep?

_____________________ 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 takingor 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 theprevious treatments worked.________________________________________________________________

________________________________________________________________

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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 (�) in the boxes beside those medical problems you have now orhave had in the past.

105

� Problem � Problem � 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:

2. What is (or was) your body weight?

A. Now _________ (lbs)

B. 6 months ago _________ (lbs)

C. When age 20 _________ (lbs)

D. When heaviest ever _________ (lbs)

3. What is your height? _________ feet _________ inches

4. Allergies __________________________________________________________

_________________________________________________________________

5. Have you ever been treated by a psychiatrist, psychologist, or other mental 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)

——————–————–————–————–—

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7. Have you or anyone in your family ever had your sleep recorded in a sleep laboratory?Yes No (circle one)If yes, please give details and describe the results of the recording(s) if you areaware of them.

——————–——————–—————————–——–——–——–——–

——————–————–————–——————–——–——––——–——–

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——————–————–—–—————————–——–——–——–——–

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Part IV: Other Information

In the spaces provided below, please add any information that you feel is important.

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——————–—————–———————————–——–——–——–——––

——————–————–———————————–——–——–——–—–––—–

——————–————–———————————–——–——–——–—–––—–

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References

American Psychiatric Association (1987). Diagnostic and StatisticalManual of Mental Disorders. Washington, DC: American PsychiatricAssociation.

American Psychiatric Association (1994). Diagnostic and StatisticalManual of Mental Disorders. Washington, DC: American PsychiatricAssociation.

Ancoli-Israel, S., & Roth, T. (1999). Characteristics of insomnia in theUnited States: Results of the 1991 National Sleep Foundation SurveyI. Sleep Suppl. 2: S347–353.

Baillargeon, L., Demers, M., et al. (1998). Stimulus-control:Nonpharmacologic treatment for insomnia. Canadian FamilyPhysician 44: 73–79.

Bastien, C., Vallieres, A., et al. (2001). Validation of the insomnia severityindex as an outcome measure for insomnia research. Sleep Medicine2(4): 297–307.

Beck, A. T., Rush, A. J., et al. (1979). Cognitive Therapy of Depression.New York, Guilford Press.

Belleville, G., Guay, C., et al. (2007). Hypnotic taper with or withoutself-help treatment of insomnia: A randomized clinical trial. Journalof Consulting and Clinical Psychology 75(2): 325–335.

Bootzin, R. (1977). Effects of self-control procedures for insomnia.In R. B. Stuart (Ed.), Behavioral self-management. (pp. 176–195). NewYork, Brunner/Mazel.

Bootzin, R. R. (1972). Stimulus control treatment for insomnia.Proceedings of the 80th Annual Meeting of the American PsychologicalAssociation 7: 395–396.

Bootzin, R. R., & Epstein, D. R. (2000). Stimulus control. InK. L. Lichstein & C. M. Morin (Eds.), Treatment of late-lifeinsomnia. Thousand Oaks, CA, Sage.

110

Borkovec, T. D., & Fowles, D. C. (1973). Controlled investigation of theeffects of progressive relaxation and hypnotic relaxation on insomnia.Journal of Abnormal Psychology 82: 153–158.

Brassington, G. S., King, A. C., et al. (2000). Sleep problems as a riskfactor for falls in a sample of community-dwelling adults aged 64–99

years. J Am Geriatr Soc. 48: 1234–1240.Brehm, J., & Cohen, A. (1962). Explorations in cognitive dissonance.

New York, Wiley.Breslau, N., Roth, T., et al. (1996). Sleep disturbance and psychiatric

disorders: A longitudinal epidemiological study of young adults.Biological Psychiatry 39: 411–418.

Burns, D. (1980). Feeling good: The new mood therapy. New York, WilliamMorrow and Company.

Buysse, D., Ancoli-Israel, S., et al. (2006). Recommendations for astandard research assessment of insomnia. Sleep 29(9): 1155–1173.

Buysse, D. J., Reynolds, C. F., et al. (1989). The Pittsburgh Sleep QualityIndex: A new instrument for psychiatric practice and research.Psychiatry Research 28: 193–213.

Carney, C., Edinger, J., et al. (2006). The contribution of general anxietyto sleep quality ratings in insomnia subtypes. Sleep 29 (suppl): A233.

Carney, C. E., & Edinger, J. D. (2006). Identifying critical dysfunctionalbeliefs about sleep in primary insomnia. Sleep 29: 325–333.

Carney, C. E., & Waters, W. F. (2006). Effects of a structured problem-solving procedure on pre-sleep cognitive arousal in college studentswith insomnia. Behavioral Sleep Medicine 4(1): 13–28.

Chang, P. P., Ford, D. E., et al. (1997). Insomnia in young men andsubsequent depression. The Johns Hopkins Precursors Study.American Journal of Epidemiology 146: 105–114.

Coleman, R. M., Roffwarg, H. P., et al. (1982). Sleep wake disorders basedon polysomnographic diagnosis: A national cooperative study. JAMA247: 997–1103.

Currie, S. R., Wilson, K. G., et al. (2000). Cognitive-behavioral treat-ment of insomnia secondary to chronic pain. Journal of Consultingand Clinical Psychology 68: 407–416.

Edinger, J., Wohlgemuth, W., et al. (2001). Cognitive behavioral therapyfor treatment of chronic primary insomnia: A randomized controlledtrial. JAMA 285: 1856–1864.

Edinger, J., Wohlgemuth, W., et al. (2007). Dose-response effects ofcognitive-behavioral insomnia therapy: A randomized clinical trial.Sleep 30(2): 193–202.

Edinger, J. D., Bonnet, M., et al. (2004). Derivation of research diagnosticcriteria for insomnia: Report on an American Academy of SleepMedicine work group. Sleep 27: 1567–1596.

Edinger, J. D., Fins, A. I., et al. (2000). Insomnia and the eye of thebeholder: Are there clinical markers of objective sleep disturbancesamong adults with and without insomnia complaints? Journal ofConsulting and Clinical Psychology 68: 586–593.

Edinger, J. D., Hoelscher, T. J., et al. (1992). A cognitive-behavioraltherapy for sleep-maintenance insomnia in older adults. Psychologyand Aging 7: 282–289.

Edinger, J. D., & Means, M. K. (2005). Cognitive-behavioral therapy forprimary insomnia. Clinical Psychology Reviews 29: 539–558.

Edinger, J. D., & Sampson, W. S. (2003). A primary care “friendly”cognitive behavioral insomnia therapy. Sleep 26: 177–182.

Edinger, J. D., & Wohlgemuth, W. K. (1999). The significance and manage-ment of persistent primary insomnia. Sleep Medicine Reviews 3: 101–118.

Edinger, J. D., Wohlgemuth, W. K., et al. (2005). Behavioral insomniatherapy for fibromyalgia patients: A randomized clinical trial.Archives of Internal Medicine 165: 2527–2535.

Espie, C., Brooks, D., et al. (1989). An evaluation of tailored psychologi-cal treatment of insomnia. Journal of Behaviour Therapy andExperimental Psychiatry 20(2): 143–153.

Espie, C. A. (2002). Insomnia: Conceptual Issues in the Development,Persistence, and Treatment of Sleep Disorder in Adults.

Espie, C., Broomfield, N., et al. (2006). The attention-intention-effortpathway in the development of psychophysiologic insomnia: Atheoretical review. Sleep Medicine Reviews 10(4): 215–45.

Espie, C., MacMahon, K., et al. (2007). Randomized clinicaleffectiveness trial of nurse-administered small-group cognitivebehavior therapy for persistent insomnia in general practice. Sleep30(5): 574–584.

Espie, C. A., Inglis, S. J., et al. (2001). The clinical effectiveness of cogni-tive behaviour therapy for chronic insomnia: Implementation andevaluation of a sleep clinic in general medical practice. BehaviourResearch & Therapy 39: 45–60.

Espie, C. A., & Lindsay, W. R. (1987). Cognitive strategies for themanagement of severe sleep maintenance insomnia: A preliminaryinvestigation. Behavioral Psychotherapy 15: 388–395.

Ford, D., & Kamerow, D. (1989). Epidemiologic study of sleep distur-bances in psychiatric disorders. JAMA 262: 1479–1484.

111

Gislason, T., & Almqvist, M. (1987). Somatic diseases and sleep com-plaints: An epidemiological study of 3,201 Swedish men. Acta MedicaScandinavica 221: 475–481.

Greenberger D., & Padesky, C. (1995). Mind over mood: A cognitivetherapy treatment manual for clients. New York, Guilford Press.

Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research &Therapy 40: 869–893.

Harvey, L., Inglis, S. J., et al. (2002). Insomniacs’ reported use of CBTcomponents and relationship to long-term clinical outcome.Behaviour Research & Therapy 40(1): 75–83.

Hauri, P. (2000). Primary insomnia. In M. H. Kryger, T. Roth, &W. C. Dement (Eds.), Principles and practice of sleep medicine(pp. 633–639). Philadelphia, W.B. Saunders.

Hoelscher, T., & Edinger, J. D. (1988). Treatment of sleep-maintenanceinsomnia in older adults: Sleep period reduction, sleep education andmodified stimulus control. Psychology and Aging 3: 258–263.

Jacobs, G. D., Pace-Schott, E. F., et al. (2004). Cognitive behavior thera-py and pharmacotherapy for insomnia: A randomized controlled trialand direct comparison. Archives of Internal Medicine 164: 1888–1896.

Jacobson, E. (1964). Anxiety and tension control. Philadelphia, Lippincott.Johns, M. (1991). A new method for measuring daytime sleepiness: The

Epworth Sleepiness Scale. Sleep 14: 540–545.Johns, M. (1994). Sleepiness in different situations measured by the

Epworth Sleepiness Scale. Sleep 17: 703–710.Johnson, E., Roehrs, T., et al. (1998). Epidemiology of alcohol and

medication as aids to sleep in early adulthood. Sleep 21(2): 178–186.Johnson, L., & Spinweber, C. (1983). Quality of sleep and performance

in the Navy: A longitudinal study of good and poor sleepers. InC. Guilleminault and E. Lugaresi (Eds.), Sleep/wake disorders:Natural history, epidemiology, and long-term evolution (pp. 13–28).New York, Raven Press.

Katz, D. A., & McHorney, C. A. (1998). Clinical correlates of insomniain patients with chronic illness. Archives of Internal Medicine 158(10):1099–1107.

Krystal, A., Edinger, J., et al. (2002). Non-REM sleep EEG frequencyspectral correlates of sleep complaints in primary insomnia subtypes.Sleep 25: 630–640.

Krystal, A. D., Walsh, J. K., et al. (2003). Sustained efficacy ofEszopiclone over 6 months of nightly treatment: Results of a ran-domized, double-blind, placebo-controlled study in adults withchronic insomnia. Sleep 26(7): 793–799.

112

Kuo, T., Manber, R., et al. (2001). Insomniacs with comorbid depressionachieved comparable improvement in a cognitive-behavioral grouptreatment program as insomniacs without comorbid depression. Sleep24(Suppl): A62.

Lacks, P., & Morin, C. (1992). Recent advances in the assessment andtreatment of insomnia. Journal of Consulting and Clinical Psychology60: 586–594.

Lichstein, K., & Rosenthal, T. (1980). Insomniacs’ perceptions of cogni-tive versus somatic determinants of sleep disturbance. Journal ofAbnormal Psychology 89(1): 105–107.

Livingston, G., Blizard, B., et al. (1993). Does sleep disturbance predictdepression in elderly people? A study in inner London. BritishJournal of General Practice 43: 445–448.

Mimeault, V., & Morin, C. M. (1999). Self-help treatment for insomnia:Bibliotherapy with and without professional guidance. Journal ofConsulting & Clinical Psychology 67(4): 511–519.

Morawetz, D. (2003). Depression and insomnia: What comes first?Australian Journal of Counselling Psychology 3: 19–24.

Morin, C., Bootzin, R., et al. (2006). Psychological and behavioral treat-ment of insomnia: Update of the recent evidence (1998–2004). Sleep29(11): 1398–1414.

Morin, C., Gaulier, B., et al. (1992). Patients’ acceptance of psychologicaland pharmacological therapies for insomnia. Sleep 15: 302–305.

Morin, C. M. (1993). Insomnia: Psychological assessment and management.New York, Guilford Press.

Morin, C. M., Belanger, L., et al. (2005). Long-term outcome afterdiscontinuation of benzodiazepines for insomnia: A survival analysisof relapse. Behav Res Ther 43(1): 1–14.

Morin, C. M., Colecchi, C., et al. (1999). Behavioral and pharmacologicaltherapies for late-life insomnia: A randomized controlled trial. JAMA281: 991–999.

Morin, C. M., Kowatch, R. A., et al. (1989). Behavioral management ofsleep disturbances secondary to chronic pain. Journal of BehaviorTherapy and Experimental Psychiatry 20: 295–302.

Morin, C. M., Kowatch, R. A., et al. (1993). Cognitive-behavior therapyfor late-life insomnia. Journal of Consulting and Clinical Psychology 61:137–147.

Morin, C. M., Stone, J., et al. (1993). Dysfunctional beliefs and attitudesabout sleep among older adults with and without insomnia com-plaints. Psychology and Aging 8: 463–467.

113

Morin, C. M., Vallieres, A., et al. (2003). Dysfunctional Beliefs andAttitudes and Sleep (DBAS): Validation of a briefer version (DBAS-16). Sleep 26(Suppl.): A294.

Nicassio, P., & Bootzin, R. R. (1974). A comparison of progressive relax-ation and autogenic training as treatments for insomnia. Journal ofAbnormal Psychology 83: 253–260.

Oosterhuis, A., & Klip, E. C. (1997). The treatment of insomnia throughmass media, the results of a televised behavioral training programme.Social Science and Medicine 45(8): 1223–1229.

Ozminkowski, R., Wang, S., et al. (2007). The direct and indirect costs ofuntreated insomnia in adults in the United States. Sleep 30(3):263–273.

Roth, T., Walsh, J., et al. (2005). An evaluation of the efficacy and safetyof eszopiclone over 12 months in patients with chronic primaryinsomnia. Sleep Medicine 6(6): 487–495.

Rybarczyk, B., Lopez, M., et al. (2002). Efficacy of two behavioral treat-ment programs for comorbid geriatric insomnia. Psychology andAging 17: 288–298.

Savard, J., & Morin, C. (2002). Insomnia. In M. M. Antony &D. H. Barlow (Eds.), Handbook of assessment and treatment planningfor psychological disorders (pp. 523–555). New York, Guilford Press.

Savard, J., Simard, S., et al. (2005). Randomized study on the efficacy ofcognitive-behavioral therapy for insomnia secondary to breast cancer,part I sleep and psychological effects. Archives of Internal Medicine 23:6083–6096.

Schultz, J. H., & Luthe, W. (1959). Augenic training. New York, Grune &Stratton.

Simon, G. E., & VonKorff, M. (1997). Prevalence, burden, and treatmentof insomnia in primary care. American Journal of Psychiatry 154:1417–1423.

Sivertsen, B., Omvik, S., et al. (2006). Cognitive behavioral therapy vsZopiclone for treatment of chronic primary insomnia in older adults:A randomized controlled trial. JAMA 295: 2851–2858.

Smith, M. T., Huang, M. I., et al. (2005). Cognitive Behavior Therapy forchronic insomnia occurring within the context of medical and psy-chiatric disorders. Clinical Psychology Review 25: 559–592.

Soeffing, J., Lichstein, K., et al. (2007). Psychological treatment of insom-nia in hypnotic-dependant older adults. Sleep Medicine 16: Epubahead of print.

Spielman, A., & Anderson, M. (1999). The clinical interview and treat-ment planning as a guide to understanding the nature of insomnia:

114

The CCNY insomnia interview. In S. Chokroverty (Ed.), Sleep disor-ders medicine: Basic science, technical considerations, and clinical aspects(2nd ed., pp. 385–416). Boston: Butterworth-Heinemann.

Spielman, A. J., Caruso, L. S., et al. (1987). A behavioral perspective oninsomnia treatment. Psychiatric Clinics of North America 10: 541–553.

Spielman, A. J., Saskin, P., et al. (1987). Treatment of chronic insomnia byrestriction of time in bed. Sleep 10: 45–55.

Strom, L., Pettersson, R., et al. (2004). Internet-based treatment forinsomnia: A controlled evaluation. Journal of Consulting & ClinicalPsychology 72(1): 113–120.

Vollrath, M., Wicki, W., et al. (1989). The Zurich study. VIII. Insomnia:Association with depression, anxiety, somatic syndromes, and courseof insomnia. European Archives of Psychiatry & Neurological Sciences239: 113–124.

Walsh, J., & Schweitzer, P. (1999). Ten-year trends in the pharmacologictreatment of insomnia. Sleep 22: 371–375.

Webb, W. (1988). An objective behavioral model of sleep. Sleep 11:488–496.

Weissman, M. M., Greenwald, S., et al. (1997). The morbidity of insom-nia uncomplicated by psychiatric disorders. General HospitalPsychiatry 19: 245–250.

Wicklow, A., & Espie, C. A. (2000). Intrusive thoughts and their rela-tionship to actigraphic measurement of sleep: Towards a cognitivemodel of insomnia. Behaviour Research and Therapy 38: 679–693.

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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.